Non-Opioid Treatments for Opioid Use Disorder: Rationales and Data to Date

Treadmill exercise training inhibits morphine CPP by reversing morphine effects on GABA neurotransmission in D2-MSNs of the accumbens-pallidal pathway in male mice

Relapse is a major challenge in the treatment of drug addiction, and exercise has been shown to decrease relapse to drug seeking in animal models. However, the neural circuitry mechanisms by which exercise inhibits morphine relapse remain unclear. In this study, we report that 4-week treadmill training prevented morphine conditioned place preference (CPP) expression during abstinence by acting through the nucleus accumbens (NAc)-ventral pallidum (VP) pathway. We found that neuronal excitability was reduced in D2-dopamine receptor-expressing medium spiny neurons (D2-MSNs) following repeated exposure to morphine and forced abstinence. Enhancing the excitability of NAc D2-MSNs via treadmill training decreased the expression of morphine CPP. We also found that the effects of treadmill training were mediated by decreasing enkephalin levels and that restoring opioid modulation of GABA neurotransmission in the VP, which increased neurotransmitter release from NAc D2-MSNs to VP, decreased morphine CPP. Our findings suggest the inhibitory effect of exercise on morphine CPP is mediated by reversing morphine-induced neuroadaptations in the NAc-to-VP pathway.

Exploring factors jointly associated with recurrent relapse and dropout of methadone maintenance treatment clients in Guangdong, China: A retrospective cohort study

BACKGROUND

Clients receiving methadone maintenance treatment (MMT) may experience multiple relapses, which may lead to dropout. However, previous studies mostly only explored the influencing factors of relapse or dropout separately. In this study, we investigated the influencing factors jointly associated with both recurrent relapse and dropout.

METHODS

This study was conducted in 16 MMT clinics in Guangdong, China. Data on the clients' demographic characteristics; drug-related behavior; HIV, HCV, and urine morphine test results; and daily methadone doses were collected. The outcomes were time to recurrent relapse and time to dropout. A joint frailty model was used to explore factors jointly associated with recurrent relapse and dropout. The hazard ratios (HRs) of the covariates in the multivariable model were adjusted, with HR > 1 indicating a faster time to recurrent relapse and dropout.

RESULTS

Among 1539 clients, 39.5% had ≥ 2 relapse events, and 90.8% of the clients dropped out. A high attendance rate was protective for recurrent relapse (HR_50-80%=0.63, 95% CI: 0.51, 0.79; HR_>80%=0.35, 95% CI: 0.28, 0.44) and dropout (HR_50-80%=0.56, 95% CI: 0.47, 0.68; HR_>80%=0.27, 95% CI: 0.23, 0.33). Being married (HR=0.80, 95% CI: 0.67, 0.96), having a fair relationship with family (HR=0.79, 95% CI: 0.67, 0.93) and drug injection (HR=0.80, 95% CI: 0.67, 0.96) were also protective for recurrent relapse. Female (HR=0.64, 95% CI: 0.50, 0.82) and a high methadone dose (≥60 ml/day; HR=0.79, 95% CI: 0.65, 0.96) were protective for dropout, and a longer traveling time to the clinic (>60 min; HR=1.59, 95% CI: 1.20, 2.10) was associated with an increased risk of dropout.

CONCLUSIONS

It is common for clients to experience recurrent relapse and dropout. The findings suggest that MMT clinics should provide holistic interventions and appropriate methadone doses for clients to improve treatment compliance.

Negative allosteric modulation of CB1 cannabinoid receptor signaling suppresses opioid-mediated reward

Blockade of cannabinoid type 1 (CB₁)-receptor signaling decreases the rewarding properties of many drugs of abuse and has been proposed as an anti-addiction strategy. However, psychiatric side-effects limit the clinical potential of orthosteric CB₁ antagonists. Negative allosteric modulators (NAMs) represent a novel and indirect approach to attenuate CB₁ signaling by decreasing affinity and/or efficacy of CB₁ ligands. We hypothesized that a CB₁-NAM would block opioid reward while avoiding the unwanted effects of orthosteric CB₁ antagonists. GAT358, a CB₁-NAM, failed to elicit cardinal signs of direct CB₁ activation or inactivation when administered by itself. GAT358 decreased catalepsy and hypothermia but not antinociception produced by the orthosteric CB₁ agonist CP55,940, suggesting that a CB₁-NAM blocked cardinal signs of CB₁ activation. Next, GAT358 was evaluated using in vivo assays of opioid-induced dopamine release and reward in male rodents. In the nucleus accumbens shell, a key component of the mesocorticolimbic reward pathway, morphine increased electrically-evoked dopamine efflux and this effect was blocked by a dose of GAT358 that lacked intrinsic effects on evoked dopamine efflux. Moreover, GAT358 blocked morphine-induced reward in a conditioned place preference (CPP) assay without producing reward or aversion alone. GAT358-induced blockade of morphine CPP was also occluded by GAT229, a CB₁ positive allosteric modulator (CB₁-PAM), and absent in CB₁-knockout mice. Finally, GAT358 also reduced oral oxycodone (but not water) consumption in a two-bottle choice paradigm. Our results support the therapeutic potential of CB₁-NAMs as novel drug candidates aimed at preventing opioid reward and treating opioid abuse while avoiding unwanted side-effects.

Astrocytes in the ventral pallidum extinguish heroin seeking through GAT-3 upregulation and morphological plasticity at D1-MSN terminals

GABAergic projections from the nucleus accumbens core to the dorsolateral ventral pallidum are necessary for drug-conditioned cues to initiate relapse-like drug seeking. Astrocytes in the ventral pallidum are situated perisynaptically and regulate GABA transmission through expression of GABA uptake transporters, but whether they are involved in regulating drug seeking is unknown. To determine the contribution of ventral pallidal astrocytes to heroin seeking, we labeled astrocytes in male and female rats with a membrane-bound fluorescent tag and used confocal microscopy to quantify astroglial expression of the GABA transporter GAT-3 and astrocyte synaptic proximity after withdrawal from heroin self-administration and during 15 min of cued heroin seeking. We found that GAT-3 was upregulated in rats that had extinguished heroin seeking, but not in animals that were withdrawn from heroin without extinction training or in rats that extinguished sucrose seeking. When GAT-3 upregulation was reversed using a vivo-morpholino oligo, heroin seeking was restored in the extinguished context and extinction of cued heroin seeking was disrupted compared to control animals. Although astrocyte synaptic proximity was not altered overall after heroin withdrawal, examination of astrocyte proximity to accumbens D1- or D2-expressing afferents revealed a selective increase in astrocyte proximity with D1-expressing terminals during extinction of heroin self-administration. Experimentally-induced reduction of astrocyte synaptic proximity through knockdown of the astrocyte-selective actin-binding protein ezrin also markedly disrupted extinction of heroin seeking. Notably, GAT-3 or ezrin knockdown had no impact on context- or cue-induced seeking in sucrose-trained animals. These data show that astrocytes in the ventral pallidum undergo plasticity after extinction of heroin use that reduces seeking and highlight the importance of astrocyte-neuron interactions in shaping behaviors associated with opioid use disorder.

Non-Opioid Peptides Targeting Opioid Effects

Opioids are the most potent widely used analgesics, primarily, but not exclusively, in palliative care. However, they are associated with numerous side effects, such as tolerance, addiction, respiratory depression, and cardiovascular events. This, in turn, can result in their overuse in cases of addiction, the need for dose escalation in cases of developing tolerance, and the emergence of dose-related opioid toxicity, resulting in respiratory depression or cardiovascular problems that can even lead to unintentional death. Therefore, a very important challenge for researchers is to look for ways to counteract the side effects of opioids. The use of peptides and their related compounds, which have been shown to modulate the effects of opioids, may provide such an opportunity. This short review is a compendium of knowledge about the most important and recent findings regarding selected peptides and their modulatory effects on various opioid actions, including cardiovascular and respiratory responses. In addition to the peptides more commonly reported in the literature in the context of their pro- and/or anti-opioid activity-such as neuropeptide FF (NPFF), cholecystokinin (CCK), and melanocyte inhibiting factor (MIF)-we also included in the review nociceptin/orphanin (N/OFQ), ghrelin, oxytocin, endothelin, and venom peptides.