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Guo X, Akanda N, Fiorino G, Nimbalkar S, Long CJ, Colón A, Patel A, Tighe PJ, Hickman JJ. Human IPSC-Derived PreBötC-Like Neurons and Development of an Opiate Overdose and Recovery Model. Adv Biol (Weinh) 2023:e2300276. [PMID: 37675827 PMCID: PMC10921423 DOI: 10.1002/adbi.202300276] [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: 08/04/2023] [Indexed: 09/08/2023]
Abstract
Opioid overdose is the leading cause of drug overdose lethality, posing an urgent need for investigation. The key brain region for inspiratory rhythm regulation and opioid-induced respiratory depression (OIRD) is the preBötzinger Complex (preBötC) and current knowledge has mainly been obtained from animal systems. This study aims to establish a protocol to generate human preBötC neurons from induced pluripotent cells (iPSCs) and develop an opioid overdose and recovery model utilizing these iPSC-preBötC neurons. A de novo protocol to differentiate preBötC-like neurons from human iPSCs is established. These neurons express essential preBötC markers analyzed by immunocytochemistry and demonstrate expected electrophysiological responses to preBötC modulators analyzed by patch clamp electrophysiology. The correlation of the specific biomarkers and function analysis strongly suggests a preBötC-like phenotype. Moreover, the dose-dependent inhibition of these neurons' activity is demonstrated for four different opioids with identified IC50's comparable to the literature. Inhibition is rescued by naloxone in a concentration-dependent manner. This iPSC-preBötC mimic is crucial for investigating OIRD and combating the overdose crisis and a first step for the integration of a functional overdose model into microphysiological systems.
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Affiliation(s)
- Xiufang Guo
- NanoScience Technology Center, University of Central Florida, 12424 Research Parkway, Suite 400, Orlando, FL, 32826, USA
| | - Nesar Akanda
- NanoScience Technology Center, University of Central Florida, 12424 Research Parkway, Suite 400, Orlando, FL, 32826, USA
| | - Gabriella Fiorino
- NanoScience Technology Center, University of Central Florida, 12424 Research Parkway, Suite 400, Orlando, FL, 32826, USA
| | - Siddharth Nimbalkar
- NanoScience Technology Center, University of Central Florida, 12424 Research Parkway, Suite 400, Orlando, FL, 32826, USA
| | - Christopher J Long
- Hesperos Inc, 12501 Research Parkway, Suite 100, Orlando, FL, 32826, USA
| | - Alisha Colón
- NanoScience Technology Center, University of Central Florida, 12424 Research Parkway, Suite 400, Orlando, FL, 32826, USA
| | - Aakash Patel
- NanoScience Technology Center, University of Central Florida, 12424 Research Parkway, Suite 400, Orlando, FL, 32826, USA
| | - Patrick J Tighe
- College of Medicine, Department of Anesthesiology, University of Florida, 1600 SW Archer Road, Gainesville, FL, 32610, USA
| | - James J Hickman
- NanoScience Technology Center, University of Central Florida, 12424 Research Parkway, Suite 400, Orlando, FL, 32826, USA
- Hesperos Inc, 12501 Research Parkway, Suite 100, Orlando, FL, 32826, USA
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2
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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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3
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Hicks D, Baehr C, Silva-Ortiz P, Khaimraj A, Luengas D, Hamid FA, Pravetoni M. Advancing humanized monoclonal antibody for counteracting fentanyl toxicity towards clinical development. Hum Vaccin Immunother 2022; 18:2122507. [PMID: 36194773 PMCID: PMC9746415 DOI: 10.1080/21645515.2022.2122507] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/19/2022] [Accepted: 09/04/2022] [Indexed: 12/15/2022] Open
Abstract
Innovative therapies to complement current treatments are needed to curb the growing incidence of fatal overdoses related to synthetic opioids. Murine and chimeric monoclonal antibodies (mAb) specific for fentanyl and its analogs have demonstrated pre-clinical efficacy in preventing and reversing drug-induced toxicity in rodent models. However, mAb-based therapeutics require extensive engineering as well as in vitro and in vivo characterization to advance to first-in-human clinical trials. Here, novel murine anti-fentanyl mAbs were selected for development based on affinity for fentanyl, and efficacy in counteracting the pharmacological effects of fentanyl in mice. Humanization and evaluation of mutations designed to eliminate predicted post-translational modifications resulted in two humanized mAbs that were effective at preventing fentanyl-induced pharmacological effects in rats. These humanized mAbs showed favorable biophysical properties with respect to aggregation and hydrophobicity by chromatography-based assays, and thermostability by dynamic scanning fluorimetry. These results collectively support that the humanized anti-fentanyl mAbs developed herein warrant further clinical development for treatment of fentanyl toxicity.
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Affiliation(s)
- Dustin Hicks
- Department of Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Carly Baehr
- Department of Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Pedro Silva-Ortiz
- Department of Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Aaron Khaimraj
- Department of Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Diego Luengas
- Department of Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Fatima A. Hamid
- Department of Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Marco Pravetoni
- Department of Pharmacology, University of Minnesota, Minneapolis, MN, USA
- Center for Immunology, University of Minnesota, Minneapolis, MN, USA
- School of Medicine, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
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4
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Tikhomirov M, Jajor P, Śniegocki T, Poźniak B. Predicting the efficacy of opioid sequestration by intravenous lipid emulsion using biologically relevant in vitro models of drug distribution. Sci Rep 2022; 12:18683. [PMID: 36333363 PMCID: PMC9636243 DOI: 10.1038/s41598-022-21790-4] [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] [Received: 02/11/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022] Open
Abstract
Intravenous lipid emulsions (ILE), among other uses, are utilized in the treatment of poisonings caused by lipophilic substances. The body of evidence regarding the benefits of this treatment is growing but information about opioids-ILE interaction is still very scarce. In this work, the impact of ILE on the distribution of buprenorphine, fentanyl and butorphanol used in various concentrations (100-500 ng/ml) was investigated. Two different in vitro models were used: disposition of the drugs in plasma after ultracentrifugation and distribution into the simulated biophase (cell monolayer of 3T3 fibroblasts or J774.E macrophages). We confirmed the ability of ILE to sequester the three drugs of interest which results in their decrease in the aqueous part of the plasma by 34.2-38.2%, 11.7-28.5% and 6.0-15.5% for buprenorphine, fentanyl and butorphanol, respectively. Moreover, ILE affected the drug distribution to the biophase in vitro, however, in this case the drug concentration in cells decreased by 97.3 ± 3.1%, 28.6 ± 5.4% and 13.0 ± 7.5% for buprenorphine, fentanyl and butorphanol, respectively. The two models revealed notable differences in ILE's potential for drug sequestration, especially for buprenorphine. Similar, but not as pronounced tendencies were observed for the two other drugs. These discrepancies may result from the difference in protein abundance and resulting drug-protein binding in both systems. Nevertheless, the results obtained with both in vitro models correlated well with the partition coefficient (logP) values for these drugs.
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Affiliation(s)
- Marta Tikhomirov
- grid.411200.60000 0001 0694 6014Faculty of Veterinary Medicine, Department of Pharmacology and Toxicology, Wroclaw University of Environmental and Life Sciences, 50-375 Wrocław, Poland
| | - Paweł Jajor
- grid.411200.60000 0001 0694 6014Faculty of Veterinary Medicine, Department of Pharmacology and Toxicology, Wroclaw University of Environmental and Life Sciences, 50-375 Wrocław, Poland
| | - Tomasz Śniegocki
- grid.419811.4Department of Pharmacology and Toxicology, National Veterinary Research Institute, 24-100 Puławy, Poland
| | - Błażej Poźniak
- grid.411200.60000 0001 0694 6014Faculty of Veterinary Medicine, Department of Pharmacology and Toxicology, Wroclaw University of Environmental and Life Sciences, 50-375 Wrocław, Poland
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5
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Tuet WY, Pierce SA, Conroy M, Vignola JN, Tressler J, diTargiani RC, McCranor BJ, Wong B. Metabolic clearance of select opioids and opioid antagonists using hepatic spheroids and recombinant cytochrome P450 enzymes. Pharmacol Res Perspect 2022; 10:e01000. [PMID: 36045607 PMCID: PMC9433823 DOI: 10.1002/prp2.1000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 07/22/2022] [Accepted: 07/23/2022] [Indexed: 11/21/2022] Open
Abstract
The opioid crisis is a pressing public health issue, exacerbated by the emergence of more potent synthetic opioids, particularly fentanyl and its analogs. While competitive antagonists exist, their efficacy against synthetic opioids is largely unknown. Furthermore, due to the short durations of action of current antagonists, renarcotization remains a concern. In this study, metabolic activity was characterized for fentanyl‐class opioids and common opioid antagonists using multiple in vitro systems, namely, cytochrome P450 (CYP) enzymes and hepatic spheroids, after which an in vitro‐in vivo correlation was applied to convert in vitro metabolic activity to predictive in vivo intrinsic clearance. For all substrates, intrinsic hepatic metabolism was higher than the composite of CYP activities, due to fundamental differences between whole cells and single enzymatic reactions. Of the CYP isozymes investigated, 3A4 yielded the highest absolute and relative metabolism across all substrates, with largely negligible contributions from 2D6 and 2C19. Comparative analysis highlighted elevated lipophilicity and diminished CYP3A4 activity as potential considerations for the development of more efficacious opioid antagonists. Finally, antagonists with a high degree of molecular similarity exhibited comparable clearance, providing a basis for structure‐metabolism relationships. Together, these results provide multiple screening criteria for early stage drug discovery involving opioid countermeasures.
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Affiliation(s)
- Wing Y Tuet
- Pharmaceutical Sciences Department, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, Maryland, USA
| | - Samuel A Pierce
- Pharmaceutical Sciences Department, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, Maryland, USA
| | - Matthieu Conroy
- Pharmaceutical Sciences Department, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, Maryland, USA
| | - Justin N Vignola
- Pharmaceutical Sciences Department, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, Maryland, USA
| | - Justin Tressler
- Pharmaceutical Sciences Department, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, Maryland, USA
| | - Robert C diTargiani
- Pharmaceutical Sciences Department, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, Maryland, USA
| | - Bryan J McCranor
- Pharmaceutical Sciences Department, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, Maryland, USA
| | - Benjamin Wong
- Pharmaceutical Sciences Department, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, Maryland, USA
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6
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Putnam PT, Chang SWC. Interplay between the oxytocin and opioid systems in regulating social behaviour. Philos Trans R Soc Lond B Biol Sci 2022; 377:20210050. [PMID: 35858101 PMCID: PMC9272147 DOI: 10.1098/rstb.2021.0050] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 04/25/2022] [Indexed: 07/30/2023] Open
Abstract
The influence of neuromodulators on brain activity and behaviour is undeniably profound, yet our knowledge of the underlying mechanisms, or ability to reliably reproduce effects across varying conditions, is still lacking. Oxytocin, a hormone that acts as a neuromodulator in the brain, is an example of this quandary; it powerfully shapes behaviours across nearly all mammalian species, yet when manipulated exogenously can produce unreliable or sometimes unexpected behavioural results across varying contexts. While current research is rapidly expanding our understanding of oxytocin, interactions between oxytocin and other neuromodulatory systems remain underappreciated in the current literature. This review highlights interactions between oxytocin and the opioid system that serve to influence social behaviour and proposes a parallel-mechanism hypothesis to explain the supralinear effects of combinatorial neuropharmacological approaches. This article is part of the theme issue 'Interplays between oxytocin and other neuromodulators in shaping complex social behaviours'.
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Affiliation(s)
- Philip T. Putnam
- Department of Psychology, Yale University, New Haven, CT 06520, USA
| | - Steve W. C. Chang
- Department of Psychology, Yale University, New Haven, CT 06520, USA
- Department of Neuroscience, Yale University School of Medicine, New Haven, CT 06510, USA
- Kavli Institute for Neuroscience, Yale University School of Medicine, New Haven, CT 06510, USA
- Wu Tsai Institute, Yale University, New Haven, CT 06510, USA
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7
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Abstract
Harm reduction is an approach to reduce the risk of harms to an individual using substances without requiring abstinence. This review discusses substance-specific interventions for opioids, alcohol, and stimulants that can minimize harms for individuals who use these substances. Topics discussed include overdose prevention, infection prevention, and low-barrier substance use disorder treatment.
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Affiliation(s)
- Carolyn A Chan
- Program in Addiction Medicine, Section of General Internal Medicine, Department of Medicine, 367 Cedar Street, Harkness Hall A Suite - Suite 305, New Haven, CT 06510, USA
| | - Bethany Canver
- Section of General Internal Medicine, Department of Medicine, 367 Cedar Street, Harkness Hall A Suite - Suite 305, New Haven, CT 06510, USA
| | - Ryan McNeil
- Program in Addiction Medicine, Section of General Internal Medicine, Department of Medicine, 367 Cedar Street, Harkness Hall A, New Haven, CT 06510, USA
| | - Kimberly L Sue
- Program in Addiction Medicine, Section of General Internal Medicine, Department of Medicine, 367 Cedar Street, Harkness Hall A Suite - Suite 417A, New Haven, CT 06510, USA.
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8
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Ahmad N, Subhan F, Islam NU, Shahid M, Ullah N, Ullah R, Khurram M, Amin MU, Akbar S, Ullah I, Sewell RDE. Pharmacological evaluation of the gabapentin salicylaldehyde derivative, gabapentsal, against tonic and phasic pain models, inflammation, and pyrexia. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2021; 394:2033-2047. [PMID: 34254154 DOI: 10.1007/s00210-021-02118-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 06/25/2021] [Indexed: 10/20/2022]
Abstract
Gabapentinoids are effective drugs in most animal models of pain and inflammation with variable effects in humans. The current study evaluated the pharmacological activity of gabapentin (GBP) and its salicylaldehyde derivative (gabapentsal; [2-(1-(((2-hydroxybenzylidene) amino) methyl) cyclohexyl) acetic acid]; GPS) in well-established mouse models of nociceptive pain, inflammatory edema, and pyrexia at doses of 25-100 mg/kg. GPS allayed tonic visceral pain as reflected by acetic acid-induced nociception and it also diminished thermally induced nociception as a mimic of phasic thermal pain. Antagonism of GPS-induced antinociceptive activities by naloxone (NLX, 1.0 mg/kg, subcutaneously, s.c), beta-funaltrexamine (β-FNT, 5.0 mg/kg, s.c), naltrindole (NT, 1.0 mg/kg, s.c), and nor-binaltorphimine (NOR-BNI, 5.0 mg/kg, s.c), and pentylenetetrazole (PTZ-15 mg/kg, intraperitoneally, i.p) implicated an involvement of both opioidergic and GABAergic mechanisms. Tail immersion test was conducted in order to delineate the mechanistic insights of antinociceptive response. Inflammatory edema induced by carrageenan, histamine, or serotonin was also effectively reversed by GPS in a fashion analogous to aspirin (150 mg/kg, i.p), chlorpheniramine (1.0 mg/kg, i.p), and mianserin (1.0 mg/kg, i.p), respectively. Additionally, yeast-induced pyrexia was decreased by GPS in a comparable manner to acetaminophen (50 mg/kg, i.p). These observations suggest that GPS possesses ameliorative properties in tonic, phasic, and tail immersion tests of nociception via opioidergic and GABAergic mechanisms, curbs inflammatory edema, and is antipyretic in nature.
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Affiliation(s)
- Nisar Ahmad
- Islam College of Pharmacy, Pasrur Road, Sialkot, Punjab, 51040, Pakistan.
| | - Fazal Subhan
- Department of Pharmacy, Cecos University of IT and Emerging Sciences, Peshawar, Pakistan
| | - Nazar Ul Islam
- Department of Pharmacy, Sarhad University of Science and Information Technology, Peshawar, Pakistan
| | - Muhammad Shahid
- Department of Pharmacy, Sarhad University of Science and Information Technology, Peshawar, Pakistan
| | - Naseem Ullah
- Islam College of Pharmacy, Pasrur Road, Sialkot, Punjab, 51040, Pakistan
| | - Rahim Ullah
- Department of Pharmacy, University of Peshawar, Peshawar, Pakistan
| | | | | | - Shehla Akbar
- Department of Pharmacy, Cecos University of IT and Emerging Sciences, Peshawar, Pakistan
| | - Ihsan Ullah
- Department of Pharmacy, University of Swabi, Swabi, Pakistan
| | - Robert D E Sewell
- Cardiff School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, CF10 3NB, UK
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9
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Abstract
This article focuses on sedation/anesthesia of adolescent patients in the dental setting. Preoperative evaluation, treatment planning, monitoring, and management are critical components to successful sedation. The authors discuss commonly administered agents and techniques to adolescents, including nitrous oxide/oxygen analgesia. The levels and spectrum of sedation and anesthesia are reviewed. Common comorbidities are also presented as they relate to sedation of the adolescent dental patient.
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Affiliation(s)
- Matthew Cooke
- Department of Dental Anesthesiology, School of Dental Medicine, University of Pittsburgh, 3501 Terrace Street, Pittsburgh, PA 15261, USA; Department of Pediatric Dentistry, School of Dental Medicine, University of Pittsburgh, 3501 Terrace Street, Pittsburgh, PA 15261, USA.
| | - Thomas Tanbonliong
- Division of Pediatric Dentistry, Department of Orofacial Sciences, University of California San Francisco, School of Dentistry, Box 0753, 707 Parnassus Avenue, D-1021, San Francisco, CA 94143, USA
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10
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Use of Naloxone in 9-1-1 Patients without Respiratory Depression in Los Angeles County, California (USA). Prehosp Disaster Med 2021; 36:543-546. [PMID: 34425934 DOI: 10.1017/s1049023x21000820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Along with an increase in opioid deaths, there has been a desire to increase the accessibility of naloxone. However, in the absence of respiratory depression, naloxone is unlikely to be beneficial and may be deleterious if it precipitates withdrawal in individuals with central nervous system (CNS) depression due to non-opioid etiologies. OBJECTIVE The aim of this study was to evaluate how effective prehospital providers were in administering naloxone. METHODS This is a retrospective study of naloxone administration in two large urban Emergency Medical Service (EMS) systems. The proportion of patients who had a respiratory rate of at least 12 breaths per minute at the time of naloxone administration by prehospital providers was determined. RESULTS During the two-year study period, 2,580 patients who received naloxone by prehospital providers were identified. The median (interquartile range) respiratory rate prior to naloxone administration was 12 (6-16) breaths per minute. Using an a priori respiratory rate of under 12 breaths per minute to define respiratory depression, only 1,232 (47.8%; 95% CI, 50.3%-54.2%) subjects who received naloxone by prehospital providers had respiratory depression. CONCLUSION This study showed that EMS providers in Los Angeles County, California (USA) frequently administered naloxone to individuals without respiratory depression.
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11
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Ramirez JM, Burgraff NJ, Wei AD, Baertsch NA, Varga AG, Baghdoyan HA, Lydic R, Morris KF, Bolser DC, Levitt ES. Neuronal mechanisms underlying opioid-induced respiratory depression: our current understanding. J Neurophysiol 2021; 125:1899-1919. [PMID: 33826874 DOI: 10.1152/jn.00017.2021] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Opioid-induced respiratory depression (OIRD) represents the primary cause of death associated with therapeutic and recreational opioid use. Within the United States, the rate of death from opioid abuse since the early 1990s has grown disproportionally, prompting the classification as a nationwide "epidemic." Since this time, we have begun to unravel many fundamental cellular and systems-level mechanisms associated with opioid-related death. However, factors such as individual vulnerability, neuromodulatory compensation, and redundancy of opioid effects across central and peripheral nervous systems have created a barrier to a concise, integrative view of OIRD. Within this review, we bring together multiple perspectives in the field of OIRD to create an overarching viewpoint of what we know, and where we view this essential topic of research going forward into the future.
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Affiliation(s)
- Jan-Marino Ramirez
- Department of Neurological Surgery, University of Washington, Seattle, Washington.,Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington
| | - Nicholas J Burgraff
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington
| | - Aguan D Wei
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington
| | - Nathan A Baertsch
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington
| | - Adrienn G Varga
- Department of Pharmacology and Therapeutics, University of Florida, Gainesville, Florida.,Center for Respiratory Research and Rehabilitation, Department of Physical Therapy, University of Florida, Gainesville, Florida
| | - Helen A Baghdoyan
- Department of Psychology, University of Tennessee, Knoxville, Tennessee.,Oak Ridge National Laboratory, Oak Ridge, Tennessee
| | - Ralph Lydic
- Department of Psychology, University of Tennessee, Knoxville, Tennessee.,Oak Ridge National Laboratory, Oak Ridge, Tennessee
| | - Kendall F Morris
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Donald C Bolser
- Department of Physiological Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida
| | - Erica S Levitt
- Department of Pharmacology and Therapeutics, University of Florida, Gainesville, Florida.,Center for Respiratory Research and Rehabilitation, Department of Physical Therapy, University of Florida, Gainesville, Florida
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12
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Rege MG, Ayanwuyi LO, Zezi AU, Odoma S. Anti-nociceptive, anti-inflammatory and possible mechanism of anti-nociceptive action of methanol leaf extract of Nymphaea lotus Linn (Nymphaeceae). J Tradit Complement Med 2021; 11:123-129. [PMID: 33728272 PMCID: PMC7936113 DOI: 10.1016/j.jtcme.2020.02.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 09/15/2019] [Accepted: 02/27/2020] [Indexed: 11/18/2022] Open
Abstract
The leaf of Nymphaea lotus has been used traditionally for the management of pain and inflammatory diseases. The methanol leaf extract of Nymphaea lotus (NLE) was evaluated for possible anti-nociceptive and anti-inflammatory activities in rats and mice (at the doses of 250, 500 and 1,000 mg/kg) to investigate the existence of scientific basis for the folkloric use of the plant. The standard drugs used were piroxicam (10 mg/kg) and morphine (10 mg/kg). The possible pharmacological mechanism involved in the anti-nociceptive activity was also investigated. The acute toxicity was determined in mice and rats using method of Lorke. The anti-nociceptive activity was evaluated using acetic acid-induced writhing and hot plate tests in mice, while the anti-inflammatory activity was evaluated using carrageenan-induced hind paw edema model in rats. The oral median lethal dose of NLE was found to be greater than 5,000 mg/kg in rats and mice. NLE demonstrated significant and dose-dependent protection against acetic acid induced writhes and increased the reaction time of mice in hot plate test. Pretreatment of the animals with naloxone (2 mg/kg) significantly (p < 0.05) attenuated the anti-nociception elicited by both NLE and morphine. NLE at the doses of 250 and 1,000 mg/kg significantly (p < 0.05) decreased rat paw edema at the 2nd hour in the carrageenan-induced paw edema test. The result of the study revealed that Nymphaea lotus possesses anti-nociceptive activities which may be mediated via the opioidergic system as well as mild anti-inflammatory activities thus providing scientific basis for the use of the plant in the management of pain and inflammatory diseases.
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Affiliation(s)
- Musa G Rege
- Department of Pharmacy Technician Training, Kebbi State School of Health Technology, Jega, Nigeria
| | - Lydia O Ayanwuyi
- Department of Pharmacology and Therapeutics, Faculty of Pharmaceutical Sciences, Ahmadu Bello University, Zaria, Nigeria
| | - Abdulkadir U Zezi
- Department of Pharmacology and Therapeutics, Faculty of Pharmaceutical Sciences, Ahmadu Bello University, Zaria, Nigeria
| | - Saidi Odoma
- Department of Pharmacology and Therapeutics, College of Health Sciences, Kogi State University, Anyigba, Nigeria.,Departmennt of Pharmacology and Toxicology, Kampala International University, Western-Campus, Uganda
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13
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Tuet WY, Pierce SA, Racine MC, Tressler J, McCranor BJ, Sciuto AM, Wong B. Changes in murine respiratory dynamics induced by aerosolized carfentanil inhalation: Efficacy of naloxone and naltrexone. Toxicol Lett 2019; 316:127-135. [DOI: 10.1016/j.toxlet.2019.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 08/26/2019] [Accepted: 09/14/2019] [Indexed: 11/28/2022]
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Intranasal naloxone rapidly occupies brain mu-opioid receptors in human subjects. Neuropsychopharmacology 2019; 44:1667-1673. [PMID: 30867551 PMCID: PMC6785104 DOI: 10.1038/s41386-019-0368-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 03/03/2019] [Accepted: 03/06/2019] [Indexed: 12/14/2022]
Abstract
Nasal spray formulations of naloxone, a mu-opioid receptor (MOR) antagonist, are currently used for the treatment of opioid overdose. They may have additional therapeutic utility also in the absence of opioid agonist drugs, but the onset and duration of action at brain MORs have been inadequately characterized to allow such projections. This study provides initial characterization of brain MOR availability at high temporal resolution following intranasal (IN) naloxone administration to healthy volunteers in the absence of a competing opioid agonist. Fourteen participants were scanned twice using positron emission tomography (PET) and [11C]carfentanil, a selective MOR agonist radioligand. Concentrations of naloxone in plasma and MOR availability (relative to placebo) were monitored from 0 to 60 min and at 300-360 min post naloxone. Naloxone plasma concentrations peaked at ~20 min post naloxone, associated with slightly delayed development of brain MOR occupancy (half of peak occupancy reached at ~10 min). Estimated peak occupancies were 67 and 85% following 2 and 4 mg IN doses, respectively. The estimated half-life of occupancy disappearance was ~100 min. The rapid onset of brain MOR occupancy by IN naloxone, evidenced by the rapid onset of its action in opioid overdose victims, was directly documented in humans for the first time. The employed high temporal-resolution PET method establishes a model that can be used to predict brain MOR occupancy from plasma naloxone concentrations. IN naloxone may have therapeutic utility in various addictions where brain opioid receptors are implicated, such as gambling disorder and alcohol use disorder.
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Blanco-Gandía MC, Rodríguez-Arias M. Pharmacological treatments for opiate and alcohol addiction: A historical perspective of the last 50 years. Eur J Pharmacol 2018; 836:89-101. [DOI: 10.1016/j.ejphar.2018.08.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 07/13/2018] [Accepted: 08/03/2018] [Indexed: 12/17/2022]
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Howard J, Hornsby-Myers J. Fentanyls and the safety of first responders: Science and recommendations. Am J Ind Med 2018; 61:633-639. [PMID: 29938814 DOI: 10.1002/ajim.22874] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2018] [Indexed: 12/26/2022]
Abstract
Opioids have many beneficial uses in medicine, but, taken inappropriately, they can cause life-threatening health effects. The increasing use of physician-prescribed and illicit opioids, including highly potent fentanyl and its analogs, have contributed to a significant increase in opioid-related drug overdoses in the United States, leading to a public health emergency. There have been a number of reports describing adverse health effects experienced by police officers, fire-fighter emergency medical services providers, and private sector ambulance personnel when responding to drug overdose incidents. Several sets of exposure prevention recommendations for first responders are available from government and the private sector. Understanding the scientific basis for these recommendations, increasing awareness by responders of the potential risks associated with opioid exposure during a response, and educating responders about safe work practices when exposure to opioids is suspected or confirmed are all critical prevention measures that can keep first responders safe.
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Affiliation(s)
- John Howard
- National Institute for Occupational Safety and Health, Washington, District of Columbia
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France CR, Burns JW, Gupta RK, Buvanendran A, Chont M, Schuster E, Orlowska D, Bruehl S. Expectancy Effects on Conditioned Pain Modulation Are Not Influenced by Naloxone or Morphine. Ann Behav Med 2017; 50:497-505. [PMID: 26809850 DOI: 10.1007/s12160-016-9775-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Recent studies suggest that participant expectations influence pain ratings during conditioned pain modulation testing. The present study extends this work by examining expectancy effects among individuals with and without chronic back pain after administration of placebo, naloxone, or morphine. PURPOSE This study aims to identify the influence of individual differences in expectancy on changes in heat pain ratings obtained before, during, and after a forearm ischemic pain stimulus. METHODS Participants with chronic low back pain (n = 88) and healthy controls (n = 100) rated heat pain experience (i.e., "test stimulus") before, during, and after exposure to ischemic pain (i.e., "conditioning stimulus"). Prior to testing, participants indicated whether they anticipated that their heat pain would increase, decrease, or remain unchanged during ischemic pain. RESULTS Analysis of the effects of expectancy (pain increase, decrease, or no change), drug (placebo, naloxone, or morphine), and group (back pain, healthy) on changes in heat pain revealed a significant main effect of expectancy (p = 0.001), but no other significant main effects or interactions. Follow-up analyses revealed that individuals who expected lower pain during ischemia reported significantly larger decreases in heat pain as compared with those who expected either no change (p = 0.004) or increased pain (p = 0.001). CONCLUSIONS The present findings confirm that expectancy is an important contributor to conditioned pain modulation effects, and therefore significant caution is needed when interpreting findings that do not account for this individual difference. Opioid mechanisms do not appear to be involved in these expectancy effects.
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Affiliation(s)
- Christopher R France
- Department of Psychology, Ohio University, 251 Porter Hall, Athens, OH, 45701, USA.
| | - John W Burns
- Department of Behavioral Science, Rush University, Chicago, IL, USA
| | - Rajnish K Gupta
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | - Melissa Chont
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Erik Schuster
- Department of Behavioral Science, Rush University, Chicago, IL, USA
| | - Daria Orlowska
- Department of Behavioral Science, Rush University, Chicago, IL, USA
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN, USA
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Abstract
Use of opioid analgesics for management of chronic nonmalignant pain has become common, yet there are presently no well-validated predictors of optimal opioid analgesic efficacy. We examined whether psychosocial factors (eg, depressive symptoms) predicted changes in spontaneous low back pain after administration of opioid analgesics, and whether endogenous opioid (EO) function mediated these relationships. Participants with chronic low back pain but who were not chronic opioid users (N = 89) underwent assessment of low back pain intensity pre- and post-drug in 3 (counterbalanced) conditions: (1) placebo, (2) intravenous naloxone, and (3) intravenous morphine. Comparison of placebo condition changes in back pain intensity to those under naloxone and morphine provided indexes of EO function and opioid analgesic responses, respectively. Results showed that (1) most psychosocial variables were related significantly and positively to morphine analgesic responses for low back pain, (2) depressive symptoms, trait anxiety, pain catastrophizing, and pain disability were related negatively to EO function, and (3) EO function was related negatively to morphine analgesic responses for low back pain. Bootstrapped mediation analyses showed that links between morphine analgesic responses and depressive symptoms, trait anxiety, pain catastrophizing, and perceived disability were partially mediated by EO function. Results suggest that psychosocial factors predict elevated analgesic responses to opioid-based medications, and may serve as markers to identify individuals who benefit most from opioid therapy. Results also suggest that people with greater depressive symptoms, trait anxiety, pain catastrophizing, and perceived disability may have deficits in EO function, which may predict enhanced response to opioid analgesics.
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Sivanesan E, Gitlin MC, Candiotti KA. Opioid-induced Hallucinations: A Review of the Literature, Pathophysiology, Diagnosis, and Treatment. Anesth Analg 2017; 123:836-43. [PMID: 27258073 DOI: 10.1213/ane.0000000000001417] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Despite their association with multiple adverse effects, opioid prescription continues to increase. Opioid-induced hallucination is an uncommon yet significant adverse effect of opioid treatment. The practitioner may encounter patient reluctance to volunteer the occurrence of this phenomenon because of fears of being judged mentally unsound. The majority of the literature concerning opioid-induced hallucinations arises from treatment during end-of-life care and cancer pain. Because the rate of opioid prescriptions continues to increase in the population, the rate of opioid-associated hallucinations may also conceivably increase. With a forecasted increase in the patient-to-physician ratio, opioid therapy is predicted to be provided by practitioners of varying backgrounds and medical specialties. Hence, knowledge of the pharmacology and potential adverse effects of these agents is required. This review seeks to increase awareness of this potential complication through a discussion of the literature, potential mechanisms of action, diagnosis, and treatment strategies.
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Affiliation(s)
- Eellan Sivanesan
- From the Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
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McDonald R, Danielsson Glende Ø, Dale O, Strang J. International patent applications for non-injectable naloxone for opioid overdose reversal: Exploratory search and retrieve analysis of the PatentScope database. Drug Alcohol Rev 2017; 37:205-215. [PMID: 28597483 DOI: 10.1111/dar.12571] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 04/20/2017] [Accepted: 04/21/2017] [Indexed: 12/23/2022]
Abstract
ISSUES Non-injectable naloxone formulations are being developed for opioid overdose reversal, but only limited data have been published in the peer-reviewed domain. Through examination of a hitherto-unsearched database, we expand public knowledge of non-injectable formulations, tracing their development and novelty, with the aim to describe and compare their pharmacokinetic properties. APPROACH (i) The PatentScope database of the World Intellectual Property Organization was searched for relevant English-language patent applications; (ii) Pharmacokinetic data were extracted, collated and analysed; (iii) PubMed was searched using Boolean search query '(nasal OR intranasal OR nose OR buccal OR sublingual) AND naloxone AND pharmacokinetics'. KEY FINDINGS Five hundred and twenty-two PatentScope and 56 PubMed records were identified: three published international patent applications and five peer-reviewed papers were eligible. Pharmacokinetic data were available for intranasal, sublingual, and reference routes. Highly concentrated formulations (10-40 mg mL-1 ) had been developed and tested. Sublingual bioavailability was very low (1%; relative to intravenous). Non-concentrated intranasal spray (1 mg mL-1 ; 1 mL per nostril) had low bioavailability (11%). Concentrated intranasal formulations (≥10 mg mL-1 ) had bioavailability of 21-42% (relative to intravenous) and 26-57% (relative to intramuscular), with peak concentrations (dose-adjusted Cmax = 0.8-1.7 ng mL-1 ) reached in 19-30 min (tmax ). IMPLICATIONS Exploratory analysis identified intranasal bioavailability as associated positively with dose and negatively with volume. CONCLUSION We find consistent direction of development of intranasal sprays to high-concentration, low-volume formulations with bioavailability in the 20-60% range. These have potential to deliver a therapeutic dose in 0.1 mL volume. [McDonald R, Danielsson Glende Ø, Dale O, Strang J. International patent applications for non-injectable naloxone for opioid overdose reversal: Exploratory search and retrieve analysis of the PatentScope database. Drug Alcohol Rev 2017;00:000-000].
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Affiliation(s)
- Rebecca McDonald
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Øyvind Danielsson Glende
- Department of Circulation and Medical Imaging, NTNU-The Norwegian University of Science and Technology, Trondheim, Norway.,Apotek 1 Nardo, Trondheim, Norway
| | - Ola Dale
- Department of Circulation and Medical Imaging, NTNU-The Norwegian University of Science and Technology, Trondheim, Norway.,St. Olav's Hospital, University Hospital of Trondheim, Trondheim, Norway
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,South London and Maudsley NHS Foundation Trust, London, UK
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Endogenous Opioid Function and Responses to Morphine: The Moderating Effects of Anger Expressiveness. THE JOURNAL OF PAIN 2017; 18:923-932. [PMID: 28365372 DOI: 10.1016/j.jpain.2017.02.439] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 02/11/2017] [Accepted: 02/26/2017] [Indexed: 11/22/2022]
Abstract
Long-term use of opioid analgesics may be ineffective or associated with significant negative side effects for some people. At present, there is no sound method of identifying optimal opioid candidates. Individuals with chronic low back pain (n = 89) and healthy control individuals (n = 102) underwent ischemic pain induction with placebo, opioid blockade (naloxone), and morphine in counterbalanced order. They completed the Spielberger Anger-Out subscale. Endogenous opioid function × Anger-out × Pain status (chronic pain, healthy control) interactions were tested for morphine responses to ischemic threshold, tolerance, and pain intensity (McGill Sensory and Affective subscales) and side effects. For individuals with chronic pain and healthy control participants, those with low endogenous opioid function and low anger-out scores exhibited the largest morphine analgesic responses, whereas those with high anger-out and low endogenous opioid function showed relatively weaker morphine analgesic responses. Further, individuals with chronic pain with low endogenous opioid function and low anger-out scores also reported the fewest negative effects to morphine, whereas those with low endogenous opioid function and high anger-out reported the most. Findings point toward individuals with chronic pain who may strike a favorable balance of good analgesia with few side effects, as well as those who have an unfavorable balance of poor analgesia and many side effects. PERSPECTIVE We sought to identify optimal candidates for opioid pain management. Low back pain patients who express anger and also have deficient endogenous opioid function may be poor candidates for opioid therapy. In contrast, low back patients who tend not to express anger and who also have deficient endogenous opioid function may make optimal candidates for opioid therapy.
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Abstract
In recent years, there has been a substantial increase in opioid use and abuse, and in opioid-related fatal overdoses. The increase in opioid use has resulted at least in part from individuals transitioning from prescribed opioids to heroin and fentanyl, which can cause significant respiratory depression that can progress to apnea and death. Heroin and fentanyl may be used individually, together, or in combination with other substances such as ethanol, benzodiazepines, or other drugs that can have additional deleterious effects on respiration. Suspicion that a death is drug-related begins with the decedent's medical and social history, and scene investigation, where drugs and drug paraphernalia may be encountered, and examination of the decedent, which may reveal needle punctures and needle track marks. At autopsy, the most significant internal finding that is reflective of opioid toxicity is pulmonary edema and congestion, and frothy watery fluid is often present in the airways. Various medical ailments such as heart and lung disease and obesity may limit an individual's physiologic reserve, rendering them more susceptible to the toxic effects of opioids and other drugs. Although many opioids will be detected on routine toxicology testing, more specialized testing may be warranted for opioid analogs, or other uncommon, synthetic, or semisynthetic drugs.
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Kim HK, Nelson LS. Reducing the harm of opioid overdose with the safe use of naloxone: a pharmacologic review. Expert Opin Drug Saf 2015; 14:1137-46. [DOI: 10.1517/14740338.2015.1037274] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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25
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Relationship between endogenous opioid function and opioid analgesic adverse effects. Reg Anesth Pain Med 2015; 39:219-24. [PMID: 24682081 DOI: 10.1097/aap.0000000000000083] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Our recent work indicates that endogenous opioid activity influences analgesic responses to opioid medications. This secondary analysis evaluated whether endogenous opioid activity is associated with degree of opioid analgesic adverse effects, and whether chronic pain status and sex affect these adverse effects. METHODS Using a double-blind, randomized, placebo-controlled, crossover design, 51 subjects with chronic low back pain and 38 healthy controls participated in 3 separate sessions, undergoing 2 laboratory-evoked pain tasks (ischemic and thermal) after receiving placebo, naloxone, or morphine. Endogenous opioid system function was indexed by the difference in pain responses between the placebo and naloxone conditions. These measures were examined for associations with morphine-related adverse effects. RESULTS Chronic pain subjects reported significantly greater itching and unpleasant bodily sensations with morphine than controls (P < 0.05). Across groups, only 6 of 112 possible associations between adverse effects and blockade effects were significant. For the ischemic task, higher endogenous opioid function was associated with greater itching (visual analog scale [VAS]; P < 0.05), numbness (tolerance; P < 0.001), dry mouth (tolerance; P < 0.05), and unpleasant bodily sensations (VAS; P < 0.05). For the thermal task, higher endogenous opioid function was associated with greater numbness (VAS; P < 0.05) and feeling carefree (VAS; P < 0.05). There were no significant main or interaction effects of chronic pain status or sex on these findings. CONCLUSIONS No consistent relationships were observed between endogenous opioid function and morphine-related adverse effects. This is in stark contrast to our previous observation of strong relationships between elevated endogenous opioid function and smaller morphine analgesic effects.
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Endogenous opioid inhibition of chronic low-back pain influences degree of back pain relief after morphine administration. Reg Anesth Pain Med 2014; 39:120-5. [PMID: 24553304 DOI: 10.1097/aap.0000000000000058] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Factors underlying differential responsiveness to opioid analgesic medications used in chronic pain management are poorly understood. We tested whether individual differences in endogenous opioid inhibition of chronic low-back pain were associated with the magnitude of acute reductions in back pain ratings after morphine administration. METHODS In randomized counterbalanced order over three sessions, 50 chronic low-back pain patients received intravenous naloxone (8 mg), morphine (0.08 mg/kg), or placebo. Back pain intensity was rated predrug and again after peak drug activity was achieved using the McGill Pain Questionnaire-Short Form (Sensory and Affective subscales, VAS Intensity measure). Opioid blockade effect measures to index degree of endogenous opioid inhibition of back pain intensity were derived as the difference between predrug to postdrug changes in pain intensity across placebo and naloxone conditions, with similar morphine responsiveness measures derived across placebo and morphine conditions. RESULTS Morphine significantly reduced back pain compared with placebo (McGill Pain Questionnaire-Short Form Sensory, VAS; P < 0.01). There were no overall effects of opioid blockade on back pain intensity. However, individual differences in opioid blockade effects were significantly associated with the degree of acute morphine-related reductions in back pain on all measures, even after controlling for effects of age, sex, and chronic pain duration (P < 0.03). Individuals exhibiting greater endogenous opioid inhibition of chronic back pain intensity reported less acute relief of back pain with morphine. CONCLUSIONS Morphine appears to provide better acute relief of chronic back pain in individuals with lower natural opioidergic inhibition of chronic pain intensity. Possible implications for personalized medicine are discussed.
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Szychowski J, Truchon JF, Bennani YL. Natural products in medicine: transformational outcome of synthetic chemistry. J Med Chem 2014; 57:9292-308. [PMID: 25144261 DOI: 10.1021/jm500941m] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
This review brings to the forefront key synthetic modifications on natural products (NPs) that have yielded successful drugs. The emphasis is placed on the power of targeted chemical transformations in enhancing the therapeutic value of NPs through optimization of pharmacokinetics, stability, potency, and/or selectivity. Multiple classes of NPs such as macrolides, opioids, steroids, and β-lactams used to treat a variety of conditions such as cancers, infections, inflammation are exemplified. Molecular modeling or X-ray structures of NP/protein complexes supporting the observed boost in therapeutic value of the modified NPs are also discussed. Significant advancement in synthetic chemistry, in structure determination, and in the understanding of factors controlling pharmacokinetics can now better position drug discovery teams to undertake NPs as valuable leads. We hope that the beneficial NPs synthetic modifications outlined here will reignite medicinal chemists' interest in NPs and their derivatives.
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Affiliation(s)
- Janek Szychowski
- Vertex Pharmaceuticals (Canada), Inc. , 275 Armand-Frappier, Laval, Québec H7V 4A7, Canada
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Endogenous opioid function mediates the association between laboratory-evoked pain sensitivity and morphine analgesic responses. Pain 2013; 154:1856-1864. [PMID: 23748117 DOI: 10.1016/j.pain.2013.06.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 05/21/2013] [Accepted: 06/03/2013] [Indexed: 01/12/2023]
Abstract
Predictors of responsiveness to opioid analgesic medications are not well understood. This study tested whether individual differences in endogenous opioid (EO) function are associated with analgesic responsiveness to morphine. In randomized, counterbalanced order over 3 sessions, 45 chronic low back pain participants and 31 healthy controls received an opioid antagonist (8 mg naloxone), morphine (0.08 mg/kg), or placebo. Participants then engaged in 2 laboratory-evoked pain tasks (ischemic and thermal). Outcomes included pain threshold, pain tolerance, and pain ratings. Indexes of EO function and morphine analgesic responsiveness were derived for each measure as the difference in pain responses between the placebo condition and naloxone or morphine condition, respectively. For all 7 pain measures across the 2 laboratory pain tasks, greater EO function was associated with significantly lower morphine analgesic responsiveness (P<0.001-P=0.02). Morphine reduced pain responses of low EO individuals to levels similar to those of high EO individuals receiving placebo. Higher placebo condition-evoked pain sensitivity was associated with significantly greater morphine analgesic responsiveness for 5 of 7 pain measures (P<0.001-P=0.02). These latter associations were significantly mediated by EO function for 4 of these 5 pain outcomes (all P values<0.05). In the laboratory-evoked pain context, opioid analgesic medications may supplement inadequate EO analgesia, with little incremental benefit in those with preexisting high EO function. Implications for personalized medicine are discussed.
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Augmented breaths ('sighs') are suppressed by morphine in a dose-dependent fashion via naloxone-sensitive pathways in adult rats. Respir Physiol Neurobiol 2012; 185:296-303. [PMID: 23043875 DOI: 10.1016/j.resp.2012.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 09/27/2012] [Accepted: 09/28/2012] [Indexed: 01/02/2023]
Abstract
Morphine treatment can eliminate augmented breaths (ABs; 'sighs') during spontaneous breathing. In the present study, unanesthetized rats were studied to: (1) determine the involvement of naloxone-sensitive receptor pathways, and (2) establish the dose-response relationship of this side effect. At a dosage of 5mg/kg (2-10mg/kg is recommended range for analgesia) morphine eliminated ABs from the breathing rhythm across nearly 100 min post-administration (vs. 6.2 ± 1.6 ABs in 15 min, control condition, p<0.001). This occurred despite no apparent effect on indices of ventilation. By contrast, when naloxone was co-administered with morphine, the occurrence of ABs was not different compared to control. The suppression of ABs by morphine followed a sigmoidal pattern across the low-mid dosage range (R(2)=0.83), whereas tidal volume and breathing frequency were unaffected. We conclude that the opioid-induced suppression of ABs is mediated by naloxone-sensitive opioid receptor pathways, and that this side effect is potent across the low-mid dosage range, and cannot be simply avoided by restricting dosage.
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Role of the Opioid System in the Modulation of Thermonociceptive Sensitivity of Mollusks Affected by Weak Electromagnetic Factors. NEUROPHYSIOLOGY+ 2012. [DOI: 10.1007/s11062-012-9234-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Bell HJ, Azubike E, Haouzi P. The "other" respiratory effect of opioids: suppression of spontaneous augmented ("sigh") breaths. J Appl Physiol (1985) 2011; 111:1296-303. [PMID: 21868678 DOI: 10.1152/japplphysiol.00335.2011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The purpose of this study was to examine the effects of a clinically relevant opioid on the production of augmented breaths (ABs) in unanesthetized animals breathing normal room air, using a dosage which does not depress breathing. To do this we monitored breathing noninvasively, in unrestrained animals before and after subcutaneous injection of either morphine, or a saline control. The effect of ketamine/xylazine was also studied to determine the potential effect of an alternative sedative agent. Last, the effect of naloxone was studied to determine the potential influence of endogenous opioids in regulating the normal incidence of ABs. Morphine (5 mg/kg) had no depressive effect on breathing, but completely eliminated ABs in all animals in room air (P = 0.027). However, when animals breathed hypoxic air (10% O(2)), animals did express ABs, although their incidence was still reduced by morphine (P < 0.001). This was not a result of sedation per se, as ABs continued at their normal rate in room air during sedation with ketamine. Naloxone had no effect on breathing or AB production, and so endogenous opioids are not likely involved in regulating their rate of production under normal conditions. Our results show that in unanesthetized animals breathing normal room air, a clinically relevant opioid eliminates ABs, even at a dose that does not cause respiratory depression. Despite this, hypoxia-induced stimulation of breathing can facilitate the production of ABs even with the systemic opioid present, indicating that peripheral chemoreceptor stimulation provides a potential means of overcoming the opioid-induced suppression of these respiratory events.
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Affiliation(s)
- Harold J Bell
- Div. of Pulmonary and Critical Care Medicine, Penn State College of Medicine, Hershey, PA 17033-0850, USA.
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Jiang H, Wang Y, Shet MS, Zhang Y, Zenke D, Fast DM. Development and validation of a sensitive LC/MS/MS method for the simultaneous determination of naloxone and its metabolites in mouse plasma. J Chromatogr B Analyt Technol Biomed Life Sci 2011; 879:2663-8. [PMID: 21798826 DOI: 10.1016/j.jchromb.2011.06.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 06/27/2011] [Accepted: 06/27/2011] [Indexed: 10/18/2022]
Abstract
A rapid, specific, and reliable LC-MS/MS based bioanalytical method was developed and validated for the simultaneous determination of naloxone (NLX) and its two metabolites, 6β-naloxol (NLL) and naloxone-3β-D-glucuronide (NLG) in mouse plasma. The optimal chromatographic behavior of these analytes was achieved on an Aquasil C18 column (50 mm × 2.1 mm, 5 μm) using reversed phase chromatography. The total LC analysis time per injection was 2.5 min with a flow rate of 1.0 mL/min with gradient elution. Sample preparation via protein precipitation with acetonitrile in a 96-well format was applied for analyses of these analytes. The analytes were monitored by electrospray ionization in positive ion multiple reaction monitoring (MRM) mode. Modification of collision energy besides chromatographic separation was applied to further eliminate interference peaks for NLL and NLG. The method validation was conducted over the curve range of 0.200/0.400/0.500 to 100/200/250 ng/mL for NLX/NLL/NLG, respectively, using 0.0250 mL of plasma sample. The intra- and inter-day precision and accuracy of the quality control samples at low, medium, and high concentration levels showed ≤ 6.5% relative standard deviation (RSD) and -8.3 to -2.5% relative error (RE). The method was successfully applied to determine the concentrations of NLX, NLL, and NLG in incurred mouse plasma samples.
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Affiliation(s)
- Hongliang Jiang
- Tongji School of Pharmacy, Huazhong University of Science and Technology, 13 Hangkong Road, Wuhan 430030, Hubei, China.
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Jan WC, Chen CH, Hsu K, Tsai PS, Huang CJ. L-Type Calcium Channels and μ-Opioid Receptors are Involved in Mediating the Anti-Inflammatory Effects of Naloxone. J Surg Res 2011; 167:e263-72. [DOI: 10.1016/j.jss.2010.03.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Revised: 02/13/2010] [Accepted: 03/16/2010] [Indexed: 11/24/2022]
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Courtney J, Boyer E. Case files of the University of Massachusetts fellowship in medical toxicology: lethal dose of opioids contained in an elastomeric capsule labeled as vancomycin. J Med Toxicol 2008; 4:192-6. [PMID: 18821494 DOI: 10.1007/bf03161200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
UNLABELLED A 67 year-old male presented to the emergency department with alteration in mental status. On arrival he had vital signs: pulse 110, BP 173/83, respiratory rate 4, oxygen saturation 57% and temperature 36.1 degrees Celsius. His past medical history included hypertension, vitamin B12 deficiency, hyperlipidemia, and recurrent cellulitis treated with vancomycin. The patient had no response to noxious stimuli, pinpoint pupils, and agonal respirations. Secondary to his wife's vehement denial that he had access to or history of using any narcotics, he was intubated after 2.2mg IV naloxone failed to reverse respiratory depression. Thirty minutes before presentation, however, he had received an intravenous infusion of vancomycin administered by his wife at home. The vancomycin, obtained from a home infusion medication supply company, was contained in one of five sealed elastomeric capsules delivered earlier that day. A qualitative comprehensive toxicology screen of urine for 1043 substances identified morphine, codeine, naloxone, lidocaine and caffeine. The original elastomeric container was not available for testing, but another container from the same delivery was submitted for testing to the state forensic laboratory. This intact container was labeled as Vancomycin 1g in 240mL of normal saline. The forensic laboratory confirmed that the alkaloidal contents of the elastomeric capsule were 10% codeine, 4.4% 6-monoacetyl morphine, and 84% morphine. No vancomycin was identified in the infusion bottles. The case was referred to the local police department and the state department of health drug control board. The home infusion company was also immediately notified to prevent similar occurrence. CONCLUSION We are reporting the first known case of opioid overdose from an adulterated elastomeric capsule that was labeled as containing an antimicrobial agent.
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Affiliation(s)
- James Courtney
- Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical School, Worcester, MA 01655, USA.
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van Dorp ELA, Yassen A, Dahan A. Naloxone treatment in opioid addiction: the risks and benefits. Expert Opin Drug Saf 2007; 6:125-32. [PMID: 17367258 DOI: 10.1517/14740338.6.2.125] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Naloxone is a non-selective, short-acting opioid receptor antagonist that has a long clinical history of successful use and is presently considered a safe drug over a wide dose range (up to 10 mg). In opioid-dependent patients, naloxone is used in the treatment of opioid-overdose-induced respiratory depression, in (ultra)rapid detoxification and in combination with buprenorphine for maintenance therapy (to prevent intravenous abuse). Risks related to naloxone use in opioid-dependent patients are: i) the induction of an acute withdrawal syndrome (the occurrence of vomiting and aspiration is potentially life threatening); ii) the effect of naloxone may wear off prematurely when used for treatment of opioid-induced respiratory depression; and iii) in patients treated for severe pain with an opioid, high-dose naloxone and/or rapidly infused naloxone may cause catecholamine release and consequently pulmonary edema and cardiac arrhythmias. These risks warrant the cautious use of naloxone and adequate monitoring of the cardiorespiratory status of the patient after naloxone administration where indicated.
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Affiliation(s)
- Eveline L A van Dorp
- Leiden University Medical Center, Department of Anesthesiology, RC Leiden, The Netherlands
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Chuyan EN, Dzheldubayeva ÉR. Roles of different neurochemical systems in mechanisms underlying the antinociceptive effect of extrahigh-frequency electromagnetic radiation. NEUROPHYSIOLOGY+ 2007. [DOI: 10.1007/s11062-007-0020-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Zhang Q, Rich JO, Cotterill IC, Pantaleone DP, Michels PC. 14-Hydroxylation of Opiates: Catalytic Direct Autoxidation of Codeinone to 14-Hydroxycodeinone. J Am Chem Soc 2005; 127:7286-7. [PMID: 15898757 DOI: 10.1021/ja051682z] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Codeinone (3) was efficiently and directly converted to 14-hydroxycodeinone (1) by catalytic air oxidation in aqueous solution. A number of simple manganese and copper salts were identified to be effective catalysts, including MnSO4, KMnO4, and CuSO4. An appropriate reducing agent, such as sodium thiosulfate, is required in the reaction mixture presumably for the reduction of a detrimental peroxide intermediate. This discovery allows the more abundant codeine to be employed as the starting material for the synthesis of 14-hydroxylated opiate drugs without recourse to a thebaine-like intermediate. These discoveries were inspired from our study of microbial transformation of codeine to 14-hydroxycodeine by Mycobacterium neoaurum, where we found the actual 14-hydroxylation step is a chemical reaction rather than an enzymatic reaction, as previously believed.
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Affiliation(s)
- Qibo Zhang
- Albany Molecular Research, Inc., Bioscience Division, Albany, New York 12212-5098, USA
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Lewanowitsch T, Irvine RJ. Naloxone methiodide reverses opioid-induced respiratory depression and analgesia without withdrawal. Eur J Pharmacol 2002; 445:61-7. [PMID: 12065195 DOI: 10.1016/s0014-2999(02)01715-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Illicit opioid overdoses are a significant problem throughout the world, with most deaths being attributed to opioid-induced respiratory depression which may involve peripheral mechanisms. The current treatment for overdoses is naloxone hydrochloride, which is effective but induces significant withdrawal. We propose that selectively peripherally acting opioid receptor antagonists, such as naloxone methiodide, could reverse respiratory depression without inducing predominantly centrally mediated withdrawal. Acute administration of morphine (300 mg/kg, i.p.) was found to significantly depress respiratory rate and induce analgesia (P<0.0001). Both naloxone hydrochloride and naloxone methiodide were able to reverse these effects but naloxone methiodide precipitated no significant withdrawal. Naloxone methiodide was also able to reverse opioid-induced respiratory depression (P<0.001) and antinociception (P<0.01) after chronic morphine administration (300 mg/kg/day for 5 days) without inducing significant withdrawal. Therefore, peripherally selective opioid receptor antagonists should be investigated as possible treatments for opioid-induced respiratory depression which do not induce adverse effects, such as withdrawal.
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Affiliation(s)
- Tanya Lewanowitsch
- Department of Clinical and Experimental Pharmacology, University of Adelaide, 5th Floor Medical School North, Adelaide, South Australia 5005, Australia.
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Pedrón N, González-Unzaga M, Galván RE, Fonseca ME. Effect of naloxone on serum prolactin levels in adult male rabbits. Life Sci 1998; 63:485-8. [PMID: 9718072 DOI: 10.1016/s0024-3205(98)00297-5] [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: 02/08/2023]
Abstract
In order to clarify the possible physiological role of endogenous opioid peptides (EOP), we studied the effect of low doses of naloxone (specific opiate antagonist) on plasma prolactin levels in male rabbits. Five groups of five male rabbits each was injected daily between 8-9 a.m., with naloxone 12.5, 25, 50, 100 and 200 microg/kg/day. An additional group of ten animals was injected with saline solution and considered the control group. Blood samples were taken at baseline before naloxone administration and later at 90 min and 1, 2, 4, 7, 10 days after its administration. Samples were also taken 4 days after stopping naloxone administration (day 14). Plasma prolactin levels were measured by RIA. A significant constant decrease in PRL levels was seen with the 12.5 microg at 90 minutes, while with the remaining doses a progressive decrease was recorded throughout the study.
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Affiliation(s)
- N Pedrón
- Unidad de Investigación Médica en Biologia de la Reproducción, Instituto Mexicxano del Seguro Social, México, DF
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Coop A, Janetka JW, Lewis JW, Rice KC. L-Selectride as a General Reagent for the O-Demethylation and N-Decarbomethoxylation of Opium Alkaloids and Derivatives1. J Org Chem 1998. [DOI: 10.1021/jo9801972] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Andrew Coop
- Laboratory of Medicinal Chemistry, National Institute of Diabetes, Digestive and Kidney Diseases, Building 8, Room B1-23, Bethesda, Maryland 20892-0815, and School of Chemistry, University of Bristol, Cantock's Close, Bristol, BS8 1TS, U.K
| | - James W. Janetka
- Laboratory of Medicinal Chemistry, National Institute of Diabetes, Digestive and Kidney Diseases, Building 8, Room B1-23, Bethesda, Maryland 20892-0815, and School of Chemistry, University of Bristol, Cantock's Close, Bristol, BS8 1TS, U.K
| | - John W. Lewis
- Laboratory of Medicinal Chemistry, National Institute of Diabetes, Digestive and Kidney Diseases, Building 8, Room B1-23, Bethesda, Maryland 20892-0815, and School of Chemistry, University of Bristol, Cantock's Close, Bristol, BS8 1TS, U.K
| | - Kenner C. Rice
- Laboratory of Medicinal Chemistry, National Institute of Diabetes, Digestive and Kidney Diseases, Building 8, Room B1-23, Bethesda, Maryland 20892-0815, and School of Chemistry, University of Bristol, Cantock's Close, Bristol, BS8 1TS, U.K
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Pedrón N, Pedroza D, Calzada L, Salazar L, Fuentes V. Effect of naloxone on serum testosterone in adult male rabbits. ARCHIVES OF ANDROLOGY 1996; 37:15-8. [PMID: 8827343 DOI: 10.3109/01485019608988497] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Considerable evidence suggests that endogenous opioids may play an important role in the hypothalamic LH-releasing hormone. Administration of high doses of naloxone, an opiate antagonist, produces an increase in plasma concentration of LH. Naltrexone administration to healthy males produces an increase in both immunoactive and bioactive LH. The objective of the present work was to assess the effect of low doses of naloxone during 10 consecutive days on testosterone serum levels in rabbit. Three groups of five rabbits were injected with naloxone or saline. Naloxone was tested at 0.1 and 0.01 mg/kg day-1. Blood samples were taken at 90 min and 1, 2, 4, 7, 10, and 14 days after starting naloxone administration. Plasma testosterone (T) levels were measured by RIA. T levels increased progressively through the study in the experimental groups. The differences were significant after days 4 and 7 for 0.01-mg/kg and 0.1-mg/kg doses, respectively. T levels in both groups peaked at day 10 and decreased at day 14 (4 days after treatment).
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Affiliation(s)
- N Pedrón
- Unidad de Investigación Médica en Biología de la Reproducción, IMSS, México DF, México
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Loimer N, Hofmann P, Chaudhry HR. Nasal administration of naloxone is as effective as the intravenous route in opiate addicts. THE INTERNATIONAL JOURNAL OF THE ADDICTIONS 1994; 29:819-27. [PMID: 8034388 DOI: 10.3109/10826089409047912] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Naloxone is used intravenously in opiate addiction in emergency cases, in rapid opiate detoxification, and as a diagnostic tool. This is a study comparing the efficacy of intranasal naloxone to other routes (intravenous/intramuscular) in 17 opiate-dependent patients. The nasal drug administration of naloxone was found to be as effective as the intravenous route. The nasal drug application offers a wide margin of safety for patients and medical staff, especially in emergency situations in regard to infection risks associated with vessel puncture.
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Affiliation(s)
- N Loimer
- Psychiatrische Universitätsklinik Wien, Austria
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Abstract
STUDY OBJECTIVES To investigate the time of onset and incidence of complications in patients presenting to the emergency department with an IV heroin overdose and the need for routine admission of such patients. METHODS A retrospective chart review of hospital and emergency medical service records of 124 patient visits involving IV heroin overdose over a five-month period. We also reviewed the death certificates of 115 persons having succumbed to a narcotic overdose over a 44-month period and compared these with our hospital records. SETTING Urban county hospital. TYPE OF PARTICIPANTS Patients presenting to the ED with an IV heroin overdose. RESULTS There were five deaths in the ED, 12 hospital admissions, and 107 patients who were discharged home. Neither delayed onset of pulmonary edema nor recurrence of respiratory depression was observed. Of the 115 persons having succumbed to a narcotic overdose, eight had been seen previously at our hospital for a heroin overdose. There is no evidence that any of these eight deaths would have been prevented by a 24-hour hospital observation period. CONCLUSION Complications arising from an IV overdose of heroin are usually evident on arrival in the ED or shortly thereafter. On retrospective review we have found no evidence that admission to the hospital and 24 hours of observation are of benefit to patients who are awake, alert, and lacking evidence of pulmonary complications after an IV heroin overdose.
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Affiliation(s)
- D A Smith
- Division of Emergency Medicine, Texas A&M University College of Medicine, College Station, Texas
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Abstract
In clinical trials, nasally applied naloxone was used to identify opiate dependence in humans for the first time. Withdrawal distress was recorded, and pupillary response, pulse rate and blood pressure measured. A significant increase in withdrawal distress and pupillary dilation was observed after nasal administration of 1mg (1mg/400 microliters) naloxone in all subjects who also showed opiate-positive urine samples. In control subjects, no reaction to naloxone was observed. It may be concluded that the nasal route for naloxone administration is as effective as the parenteral route. This test is sensitive enough to identify the physically-dependent opiate user and might have a role in emergency medicine and withdrawal treatment.
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Affiliation(s)
- N Loimer
- Psychiatrische Universitätsklinik Wien, Vienna, Austria
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Abstract
To determine whether sublingual naloxone could precipitate withdrawal in opioid-dependent subjects, naloxone was administered in increasing doses (0-8 mg in four or six sessions conducted over 2 days) to six heroin abusers and three methadone (30 mg/day, p.o.) maintenance patients. Two or three sessions were conducted per day with 2- to 2.5-h intervals between same-day sessions. Naloxone precipitated withdrawal in two of six heroin abusers and in all three methadone subjects. Naloxone is sufficiently absorbed sublingually to precipitate abstinence in dependent subjects, but naloxone doses up to 1-2 mg can be administered sublingually to opioid abusers/addicts without precipitating withdrawal.
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Affiliation(s)
- K L Preston
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21224
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Abstract
Overdose of pentazocine (Talwin), an agonist/antagonist opioid analgesic, is relatively uncommon. Fifty-seven cases occurring over ten years are reported. Twenty-three patients (40%) had ingested only pentazocine and did not have the classic opioid toxidrome of CNS and respiratory depression with miosis. Most patients were awake, and no patient had a respiratory rate below 12/minute. Other findings included: grand mal seizures, hypertension, hypotonia, dysphoria, hallucinations, delusions, and agitation. Eleven of 23 patients received IV naloxone (0.4-2.4 mg), but only two showed improvement. Thirty-four patients (60%) had coingested pentazocine with one to five additional substances. Patients who had ingested pentazocine with alcohol, a sedative/hypnotic drug, or an antihistamine, showed increased toxicity, including apnea, deep coma, and recurrent seizures. One patient developed opioid pulmonary edema. One patient died. Three of five patients with coma and inadequate respirations responded to IV naloxone in doses of 0.4 to 1.2 mg.
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Affiliation(s)
- K R Challoner
- Department of Emergency Medicine, Los Angeles County/University of Southern California Medical Center 90033
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