Opioid pharmaceuticals and addiction: the issues, and research directions seeking solutions

Nalmefene Hydrochloride: Potential Implications for Treating Alcohol and Opioid Use Disorder

Nalmefene hydrochloride was first discovered as an opioid antagonist derivative of naltrexone in 1975. It is among the most potent opioid antagonists currently on the market and is differentiated from naloxone and naltrexone by its partial agonist activity at the kappa-opioid receptor which may benefit in the treatment of alcohol use disorder. Oral nalmefene has been approved in the European Union for treatment of alcohol use disorder since 2013. As of 2023, nalmefene is available in the United States as an intranasal spray for reversal of opioid overdose but is not approved for alcohol or opioid use disorder as a maintenance treatment. The substantially longer half-life of nalmefene and 5-fold higher binding affinity to opioid receptors makes it a superior agent over naloxone in the reversal of high potency synthetic opioids like fentanyl and the emerging nitazenes. Nalmefene presents with a comparable side effect profile to other opioid antagonists and should be considered for further development as a maintenance treatment for opioid and other substance use disorders.

Opioid ligands addressing unconventional binding sites and more than one opioid receptor subtype

Opioid receptors (ORs) represent one of the most significant groups of G-protein coupled receptor (GPCR) drug targets and also act as prototypical models for GPCR function. In a constant effort to develop drugs with less side effects, and tools to explore the ORs nature and function, various (poly)pharmacological ligand design approaches have been performed. That is, besides classical ligands, a great number of bivalent ligands (i.e. aiming on two distinct OR subtypes), univalent heteromer-selective ligands and bitopic and allosteric ligands have been synthesized for the ORs. The scope of our review is to present the most important of the aforementioned ligands, highlight their properties and exhibit the current state-of-the-art pallet of promising drug candidates or useful molecular tools for the ORs.

[Use of rapid-onset fentanyl preparations beyond indication : A random questionnaire survey among congress participants and pain physicians]

BACKGROUND

Despite publicised advice and warnings, there are only scant data on the non-indicated prescription of rapid-onset preparations of fentanyl (ROF) in non-cancer pain (NCP). Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation.

OBJECTIVE

Initiated by the Working Group Cancer Pain and supported by the German Pain Society, a random sample survey was conducted to assess the non-indicated use of ROF.

METHODS

The survey addressed attendees of pain conferences who were given the option to fill in the questionnaires outside the conference or online. Primary endpoints of the structured questionnaire were quantitative and qualitative items with regard to the prescription of ROF, while secondary endpoints were opioid-induced side effects.

RESULTS

Obtaining a response rate of 44% (132/300) and an additional 51 online questionnaires revealed that 165 (90%) respondents had knowledge of non-indicated prescriptions or were involved in these. Of these, 65% were clinicians and 17% worked in an outpatient capacity. In all, 22% were trained pain or palliative physicians. Approximately 1205 patients were assessed indirectly. The main causes for dispensing ROF included NCP entities such as back pain (44%), neuropathic pain (33%), head or facial pain (12%), and dyspnea (5%) in cancer pain or lack of break-through pain or basic medication (44%). Sedation (32%), nausea/vomiting (31%), constipation (16%) and insufficient analgesia (31%) were the mostly commonly reported adverse effects.

CONCLUSION

Despite the non-ambiguous indication for ROF, physicians often demonstrate inappropriate prescription behaviour. Iatrogenic misuse of ROF should be minimized. The rates of adverse effects of ROF seems to be in line with other opioids.

A temporal relationship between nonmedical opioid Use and major depression in the U.S.: A Prospective study from the National Epidemiological Survey on Alcohol and Related Conditions

BACKGROUND

Given the existing strong cross-sectional relationship between nonmedical opioid use (NMOU) and major depressive disorder (MDD), this study focused on the temporal relationship between NMOU and major depression.

METHODS

Data sources were derived from Wave 1 and Wave 2 of the National Epidemiological Survey on Alcohol and Related Conditions. Logistic regression was applied to predicted NMOU at the follow-up survey based on baseline MDD diagnosis and symptoms of MDD among the sample without lifetime NMOU at baseline (N=32,982). In parallel, we examined the relationship between past year NMOU at baseline and new onset of MDD diagnosis (N=28,649) and between past year NMOU at baseline and new onset of symptoms of MDD (N=23,214) among people without major depression diagnosis or symptoms at baseline.

RESULTS

MDD diagnosis (aOR=1.68, 95% CI=1.43, 1.98) and symptoms of major depression (aOR=1.25, 95% CI=1.14, 1.38) at baseline were associated with higher odds of incident NMOU. The baseline NMOU was associated with lower odds incident MDD diagnosis (aOR=0.79, 95%CI=0.66, 0.94) in the adjusted model. However, the baseline NMOU was associated with higher odds of new onset of major depressive symptoms at wave 2 in the sample without baseline symptoms of MDD (aOR=1.42, 95%CI=1.23, 1.63).

CONCLUSION

Symptoms of MDD and MDD diagnosis increased the new onset of NMOU, while NMOU only increased the risks of new onset of symptoms of MDD.

Anticonvulsant Effects of Thalidomide on Pentylenetetrazole-Induced Seizure in Mice: A Role for Opioidergic and Nitrergic Transmissions

Although accumulating evidence indicates that the immunomodulatory medication thalidomide exerts anticonvulsant properties, the mechanisms underlying such effects of thalidomide are still unknown. Our previous preclinical study suggested that nitric oxide (NO) signaling may be involved in the anticonvulsant effects of thalidomide in a mouse model of clonic seizure. Additionally, several studies have shown a modulatory interaction between thalidomide and opioids in opioids intolerance, nociception and neuropathic pain. However, it is unclear whether opioidergic transmission or its interaction with NO signaling is involved in the anticonvulsant effects of thalidomide. Given the fact that both opioidergic and nitrergic transmissions have bimodal modulatory effects on seizure thresholds, in the present study we explored the involvement of these signaling pathways in the possible anticonvulsant effects of thalidomide on the pentylenetetrazole (PTZ)-induced clonic seizure in mice. Our data showed that acute administration of thalidomide (5-50 mg/kg, i.p., 30 min prior PTZ injection) dose-dependently elevated PTZ-induced clonic seizure thresholds. Acute administration of low doses (0.5-3 mg/kg, i.p., 60 min prior PTZ) of morphine exerted anticonvulsant effects (P < 0.001), whereas higher doses (15-60 mg/kg, 60 min prior PTZ) had proconvulsant effects (P < 0.01). Acute administration of a non-effective anticonvulsant dose of morphine (0.25 mg/kg) prior non-effective dose of thalidomide (5 mg/kg) exerted a robust (P < 0.01) anticonvulsant effect. Administration of a non-effective proconvulsant dose of morphine (7.5 mg/kg) prior thalidomide (5 mg/kg) didn't affect clonic seizure thresholds. Acute administration of a non-effective dose of the opioid receptor antagonist naltrexone (1 mg/kg, i.p.) significantly prevented anticonvulsant effects of thalidomide (10 mg/kg, i.p.). Pretreatment with non-effective dose of the NO precursor L-arginine (60 mg/kg, i.p.) significantly (P < 0.01) reduced the anticonvulsant effects of combined low doses of morphine (0.25 mg/kg) and thalidomide (5 mg/kg). Conversely, pretreatment with non-effective doses of either non-selective (L-NAME, 5 mg/kg, i.p.) or selective neuronal (7-nitroindazole, 30 mg/kg, i.p.) NO synthase (NOS) inhibitors significantly augmented the anticonvulsant effects of combined low doses of thalidomide and morphine, whereas the inducible NOS inhibitor aminoguanidine (100 mg/kg, i.p.) did not exert such effect. Our results indicate that opioidergic transmission and its interaction with neuronal NO signaling may contribute to the anti-seizure activity of thalidomide in the mice PTZ model of clonic seizure.

Effect of fentanyl and its three novel analogues on biochemical, oxidative, histological, and neuroadaptive markers after sub-acute exposure in mice

AIMS

Comparative sub-acute toxicity, including tolerance and dependence potential of fentanyl and its three novel and potent analogues was determined in mice.

MAIN METHODS

Comparative sub-acute (21 d, intraperitoneal; 1/10 LD₅₀) toxicity of fentanyl and its three novel analogues viz., N-(1-(2-phenoxyethyl)-4-piperidinyl) propionanilide (2), N-isopropyl-3-(4-(N-phenylpropionamido)piperidin-1-yl)propanamide (5), and N-t-butyl-3-(4-(N-phenylpropionamido)piperidin-1-yl)propanamide (6) was determined in mice. Animals were observed for additional seven days to assess the recovery. The brain, liver and kidney toxicity was assessed on the basis of various biochemical, oxidative, histological, and neuroadaptive markers. The expression levels of key neuronal markers associated with drug tolerance and dependence were investigated by western blot and immunohistochemistry.

KEY FINDINGS

Fentanyl and its analogues caused abnormal levels of liver and kidney specific biomarkers in plasma. Brain malondialdehyde (MDA) levels were raised by all the treatments and kidney MDA level by analogue 6 (21 d). Reduced glutathione levels in brain, liver, and kidney were diminished by all the treatments (21 & 28 d) and a significant change in the levels of antioxidant enzymes was also produced mainly after 21 d. The deleterious effects of fentanyl and its analogues were further substantiated by corresponding histopathological changes in brain, liver and kidney (21 & 28 d). These compounds were also found to produce neuroadaptive changes as evidenced by the increased expression levels of c-Fos, glucocorticoid receptor, N-methyl-d-aspartate receptor1 and μ-opioid receptor (21 & 28 d).

SIGNIFICANCE

Three novel analogues of fentanyl were envisaged to have alternative therapeutic potentials. However, their comparative sub-acute toxicity revealed undesirable side effects, thereby masking their therapeutic ability.

Opioid addiction, diversion, and abuse in chronic and cancer pain

PURPOSE OF REVIEW

The primary cause of overdose death in the United States is related to pharmaceutical opioids. A few particular populations that struggle with adverse outcomes related to opioid abuse are those in palliative care, those with chronic pain, and those receiving pain treatments secondary to cancer or chemotherapy.

RECENT FINDINGS

There have been massive efforts to decrease the use of opioid abuse in patient care in a gestalt manner, but palliative care provides unique challenges in applying these reduction tactics used by other specialties.

SUMMARY

We explore behavioral interventions, provider education, alternative pain management techniques, postmarketing surveillance, and abuse-deterrent formulas as emerging methods to counteract opioid abuse in these populations.

Fentanyls and the safety of first responders: Science and recommendations

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.

Botulinum toxin: A review of the mode of action in migraine

Botulinum toxin serotype A (BoNT/A) was originally used in neurology for the treatment of dystonia and blepharospasms, but is now clinically used worldwide for the treatment of chronic migraine. Still, the possible mode of action of BoNT/A in migraine is not fully known. However, the mode of action of BoNT/A has been investigated in experimental pain as well as migraine models, which may elucidate the underlying mechanisms in migraine. The aim of this study was to review studies on the possible mode of action of BoNT/A in relation to chronic migraine treatment. Observations suggest that the mode of action of BoNT/A may not be limited to the injection site, but also includes anatomically connected sites due to axonal transport. The mechanisms behind the effect of BoNT/A in chronic migraine may also include modulation of neurotransmitter release, changes in surface expression of receptors and cytokines as well as enhancement of opioidergic transmission. Clinical and experimental studies with botulinum toxin in the last decade have advanced our understanding of headache and other pain states. More research into botulinum toxin as treatment for headache is warranted as it can be an attractive alternative for patients who do not respond positively to other drugs.

Suppression of RGSz1 function optimizes the actions of opioid analgesics by mechanisms that involve the Wnt/β-catenin pathway

Regulator of G protein signaling z1 (RGSz1), a member of the RGS family of proteins, is present in several networks expressing mu opioid receptors (MOPRs). By using genetic mouse models for global or brain region-targeted manipulations of RGSz1 expression, we demonstrated that the suppression of RGSz1 function increases the analgesic efficacy of MOPR agonists in male and female mice and delays the development of morphine tolerance while decreasing the sensitivity to rewarding and locomotor activating effects. Using biochemical assays and next-generation RNA sequencing, we identified a key role of RGSz1 in the periaqueductal gray (PAG) in morphine tolerance. Chronic morphine administration promotes RGSz1 activity in the PAG, which in turn modulates transcription mediated by the Wnt/β-catenin signaling pathway to promote analgesic tolerance to morphine. Conversely, the suppression of RGSz1 function stabilizes Axin2-Gαz complexes near the membrane and promotes β-catenin activation, thereby delaying the development of analgesic tolerance. These data show that the regulation of RGS complexes, particularly those involving RGSz1-Gαz, represents a promising target for optimizing the analgesic actions of opioids without increasing the risk of dependence or addiction.

Discovery of SHR9352: A Highly Potent G Protein-Biased μ-Opioid Receptor Agonist

Recently, targeting the G protein-biased signaling has emerged as an attractive therapeutic strategy for treating severe acute pain with the potential to reduce the side effect of the traditional opioid drug. Herein, we describe the discovery of a highly potent G protein-biased μ-opioid receptor (MOR) agonist, SHR9352. This novel molecule exhibited excellent MOR activity and limited β-arrestin recruitment, as well as a high selectivity over κ-opioid receptor and δ-opioid receptor demonstrated robust in vivo efficacy and displayed favorable pharmacokinetic properties across species.

Differential Desensitization Observed at Multiple Effectors of Somatic μ-Opioid Receptors Underlies Sustained Agonist-Mediated Inhibition of Proopiomelanocortin Neuron Activity

Activation of somatic μ-opioid receptors (MORs) in hypothalamic proopiomelanocortin (POMC) neurons leads to the activation of G-protein-coupled inward rectifier potassium (GIRK) channels and hyperpolarization, but in response to continued signaling MORs undergo acute desensitization resulting in robust reduction in the peak GIRK current after minutes of agonist exposure. We hypothesized that the attenuation of the GIRK current would lead to a recovery of neuronal excitability whereby desensitization of the receptor would lead to a new steady state of POMC neuron activity reflecting the sustained GIRK current observed after the initial decline from peak with continued agonist exposure. However, electrophysiologic recordings and GCaMP6f Ca²⁺ imaging in POMC neurons in mouse brain slices indicate that maximal inhibition of cellular activity by these measures can be maintained after the GIRK current declines. Blockade of the GIRK current by Ba²⁺ or Tertiapin-Q did not disrupt the sustained inhibition of Ca²⁺ transients in the continued presence of agonist, indicating the activation of an effector other than GIRK channels. Use of an irreversible MOR antagonist and Furchgott analysis revealed a low receptor reserve for the activation of GIRK channels but a >90% receptor reserve for the inhibition of Ca²⁺ events. Altogether, the data show that somatodendritic MORs in POMC neurons inhibit neuronal activity through at least two effectors with distinct levels of receptor reserve and that differentially reflect receptor desensitization. Thus, in POMC cells, the decline in the GIRK current during prolonged MOR agonist exposure does not reflect an increase in cellular activity as expected.SIGNIFICANCE STATEMENT Desensitization of the μ-opioid receptor (MOR) is thought to underlie the development of cellular tolerance to opiate therapy. The present studies focused on MOR desensitization in hypothalamic proopiomelanocortin (POMC) neurons as these neurons produce the endogenous opioid β-endorphin and are heavily regulated by opioids. Prolonged activation of somatic MORs in POMC neurons robustly inhibited action potential firing and Ca²⁺ activity despite desensitization of the MOR and reduced activation of a potassium current over the same time course. The data show that somatic MORs in POMC neurons couple to multiple effectors that have differential sensitivity to desensitization of the receptor. Thus, in these cells, the cellular consequence of MOR desensitization cannot be defined by the activity of a single effector system.

RGS9-2 Modulates Responses to Oxycodone in Pain-Free and Chronic Pain States

Regulator of G-protein signaling 9-2 (RGS9-2) is a striatal-enriched signal-transduction modulator known to have a critical role in the development of addiction-related behaviors following exposure to psychostimulants or opioids. RGS9-2 controls the function of several G-protein-coupled receptors, including dopamine receptor and mu opioid receptor (MOR). We previously showed that RGS9-2 complexes negatively control morphine analgesia, and promote the development of morphine tolerance. In contrast, RGS9-2 positively modulates the actions of other opioid analgesics, such as fentanyl and methadone. Here we investigate the role of RGS9-2 in regulating responses to oxycodone, an MOR agonist prescribed for the treatment of severe pain conditions that has addictive properties. Using mice lacking the Rgs9 gene (RGS9KO), we demonstrate that RGS9-2 positively regulates the rewarding effects of oxycodone in pain-free states, and in a model of neuropathic pain. Furthermore, although RGS9-2 does not affect the analgesic efficacy of oxycodone or the expression of physical withdrawal, it opposes the development of oxycodone tolerance, in both acute pain and chronic neuropathic pain models. Taken together, these data provide new information on the signal-transduction mechanisms that modulate the rewarding and analgesic actions of oxycodone.

How Oliceridine (TRV-130) Binds and Stabilizes a μ-Opioid Receptor Conformational State That Selectively Triggers G Protein Signaling Pathways

Substantial attention has recently been devoted to G protein-biased agonism of the μ-opioid receptor (MOR) as an ideal new mechanism for the design of analgesics devoid of serious side effects. However, designing opioids with appropriate efficacy and bias is challenging because it requires an understanding of the ligand binding process and of the allosteric modulation of the receptor. Here, we investigated these phenomena for TRV-130, a G protein-biased MOR small-molecule agonist that has been shown to exert analgesia with less respiratory depression and constipation than morphine and that is currently being evaluated in human clinical trials for acute pain management. Specifically, we carried out multimicrosecond, all-atom molecular dynamics (MD) simulations of the binding of this ligand to the activated MOR crystal structure. Analysis of >50 μs of these MD simulations provides insights into the energetically preferred binding pathway of TRV-130 and its stable pose at the orthosteric binding site of MOR. Information transfer from the TRV-130 binding pocket to the intracellular region of the receptor was also analyzed, and was compared to a similar analysis carried out on the receptor bound to the classical unbiased agonist morphine. Taken together, these studies lead to a series of testable hypotheses of ligand-receptor interactions that are expected to inform the structure-based design of improved opioid analgesics.

Neurobiology of opioid dependence in creating addiction vulnerability

Opioid drugs are potent modulators of many physiological and psychological processes. When given acutely, they can elicit the signature responses of euphoria and analgesia that societies have coveted for centuries. Repeated, or chronic, use of opioids induces adaptive or allostatic changes that modify neuronal circuitry and create an altered normality — the “drug-dependent” state. This state, at least that exhibited by those maintained continuously on long-acting opioid drugs such as methadone or buprenorphine, is generally indistinguishable from the drug-naïve state for most overt behaviors. The consequences of the allostatic changes (cellular, circuit, and system adaptations) that accompany the drug-dependent state are revealed during drug withdrawal. Drug cessation triggers a temporally orchestrated allostatic re-establishment of neuronal systems, which is manifested as opposing physiological and psychological effects to those exhibited by acute drug intoxication. Some withdrawal symptoms, such as physical symptoms (sweating, shaking, and diarrhea) resolve within days, whilst others, such as dysphoria, insomnia, and anxiety, can linger for months, and some adaptations, such as learned associations, may be established for life. We will briefly discuss the cellular mechanisms and neural circuitry that contribute to the opioid drug-dependent state, inferring an emerging role for neuroinflammation. We will argue that opioid addictive behaviors result from a learned relationship between opioids and relief from an existing or withdrawal-induced anxiogenic and/or dysphoric state. Furthermore, a future stressful life event can recall the memory that opioid drugs alleviate negative affect (despair, sadness, and anxiety) and thereby precipitate craving, resulting in relapse. A learned association of relief of aversive states would fuel drug craving in vulnerable people living in an increasingly stressful society. We suggest that this route to addiction is contributive to the current opioid epidemic in the USA.

Switching off pain at the source: is this the end for opioid pain relief?

Opiates, like morphine or codeine, are used to suppress nociceptive pain in humans. While these drugs can provide effective pain relief, they also cause an extensive array of undesirable side effects, including central depression, sedation and addiction. Relatively recently, the sodium channel Nav1.7 was shown to be essential for pain perception in humans. Based on this, we describe a new technical approach that may be useful for the prolonged suppression of nociceptive pain. The technique uses a harmless adeno-associated virus carrying a short hairpin RNA to silence Nav1.7 ion channels only in sensory neurons underlying pain perception. The major advantage is that pain may be suppressed at the source for many months, without the side effects of opiates.

Fluorescent knock-in mice to decipher the physiopathological role of G protein-coupled receptors

G protein-coupled receptors (GPCRs) modulate most physiological functions but are also critically involved in numerous pathological states. Approximately a third of marketed drugs target GPCRs, which places this family of receptors in the main arena of pharmacological pre-clinical and clinical research. The complexity of GPCR function demands comprehensive appraisal in native environment to collect in-depth knowledge of receptor physiopathological roles and assess the potential of therapeutic molecules. Identifying neurons expressing endogenous GPCRs is therefore essential to locate them within functional circuits whereas GPCR visualization with subcellular resolution is required to get insight into agonist-induced trafficking. Both remain frequently poorly investigated because direct visualization of endogenous receptors is often hampered by the lack of appropriate tools. Also, monitoring intracellular trafficking requires real-time visualization to gather in-depth knowledge. In this context, knock-in mice expressing a fluorescent protein or a fluorescent version of a GPCR under the control of the endogenous promoter not only help to decipher neuroanatomical circuits but also enable real-time monitoring with subcellular resolution thus providing invaluable information on their trafficking in response to a physiological or a pharmacological challenge. This review will present the animal models and discuss their contribution to the understanding of the physiopathological role of GPCRs. We will also address the drawbacks associated with this methodological approach and browse future directions.

In vivo opioid receptor heteromerization: where do we stand?

Opioid receptors are highly homologous GPCRs that modulate brain function at all levels of neural integration, including autonomous, sensory, emotional and cognitive processing. Opioid receptors functionally interact in vivo, but the underlying mechanisms involving direct receptor-receptor interactions, affecting signalling pathways or engaging different neuronal circuits, remain unsolved. Heteromer formation through direct physical interaction between two opioid receptors or between an opioid receptor and a non-opioid one has been postulated and can be characterized by specific ligand binding, receptor signalling and trafficking properties. However, despite numerous studies in heterologous systems, evidence for physical proximity in vivo is only available for a limited number of opioid heteromers, and their physiopathological implication remains largely unknown mostly due to the lack of appropriate tools. Nonetheless, data collected so far using endogenous receptors point to a crucial role for opioid heteromers as a molecular entity that could underlie human pathologies such as alcoholism, acute or chronic pain as well as psychiatric disorders. Opioid heteromers therefore stand as new therapeutic targets for the drug discovery field.

LINKED ARTICLES

This article is part of a themed section on Opioids: New Pathways to Functional Selectivity. To view the other articles in this section visit http://dx.doi.org/10.1111/bph.2015.172.issue-2.

National trends in the office-based prescription of schedule II opioids

OBJECTIVE

To investigate national trends and patterns in opioid prescription within office-based medical practice.

METHOD

An analysis is presented of 1995-2010 data from the National Ambulatory Medical Care Survey, focusing on overall and stratified trends in the percentage of medical visits involving prescriptions for Schedule II opioids. Among visits with opioid prescriptions in 2003-2010, first-time visits were also compared to return visits, and visits in which pain was the primary complaint were compared to visits with other primary complaints.

RESULTS

Among all office visits, the percentage with an opioid prescription increased from 0.65% in 1995-1998 to 2.63% in 2007-2010 (odds ratio [OR] = 8.01; 95% CI, 4.96-12.94). During the study period (1995-2010), opioid prescriptions significantly increased in visits by male patients (OR = 6.54; 95% CI, 3.21-13.31); female patients (OR = 9.38; 95% CI, 6.70-13.14); and patients aged 18-35 years (OR = 5.82; 95% CI, 2.59-13.10), 36-64 years (OR = 8.30; 95% CI, 4.63-14.86), and ≥ 65 years (OR = 8.85; 95% CI, 6.13-12.77), but not ≤ 17 years (OR = 1.52; 95% CI, 0.50-4.63). Prescriptions for opioids also significantly increased in visits by patients with clinical depression (OR = 9.96; 95% CI, 5.45-18.21) or anxiety (OR = 10.99; 95% CI, 5.02-24.06) diagnoses. However, a significant decline occurred in opioid prescriptions in visits among patients with substance use diagnoses (OR = 0.10; 95% CI, 0.00-3.30). The number of opioid prescriptions rose faster among patients making a first visit (OR = 23.36; 95% CI, 11.82-46.17) versus a return visit (OR = 7.26; 95% CI, 4.38-12.03).

CONCLUSIONS

A substantial increase occurred between 1995 and 2010 in opioid prescriptions in office-based medical visits, especially in visits by middle-aged and older adults and by patients making their first visit to the treating physician. These trends suggest that physicians have pursued greater pain control despite potential risks of nonmedical use of prescription opioids.

Newly initiated opioid treatment and the risk of fall-related injuries. A nationwide, register-based, case-crossover study in Sweden

BACKGROUND

There is growing epidemiological evidence that opioids may increase the risk of unintentional injuries and it is plausible that the time of initiation is most critical in that respect. Studies on fall-related injuries remain few, limited and mostly focused on specific groups of elderly patients.

OBJECTIVE

The objective of this study was to assess the short-term effects of newly prescribed opioids on the risk of fall-related injuries in the general adult population.

METHODS

A case-crossover design was applied on national register data linking, at the individual level, fall-injury information involving adults aged 18 years and above identified in the Swedish National Inpatient Register (during the period 1 May 2006 to 31 December 2009) and dispensed drugs from the Swedish Prescribed Drug Register (n=167,257 cases with a first fall-related injury). All types of opioid substances were considered, classified according to the Anatomical Therapeutic Chemical (ATC) classification system. We investigated newly dispensed opioids 28 days preceding the injury, compared with an earlier, and equally long, control period following a 3-month washout period. Conditional logistic regression was used to estimate odds ratio (OR) and 95% confidence interval (CI). The analyses were also conducted stratified by age group, by type of fall and for each period of 1 week during the 28-day period.

RESULTS

From among the fall-injured patients, 7,450 patients (4.5%) had a new opioid dispensation within 28 days prior to the injury, of which the most frequent types were tramadol (2.0%) and codeine (1.1%). Consistently increased risks of fall-related injuries associated with a new prescription of any opioid were found and they were most pronounced among young adults, 18-29 years of age (OR, 7.17; 95% CI 5.04-10.2). The closer the dispensation date to the injury, the higher the odds: an OR of 5.14 (95% CI 4.76-5.55) during the first week of opioid treatment and 1.23 (95% CI 1.10-1.38) for the fourth week. Of the documented falls, the risk was most pronounced for falls from 'another, high level' (OR, 5.33; 95% CI 3.99-7.10).

CONCLUSIONS

Newly prescribed opioids may trigger injurious falls. The effect lowers over time and is less pronounced with increasing age. The risk is also higher for fall from height.

Gene Expression Profile of Calcium/Calmodulin-Dependent Protein Kinase IIα in Rat's Hippocampus during Morphine Withdrawal

INTRODUCTION

Calcium/calmodulin-dependent protein kinase II (CaMKII) which is highly expressed in the hippocampus is known to play a pivotal role in reward-related memories and morphine dependence.

METHODS

In the present study, repeated morphine injections once daily for 7 days was done to induce morphine tolerance in male Wistar rats, after which gene expression profile of α-isoform of CaMKII (CaMKIIα) in the hippocampus was evaluated upon discontinuation of morphine injection over 21 days of morphine withdrawal. Control groups received saline for 7 consecutive days. For gene expression study, rats' brains were removed and the hippocampus was dissected in separate groups on days 1, 3, 7, 14, and 21 since discontinuation of of morphine injection. A semi-quantitative RT-PCR method was used to evaluate the gene expression profile.

RESULTS

Tolerance to morphine was verified by a significant decrease in morphine analgesia in a hotplate test on day 8 (one day after the final repeated morphine injections). Results showed that gene expression of CaMKIIα at mRNA level on day 1, 3, 7, 14 and 21 of morphine withdrawal was significantly altered as compared to the saline control group. Post hoc Tukey's test revealed a significantly enhanced CaMKIIα gene expression on day 14.

DISCUSSION

It can be concluded that CaMKIIα gene expression during repeated injections of morphine is increased and this increase continues up to 14 days of withdrawal then settles at a new set point. Therefore, the strong morphine reward-related memory in morphine abstinent animals may, at least partly be attributed to, the up-regulation of CaMKIIα in the hippocampus over 14 days of morphine withdrawal.

Improvement of quality of life following 6 months of methadone maintenance therapy in Malaysia

BACKGROUND

Methadone Maintenance Therapy (MMT) is one of the popular choices for drug substitution therapy and is fairly new in Malaysia. Aside from its role in harm reduction against HIV infection, MMT programme may potentially enhances clients' quality of life. This study aims to identify the impact of MMT programme on clients' quality of life after 6 months in treatment and to explore factors that may be associated with changes in their quality of life.

METHODS

In this retrospective report review, 122 subjects from 2 government MMT clinics were selected from the district of Tampin, Negeri Sembilan, Malaysia. The raw score from the WHO Quality of Life questionnaire (WHOQOL-BREF), at baseline and 6 months after therapy were collected and converted to 0-100 scale form to give quality of life scores for four domains; physical, psychological, social relationships and environment. Other variables of interest were socio-demography, age when joining MMT programme, age and duration of illicit drug use, HIV and Hepatitis C status, and the Opiate Treatment Index (OTI) score on drug use, sexual and social aspect at the baseline. Statistical analysis used the SPSS version 16.

RESULTS

There was significant improvement in all four domains of quality of life, after 6 months of MMT. The largest improvement was for psychological domain (mean score difference 15.54 ± 20.81). Multivariable linear regression analysis showed that, for the physical domain, there was no significant predictor. For both the psychological and social domains, having tertiary education is a significant predictor for improvement in both aspects of quality of life. Negative HIV status is associated with improvement for the environment domain.

CONCLUSIONS

There was a significant short term improvement in the quality of life of MMT clients who stayed in the programme for at least 6 months in the district of Tampin, Negeri Sembilan, Malaysia.

Mood and anxiety disorders and their association with non-medical prescription opioid use and prescription opioid-use disorder: longitudinal evidence from the National Epidemiologic Study on Alcohol and Related Conditions

BACKGROUND

Non-medical use of prescription opioids represents a national public health concern of growing importance. Mood and anxiety disorders are highly associated with non-medical prescription opioid use. The authors examined longitudinal associations between non-medical prescription opioid use and opioid disorder due to non-medical opioid use and mood/anxiety disorders in a national sample, examining evidence for precipitation, self-medication and general shared vulnerability as pathways between disorders.

METHOD

Data were drawn from face-to-face surveys of 34 653 adult participants in waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Logistic regression models explored the temporal sequence and evidence for the hypothesized pathways.

RESULTS

Baseline lifetime non-medical prescription opioid use was associated with incidence of any mood disorder, major depressive disorder (MDD), bipolar disorder, any anxiety disorder and generalized anxiety disorder (GAD in wave 2, adjusted for baseline demographics, other substance use, and co-morbid mood/anxiety disorders). Lifetime opioid disorder was not associated with any incident mood/anxiety disorders. All baseline lifetime mood disorders and GAD were associated with incident non-medical prescription opioid use at follow-up, adjusted for demographics, co-morbid mood/anxiety disorders, and other substance use. Baseline lifetime mood disorders, MDD, dysthymia and panic disorder were associated with incident opioid disorder due to non-medical prescription opioid use at follow-up, adjusted for the same covariates.

CONCLUSIONS

These results suggest that precipitation, self-medication as well as shared vulnerability are all viable pathways between non-medical prescription opioid use and opioid disorder due to non-medical opioid use and mood/anxiety disorders.

Tolerance to the beneficial effects of prophylactic migraine drugs: a systematic review of causes and mechanisms

Loss of benefit of a previously effective treatment regimen, also known as tolerance, can be an important barrier to the successful preventive treatment of migraine. We undertook a systematic review of the literature to identify the prevalence and possible mechanisms of drug tolerance in migraine prophylaxis. Results demonstrate that the frequency of tolerance to prophylactic migraine treatment is unknown, but available data support an estimate that it occurs in 1-8% of patients receiving prophylaxis. Four broad types of tolerance were identified that are likely to be relevant to migraine prophylaxis. These are pharmacokinetic, pharmacodynamic, behavioral, and cross tolerance. The mechanisms that underlie these types of tolerance determine whether their effects can be overcome or minimized. For example, certain forms of tolerance may be affected by manipulation of environmental cues associated with drug administration, by the order in which drugs are used, and by the concomitant use of other medications. Many medications used for migraine prophylaxis exert their effects through the endogenous opioid system. The implications of this finding are explored, particularly the parallels between medication overuse headache and tolerance to migraine prophylaxis. Given the many ways in which tolerance to migraine medications may develop, in some ways it is not surprising that migraine-preventive drugs stop working; it is more surprising that in many cases they do not.

Molecular mechanisms of opioid receptor-dependent signaling and behavior

Opioid receptors have been targeted for the treatment of pain and related disorders for thousands of years and remain the most widely used analgesics in the clinic. Mu (μ), kappa (κ), and delta (δ) opioid receptors represent the originally classified receptor subtypes, with opioid receptor like-1 (ORL1) being the least characterized. All four receptors are G-protein coupled and activate inhibitory G proteins. These receptors form homo- and heterodimeric complexes and signal to kinase cascades and scaffold a variety of proteins.The authors discuss classic mechanisms and developments in understanding opioid tolerance and opioid receptor signaling and highlight advances in opioid molecular pharmacology, behavioral pharmacology, and human genetics. The authors put into context how opioid receptor signaling leads to the modulation of behavior with the potential for therapeutic intervention. Finally, the authors conclude there is a continued need for more translational work on opioid receptors in vivo.

Prescribing cannabis for harm reduction

Neuropathic pain affects between 5% and 10% of the US population and can be refractory to treatment. Opioids may be recommended as a second-line pharmacotherapy but have risks including overdose and death. Cannabis has been shown to be effective for treating nerve pain without the risk of fatal poisoning. The author suggests that physicians who treat neuropathic pain with opioids should evaluate their patients for a trial of cannabis and prescribe it when appropriate prior to using opioids. This harm reduction strategy may reduce the morbidity and mortality rates associated with prescription pain medications.

Ubiquitination in the first cytoplasmic loop of μ-opioid receptors reveals a hierarchical mechanism of lysosomal down-regulation

μ-Type opioid receptors (MORs) are members of the large seven-transmembrane receptor family which transduce the effects of both endogenous neuropeptides and clinically important opioid drugs. Prolonged activation of MORs promotes their proteolytic degradation by endocytic trafficking to lysosomes. This down-regulation process is known to contribute to homeostatic regulation of cellular opioid responsiveness, but mechanisms that mediate and control MOR down-regulation have not been defined. We show here that lysosomal down-regulation of MORs is ESCRT (endosomal sorting complex required for transport)-dependent and involves ubiquitin-promoted transfer of internalized MORs from the limiting endosome membrane to lumen. We also show that MOR down-regulation measured by conventional radioligand binding assay is determined specifically by ubiquitination in the first cytoplasmic loop. Surprisingly, we were unable to find any role of ubiquitination in determining whether internalized receptors recycle or are delivered to lysosomes. Instead, this decision is dictated specifically by the MOR C-tail and occurs irrespectively of the presence or absence of receptor ubiquitination. Our results support a hierarchical organization of discrete ubiquitin-independent and -dependent sorting operations, which function non-redundantly in the conserved down-regulation pathway to mediate precise endocytic control. Furthermore, they show that this hierarchical mechanism discriminates the endocytic regulation of naturally occurring MOR isoforms. Moreover, they are the first to reveal, we believe, for any seven-transmembrane receptor, a functional role of ubiquitination in the first cytoplasmic loop.

Effect of Bacopasides on acquisition and expression of morphine tolerance

Opioids are extensively used for the management of both chronic malignant and non malignant pains. One major serious limitation associated with chronic use of opioids is the development of tolerance to its analgesic effect. The effect of Bacopa monnieri, a renowned ayurvedic medicine for acquisition and expression of morphine tolerance in mice, was investigated. Bacopa monnieri, n-Butanol fraction was analyzed on High performance liquid chromatography (HPLC), for Bacopaside A major components i.e. Bacoside A(3), Bacopaside ll and Bacosaponin C. Antinociceptive effect of n-Butanol extract of Bacopa monnieri (n Bt-ext BM) (5, 10 and 15 mg/kg) was assessed on hot plate. Effect of different doses of n Bt-ext BM on morphine antinociception was also assessed. n Bt-ext BM was also screened for development of tolerance to antinociceptive effect of Bacopa monnieri by administering 15 mg/kg n Bt-ext BM for seven days. Tolerance to morphine analgesia was induced in mice by administering intraperitoneally (I.P.) 20 mg/kg morphine twice daily for five days. Acute and Chronic administration of 5, 10 and 15 mg/kg n Bt-ext BM significantly reduced both expression and development of tolerance to morphine analgesia in mice. Additionally, Bacopa monnieri was found to enhance antinociceptive effect of morphine in intolerant animals. However, no tolerance to Bacopa monnieri antinociceptive effect was observed in seven days treatment schedule. These findings indicate effectiveness of Bacopa monnieri for management of morphine tolerance.

Introduction to the College on Problems of Drug Dependence special issue: contemporary advances in opioid neuropharmacology

Opioid receptors are critical therapeutic targets for medications development relevant to the treatment of drug dependence and pain. With recent advances in molecular neurobiology, it has become evident that the functional activity of opioid receptors, as ligand-regulated protein complexes, is modulated by multifarious intracellular and extracellular events, that there is genetic variation in coding for receptors, and that the activity of endogenous opioid systems may underlie actions common to other addictive disorders. This supplemental issue of Drug and Alcohol Dependence, arising from an invited symposium at the 71st Annual Meeting of the College on Problems of Drug Dependence, provides a series of contemporary reviews focused on recent advances in opioid neuropharmacology. Each speaker provides herein an invited comprehensive review of the state of knowledge on a specific topic in opioid neuropharmacology. Evans and colleagues describe the multi-faceted control of the opioid G-protein coupled receptor as a dynamic "sensor" complex and identify novel targets for drug development. von Zastrow focuses on opioid receptor-mediated events regulated by endocytosis and membrane trafficking through the endocytic pathway and differential responses to opioid agonists. Blendy and colleague provide a review of human association studies on the functional relevance of the mu opioid receptor variant, A118G, and presents data from the A112G knock-in model, an analogous mouse variant to A118G. Finally, Maldonado and colleagues provide a broader systems review from genetic, pharmacologic and behavioral studies implicating the endogenous opioid systems as a substrate for the mediation of substance use disorders spanning pharmacological classes.