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Coates S, Lazarus P. Hydrocodone, Oxycodone, and Morphine Metabolism and Drug-Drug Interactions. J Pharmacol Exp Ther 2023; 387:150-169. [PMID: 37679047 PMCID: PMC10586512 DOI: 10.1124/jpet.123.001651] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 09/09/2023] Open
Abstract
Awareness of drug interactions involving opioids is critical for patient treatment as they are common therapeutics used in numerous care settings, including both chronic and disease-related pain. Not only do opioids have narrow therapeutic indexes and are extensively used, but they have the potential to cause severe toxicity. Opioids are the classical pain treatment for patients who suffer from moderate to severe pain. More importantly, opioids are often prescribed in combination with multiple other drugs, especially in patient populations who typically are prescribed a large drug regimen. This review focuses on the current knowledge of common opioid drug-drug interactions (DDIs), focusing specifically on hydrocodone, oxycodone, and morphine DDIs. The DDIs covered in this review include pharmacokinetic DDI arising from enzyme inhibition or induction, primarily due to inhibition of cytochrome p450 enzymes (CYPs). However, opioids such as morphine are metabolized by uridine-5'-diphosphoglucuronosyltransferases (UGTs), principally UGT2B7, and glucuronidation is another important pathway for opioid-drug interactions. This review also covers several pharmacodynamic DDI studies as well as the basics of CYP and UGT metabolism, including detailed opioid metabolism and the potential involvement of metabolizing enzyme gene variation in DDI. Based upon the current literature, further studies are needed to fully investigate and describe the DDI potential with opioids in pain and related disease settings to improve clinical outcomes for patients. SIGNIFICANCE STATEMENT: A review of the literature focusing on drug-drug interactions involving opioids is important because they can be toxic and potentially lethal, occurring through pharmacodynamic interactions as well as pharmacokinetic interactions occurring through inhibition or induction of drug metabolism.
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Affiliation(s)
- Shelby Coates
- Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington
| | - Philip Lazarus
- Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington
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Muñoz-Muñoz AC, Pekol T, Schubring D, Johnson C, Andrade L. Identification of Novel Opioid Interferences using High-Resolution Mass Spectrometry†. J Anal Toxicol 2017; 42:6-16. [DOI: 10.1093/jat/bkx065] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 08/02/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Teresa Pekol
- Dominion Diagnostics, 211 Circuit Drive, North Kingstown, RI 02852, USA
| | - Dana Schubring
- Dominion Diagnostics, 211 Circuit Drive, North Kingstown, RI 02852, USA
| | - Charlene Johnson
- Dominion Diagnostics, 211 Circuit Drive, North Kingstown, RI 02852, USA
| | - Lawrence Andrade
- Dominion Diagnostics, 211 Circuit Drive, North Kingstown, RI 02852, USA
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DePriest AZ, Heltsley R, Black DL, Mitchell JM, LoDico C, Flegel R, Cone EJ. Prescription Opioids. VI. Metabolism and Excretion of Hydromorphone in Urine Following Controlled Single-Dose Administration. J Anal Toxicol 2016; 40:575-582. [PMID: 27405368 DOI: 10.1093/jat/bkw066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 05/05/2016] [Indexed: 11/13/2022] Open
Abstract
Hydromorphone (HM), a prescription opioid and metabolite of morphine and hydrocodone, has been included in proposed revisions to the Mandatory Guidelines for Federal Workplace Drug Testing Programs. This study characterized the time course of HM in hydrolyzed and non-hydrolyzed urine specimens. Twelve healthy subjects were administered a single 8 mg controlled-release HM dose, followed by periodic collection of pooled urine specimens for 54 h following administration. Analysis of total and free HM was conducted by liquid chromatography tandem mass spectrometry at a 50 ng/mL limit of quantitation. Detection periods were determined over a range of thresholds from 50 to 2,000 ng/mL. HM was detected in 85.3% and 47.6% of hydrolyzed and non-hydrolyzed post-dose specimens, respectively. Initial detection of total HM was frequently observed in the first 4-6 h following dosing. The period of detection at the 50 ng/mL threshold averaged 52.3 h for total HM and 38.0 h for free HM. These data support that HM detection is optimized by using low thresholds (50-100 ng/mL) and including conjugated HM in the analysis.
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Affiliation(s)
- Anne Z DePriest
- Aegis Sciences Corporation, 515 Great Circle Road, Nashville, TN 37228, USA University of Tennessee Health Science Center, College of Pharmacy, 881 Madison Avenue, Memphis, TN 38163, USA
| | - Rebecca Heltsley
- Aegis Sciences Corporation, 515 Great Circle Road, Nashville, TN 37228, USA
| | - David L Black
- Aegis Sciences Corporation, 515 Great Circle Road, Nashville, TN 37228, USA Department of Pathology, Microbiology, and Immunology, Vanderbilt University, 1161 21st Avenue South, CC-3322 Medical Center North, Nashville, TN 37232, USA
| | - John M Mitchell
- RTI International, 3040 East Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709, USA
| | - Charles LoDico
- Substance Abuse and Mental Health Services Administration (SAMHSA), Division of Workplace Programs (DWP), 5600 Fishers Lane, Rockville 20857, MD, USA
| | - Ronald Flegel
- Substance Abuse and Mental Health Services Administration (SAMHSA), Division of Workplace Programs (DWP), 5600 Fishers Lane, Rockville 20857, MD, USA
| | - Edward J Cone
- Johns Hopkins School of Medicine, 733 North Broadway, Baltimore, MD 21205, USA
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Mankes RF, Silver CD. Quantitative study of controlled substance bedside wasting, disposal and evaluation of potential ecologic effects. THE SCIENCE OF THE TOTAL ENVIRONMENT 2013; 444:298-310. [PMID: 23274246 DOI: 10.1016/j.scitotenv.2012.11.096] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 10/03/2012] [Accepted: 11/28/2012] [Indexed: 06/01/2023]
Abstract
Drugs in wastewater arise from many sources. For health care, these include excretion and direct disposal (bedside wasting). The present study reports on the dispensing and wasting of 15 controlled substances (CS) at two health care facilities in Albany, NY over a nearly two year period. The study considered measures of ecotoxicity, drug metabolism, excretion and disposal of these CS. Potential alternatives to flushing of CS into wastewaters from healthcare facilities are discussed. Drug medication and waste collection records (12,345) included: numbers of drugs dispensed, returned and wasted. Overall, 8528 g of 15 CS were wasted. Three (midazolam, acetaminophen-codeine and fentanyl) accounted for 87.5% of the total wasted. Wasting varied by hospital, 14 CS at the academic medical center hospital and 8 at the surgical care center were wasted. Liquids were more frequently wasted than tablets or pills. Some combination drugs (acetaminophen (APAP)-codeine) were frequently (50% of drug dispensed) wasted while others were less wasted (APAP-hydrocodone-6.3%; APAP-oxycodone-1.3%). The 8 CS judged more hazardous to aquatic life were: APAP-codeine, APAP-hydrocodone, APAP-oxycodone, alprazolam, diazepam, fentanyl, midazolam, and testosterone. Ketamine, morphine, oxycodone and zolpidem were of lesser acute toxicity based on available LC50 values. These CS might provide a therapeutically equivalent alternative to the more environmentally harmful drugs. In health care facilities, professionals dispose of CS by bedside wasting into water or other receptacles. This can be avoided by returning CS to the hospital's pharmacy department, thence to a licensed distributor. Study of this process of drug wasting can identify opportunities for process improvements. We found 3 CS (APAP-codeine, midazolam and testosterone) where ½ to 1/3 of the drug was wasted and 5 others with 30 to 13% wasted. Knowledge of the adverse impacts from the release of highly toxic drugs into the environment might influence CS selection and disposal alternatives.
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Affiliation(s)
- Russell F Mankes
- Center for Neuropharmacology & Neuroscience, Albany Medical College, Department of Environmental Health & Safety (MC-96) Albany Medical Center 43 New Scotland Avenue, Albany, NY 12208, USA.
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Abstract
BACKGROUND The metabolism of opioids is critical to consider for multiple reasons. The most commonly prescribed opioid agents often have metabolites that are active and are the source of both analgesic activity and an increased incidence of adverse events. Many opioids are metabolized by cytochrome P450 enzymes. Polymorphisms in cytochrome P450 genes and inhibition or induction of cytochrome P450 enzymes by coadministered drugs may significantly impact the systemic concentration of opioids and their metabolites and the associated efficacy or adverse events. METHODS This is a narrative review of the metabolism of various opioids that will highlight the impact of their active metabolites, and the potential impact of cytochrome P450 activity on analgesic activity. RESULTS An understanding of "opioid metabolic machinery," cytochrome P450 activity, and drug-drug interactions in the context of opioid selection may benefit clinicians and patients alike. CONCLUSIONS A greater appreciation of the metabolism of commonly prescribed opioid analgesics and the impact of their active metabolites on efficacy and safety may aid prescribers in tailoring care for optimal outcomes.
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Caslavska J, Thormann W. Stereoselective determination of drugs and metabolites in body fluids, tissues and microsomal preparations by capillary electrophoresis (2000–2010). J Chromatogr A 2011; 1218:588-601. [DOI: 10.1016/j.chroma.2010.08.072] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Revised: 08/20/2010] [Accepted: 08/25/2010] [Indexed: 10/19/2022]
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Affiliation(s)
- David R P Guay
- Department of experimental and clinical pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota 55455, USA.
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Coller JK, Christrup LL, Somogyi AA. Role of active metabolites in the use of opioids. Eur J Clin Pharmacol 2008; 65:121-39. [PMID: 18958460 DOI: 10.1007/s00228-008-0570-y] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2008] [Accepted: 09/16/2008] [Indexed: 11/26/2022]
Abstract
The opioid class of drugs, a large group, is mainly used for the treatment of acute and chronic persistent pain. All are eliminated from the body via metabolism involving principally CYP3A4 and the highly polymorphic CYP2D6, which markedly affects the drug's function, and by conjugation reactions mainly by UGT2B7. In many cases, the resultant metabolites have the same pharmacological activity as the parent opioid; however in many cases, plasma metabolite concentrations are too low to make a meaningful contribution to the overall clinical effects of the parent drug. These metabolites are invariably more water soluble and require renal clearance as an important overall elimination pathway. Such metabolites have the potential to accumulate in the elderly and in those with declining renal function with resultant accumulation to a much greater extent than the parent opioid. The best known example is the accumulation of morphine-6-glucuronide from morphine. Some opioids have active metabolites but at different target sites. These are norpethidine, a neurotoxic agent, and nordextropropoxyphene, a cardiotoxic agent. Clinicians need to be aware that many opioids have active metabolites that will become therapeutically important, for example in cases of altered pathology, drug interactions and genetic polymorphisms of drug-metabolizing enzymes. Thus, dose individualisation and the avoidance of adverse effects of opioids due to the accumulation of active metabolites or lack of formation of active metabolites are important considerations when opioids are used.
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Affiliation(s)
- Janet K Coller
- Discipline of Pharmacology, School of Medical Sciences, University of Adelaide, Adelaide, 5005, Australia
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Gaspar A, Englmann M, Fekete A, Harir M, Schmitt-Kopplin P. Trends in CE-MS 2005–2006. Electrophoresis 2008; 29:66-79. [DOI: 10.1002/elps.200700721] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Song EJ, Babar SME, Oh E, Hasan MN, Hong HM, Yoo YS. CE at the omics level: Towards systems biology – An update. Electrophoresis 2008; 29:129-42. [DOI: 10.1002/elps.200700467] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Abstract
This paper is the 29th consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning 30 years of research. It summarizes papers published during 2006 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurological disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); and immunological responses (Section 17).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, CUNY, 65-30 Kissena Blvd., Flushing, NY 11367, United States.
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