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Green JL, Dailey-Govoni T, Vosburg SK. Opioid-related clinical outcomes and associated healthcare costs following abuse/misuse of oxycodone formulations: A HEOR analysis from real-world data. J Opioid Manag 2024; 20:281-288. [PMID: 39321048 DOI: 10.5055/jom.0878] [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: 09/27/2024]
Abstract
OBJECTIVE The United States (US) opioid epidemic is a continued burden on the healthcare system and on the lives of individuals affected by the consequences of opioid abuse/misuse. The objective of this study was to use real-world data from intentional abuse/misuse exposures managed by US poison centers to compare clinical outcomes and quantify healthcare costs among three study cohorts: -exposures that involved Xtampza ER®, other oxycodone extended-release (ER), and oxycodone immediate-release (IR). STUDY DESIGN A real-world, observational study. MAIN OUTCOME MEASURES Descriptive statistics were used to describe patient and exposure characteristics. Drug utilization-adjusted rates of intentional abuse/misuse and clinical outcomes were used to determine relative risk. Healthcare cost estimates were calculated by extrapolating average charge per opioid-related disorder emergency department (ED) visit and per inpatient stay based upon case disposition rates, adjusted for population and drug utilization. RESULTS Compared to Xtampza ER, exposures that involved other oxycodone ER were 7.4 times more likely to be intentional abuse/misuse, 25.9 times more likely to result in major effect or death, 9.7 times more likely to require a visit to the ED, and 14.3 times more likely to result in hospital admission. Similar results were found for oxycodone IR when compared to Xtampza ER. CONCLUSIONS This study is the first of its kind to synthesize clinical outcomes with opioid-related healthcare costs, suggesting that even when Xtampza ER is abused/misused, the rates of major effect/death, ED visits, and hospital admissions were significantly lower than those for other oxycodone-containing medications, resulting in relatively low downstream opioid-related healthcare costs.
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Affiliation(s)
- Jody L Green
- Uprise Health/Inflexxion, Irvine, California. ORCID: https://orcid.org/0000-0003-1776-6400
| | - Taryn Dailey-Govoni
- Uprise Health/Inflexxion, Irvine, California. ORCID: https://orcid.org/0000-0002-2942-4267
| | - Suzanne K Vosburg
- Uprise Health/Inflexxion, Irvine, California. ORCID: https://orcid.org/0000-0002-1794-7116
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Webster L, Gudin J. Review of Opioid Abuse-Deterrent Formulations: Impact and Barriers to Access. J Pain Res 2024; 17:1989-2000. [PMID: 38854928 PMCID: PMC11162618 DOI: 10.2147/jpr.s457982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 05/06/2024] [Indexed: 06/11/2024] Open
Abstract
The misuse and abuse of opioid analgesics continue to pose a serious public health concern, but for some patients, opioids remain an important analgesic option. Extended-release (ER) opioid formulations are effective for treating chronic pain and are supported by multiple 12-week efficacy studies. ER opioids often contain a high opioid content, and similar to immediate-release (IR) formulations, are subject to abuse, misuse, and diversion. Unintentional misuse may also occur when ER formulations are manipulated for medicinal administration, such as crushing a dose for easier oral intake. As part of a multipronged strategy designed to fight the opioid epidemic, abuse-deterrent formulations (ADFs) were developed to deter misuse, abuse, and diversion of opioids by making manipulation more difficult and nonoral routes of administration less rewarding. Although ADF opioids have been shown to decrease rates of abuse and diversion, they are not equally effective in terms of deterring manipulation for abuse or misuse. Xtampza ER utilizes DETERx technology, which allows it to retain ER characteristics when chewed or crushed, making it the only ER opioid without a boxed warning against these types of manipulation. OxyContin was also developed as an ADF but uses RESISTEC technology, making the tablet hard to crush and viscous in aqueous solutions. ADF utilization has been hampered by patient access issues, including high prices due to lack of insurance coverage. Postmarket real-world studies demonstrate lower rates of abuse, misuse, and diversion for ADF ER opioids compared with non-ADF formulations. However, similar studies comparing abuse-related effectiveness and health care costs for ADF opioids are warranted if clinicians are expected to utilize these potentially safer opioid formulations. These studies would support further education surrounding the benefits and utilization of ADFs and manipulation potential of different ADFs.
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Affiliation(s)
- Lynn Webster
- Dr. Vince Clinical Research, Overland Park, KS, USA
| | - Jeffrey Gudin
- Department of Anesthesiology and Pain Management, University of Miami, Miller School of Medicine, Miami, FL, USA
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Rodriguez RD, Dailey Govoni T, Rajagopal V, Green JL. Evaluating the effectiveness of reformulated extended-release oxycodone with abuse-deterrent properties on reducing non-oral abuse among individuals assessed for substance abuse treatment with the Addiction Severity Index-Multimedia Version (ASI-MV). Curr Med Res Opin 2023; 39:579-587. [PMID: 36762423 DOI: 10.1080/03007995.2023.2178080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
OBJECTIVE Original brand extended-release (ER) oxycodone tablets (OC) for oral use were reformulated (ORF) with abuse-deterrent properties (ADP) against inhalation and injection routes in August 2010. This product transition provided an opportunity to compare "before and after" reformulation abuse trends. Our goal was to assess the change in abuse of brand oxycodone ER from before and after introduction of ORF. METHODS Change in self-reported non-oral "OxyContin®" abuse in the previous 30 days during 2 years pre- and 4 years post-reformulation was assessed among adults evaluated for substance use and treatment planning using the Addiction Severity Index-Multimedia Version (ASI-MV®). Comparator opioids were used to provide a frame of reference for changes in abuse due to competing population-level opioid abuse interventions and other factors unrelated to the reformulation. A proportion (PR) and abuse report dispensing ratio (ARDR) are reported because a single measure of abuse has not been identified that can optimally describe opioid abuse or changes in opioid abuse. RESULTS Interrupted time-series analyses indicated an immediate decline in non-oral abuse measures post-reformulation (PR=-52.1%; ARDR=-32.2%). Significant decreases from pre- to post-reformulation in non-oral abuse overall were observed (PR [95% CI]=-30.7% [-46.9%, -9.5%]; ARDR=-29.3% [-37.5%, -20.1%]). Comparator opioids did not demonstrate similar trends over the period. CONCLUSIONS Methodology applied in this study suitably assessed the effectiveness of an ADP product. Among individuals assessed for substance use, a differential decline in non-oral abuse of brand ER oxycodone was observed since introduction of ORF.
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Affiliation(s)
| | | | | | - Jody L Green
- Inflexxion, A Division of Uprise Health, Irvine, CA, USA
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Karamouzian M, Buxton JA, Hategeka C, Nosova E, Hayashi K, Milloy MJ, Kerr T. Shifts in substance use patterns among a cohort of people who use opioids after delisting of OxyContin in BC, Canada: An interrupted time series study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 109:103852. [PMID: 36122483 PMCID: PMC9885984 DOI: 10.1016/j.drugpo.2022.103852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND OxyContin was delisted from Canadian provincial drug formularies in March 2012 and replaced with a reformulated tamper-resistant form of oxycodone (i.e., OxyNeo). We assessed if delisting of OxyContin was associated with changes in the use of unregulated opioids and other substances among people who use opioids (PWUO). METHODS Data were derived from two prospective cohort studies of people who use drugs in Vancouver, BC, Canada from 2006 to 2018. PWUO who had at least one follow-up visit before and after delisting of OxyContin were included. Outcomes of interest were self-reported regular (i.e., at least weekly) use of heroin, non-prescribed prescription opioids, cannabis, methamphetamine, crack cocaine, and powder cocaine during the previous six months. Using quasi-experimental interrupted time series, we fit generalized least squares models to assess participants' immediate and long-term substance use practices after the policy change. RESULTS We analyzed data from 1014 participants who contributed to 17457 visits during the study. Following the delisting of OxyContin, heroin use increased immediately by 5.17% (95% confidence intervals [CI]: 0.68 to 9.67) and over time by 0.47% (0.35 to 0.58) per month. Non-prescribed prescription opioid use increased immediately by 1.80% (0.10 to 3.50) and over time by 0.16% (0.12 to 0.19) per month. Cannabis use increased immediately by 4.37% (0.88 to 7.87) and over time by 0.11% (0.02 to 0.19) per month. Methamphetamine use did not increase immediately but increased over time by 0.10% (0.01 to 0.18) per month. Crack cocaine use decreased immediately by 6.13% (-10.94 to -1.69) but not significantly over time. Lastly, powder cocaine use did not increase immediately or over time. CONCLUSIONS Delisting of OxyContin in BC was not associated with a reduction in unregulated opioid use among PWUO. Our findings point to a shift in substance use patterns of PWUO post-intervention and further highlight the unintended consequences of supply-reduction interventions in addressing the opioid epidemic.
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Affiliation(s)
- Mohammad Karamouzian
- British Columbia Centre on Substance use, Vancouver, BC, Canada, V6Z 2A9; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada, V6T 1Z3; Centre on Drug Policy Evaluation, Saint Michael...s Hospital, Toronto, ON, CANADA, M5B 1T8.
| | - Jane A Buxton
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada, V6T 1Z3
| | - Celestin Hategeka
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 655 Huntington Ave, Boston, MA 02115,USA; Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada, V6T 1Z3
| | - Ekaterina Nosova
- British Columbia Centre on Substance use, Vancouver, BC, Canada, V6Z 2A9
| | - Kanna Hayashi
- British Columbia Centre on Substance use, Vancouver, BC, Canada, V6Z 2A9
| | - M-J Milloy
- British Columbia Centre on Substance use, Vancouver, BC, Canada, V6Z 2A9; Department of Medicine, University of British Columbia, Vancouver, BC, Canada, V6Z 1Y6
| | - Thomas Kerr
- British Columbia Centre on Substance use, Vancouver, BC, Canada, V6Z 2A9; Department of Medicine, University of British Columbia, Vancouver, BC, Canada, V6Z 1Y6
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The release of abuse-deterrent OxyContin and adolescent heroin use. Drug Alcohol Depend 2021; 229:109114. [PMID: 34638038 DOI: 10.1016/j.drugalcdep.2021.109114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/13/2021] [Accepted: 09/26/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To determine the association between the abuse-deterrent reformulation of OxyContin and adolescent lifetime heroin use in the United States. METHODS The quasi-experimental study uses individual survey data from the 1999-2019 Youth Risk Behavior Surveillance System to examine whether the reformulation of OxyContin in August 2010 affected adolescent lifetime heroin use, exploiting heterogeneity in state-level rates of OxyContin misuse before the reformulation. Multiple regression analysis adjusted for state and year fixed effects, adolescent demographics, and time-varying state characteristics and policies. RESULTS The release of the abuse-deterrent reformulation of OxyContin was associated with a reduction in adolescents reporting ever using heroin. An adolescent in a state with a one percentage point higher state-level rate of pre-reformulation OxyContin misuse was 1.7% points less likely to report ever using heroin after the reformulation (95% confidence interval, [(CI) = -0.007, -0.027]). These effects are strongest for adolescent males (estimate: -0.028, [(CI) = -0.016, 0.040]) and non-whites (estimate: -0.021, [(CI) = -0.005, -0.037]). CONCLUSIONS These results suggest the release of abuse-deterrent OxyContin is associated with a decrease in the likelihood of adolescent lifetime heroin use in states with higher pre-reformulation rates of OxyContin misuse. Pharmaceutical innovations and policies that reduce the likelihood of prescription opioid misuse may be effective in reducing adolescent lifetime heroin use.
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Relative potency of intravenous oxymorphone compared to other µ opioid agonists in humans - pilot study outcomes. Psychopharmacology (Berl) 2021; 238:2503-2514. [PMID: 34106317 PMCID: PMC8514134 DOI: 10.1007/s00213-021-05872-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/05/2021] [Indexed: 10/21/2022]
Abstract
AIMS Intravenous (IV) misuse of the µ opioid analgesic oxymorphone has caused significant public health harms; however, no controlled data on its IV abuse potential are available. The primary aims of this pilot study were to directly compare IV oxymorphone to IV oxycodone, morphine, and hydromorphone on a subjective measure of drug liking and to assess relative potency. METHODS Participants (n = 6) with opioid use disorder, physical dependence, and current IV use completed this two-site, within-subject, double-blind, placebo-controlled, inpatient pilot study. During each session, one IV dose (mg/70 kg) was administered: oxymorphone (1.8, 3.2, 5.6, 10, 18, 32), hydromorphone (1.8, 3.2, 5.6, 10, 18), oxycodone (18, 32, 56), morphine (18, 32), and placebo. Data were collected before and for 6 h after dosing. Primary outcomes included safety/physiological effects, subjective reports of drug liking, and relative potency estimates. RESULTS All active test drugs produced prototypical, dose-related µ opioid agonist effects (e.g., miosis). Oxymorphone was more potent than the comparator opioids on several measures, including drug liking and respiratory depression (p < 0.05). Across abuse-related subjective outcomes, oxymorphone was 2.3-2.8-fold more potent than hydromorphone and 12.5-14-fold more potent than oxycodone (p < 0.05). CONCLUSIONS Despite the relatively small sample size, this pilot study detected robust oxymorphone effects. Oxymorphone was far more potent than the comparator opioids, particularly on abuse potential outcomes. Overall, these findings may help explain surveillance reports that demonstrate, after adjusting for prescription availability, oxymorphone is injected at the highest frequency, relative to other prescription opioids.
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Balsamo D, Bajardi P, Salomone A, Schifanella R. Patterns of Routes of Administration and Drug Tampering for Nonmedical Opioid Consumption: Data Mining and Content Analysis of Reddit Discussions. J Med Internet Res 2021; 23:e21212. [PMID: 33393910 PMCID: PMC7813634 DOI: 10.2196/21212] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 10/15/2020] [Accepted: 10/28/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The complex unfolding of the US opioid epidemic in the last 20 years has been the subject of a large body of medical and pharmacological research, and it has sparked a multidisciplinary discussion on how to implement interventions and policies to effectively control its impact on public health. OBJECTIVE This study leverages Reddit, a social media platform, as the primary data source to investigate the opioid crisis. We aimed to find a large cohort of Reddit users interested in discussing the use of opioids, trace the temporal evolution of their interest, and extensively characterize patterns of the nonmedical consumption of opioids, with a focus on routes of administration and drug tampering. METHODS We used a semiautomatic information retrieval algorithm to identify subreddits discussing nonmedical opioid consumption and developed a methodology based on word embedding to find alternative colloquial and nonmedical terms referring to opioid substances, routes of administration, and drug-tampering methods. We modeled the preferences of adoption of substances and routes of administration, estimating their prevalence and temporal unfolding. Ultimately, through the evaluation of odds ratios based on co-mentions, we measured the strength of association between opioid substances, routes of administration, and drug tampering. RESULTS We identified 32 subreddits discussing nonmedical opioid usage from 2014 to 2018 and observed the evolution of interest among over 86,000 Reddit users potentially involved in firsthand opioid usage. We learned the language model of opioid consumption and provided alternative vocabularies for opioid substances, routes of administration, and drug tampering. A data-driven taxonomy of nonmedical routes of administration was proposed. We modeled the temporal evolution of interest in opioid consumption by ranking the popularity of the adoption of opioid substances and routes of administration, observing relevant trends, such as the surge in synthetic opioids like fentanyl and an increasing interest in rectal administration. In addition, we measured the strength of association between drug tampering, routes of administration, and substance consumption, finding evidence of understudied abusive behaviors, like chewing fentanyl patches and dissolving buprenorphine sublingually. CONCLUSIONS This work investigated some important consumption-related aspects of the opioid epidemic using Reddit data. We believe that our approach may provide a novel perspective for a more comprehensive understanding of nonmedical abuse of opioids substances and inform the prevention, treatment, and control of the public health effects.
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Affiliation(s)
- Duilio Balsamo
- Department of Mathematics, University of Turin, Turin, Italy
| | | | | | - Rossano Schifanella
- ISI Foundation, Turin, Italy
- Department of Computer Science, University of Turin, Turin, Italy
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Coon SA, Hill LG, Hutchison RW, Arnold LM, Jarrett JB, Ottney AR, Oung AB, Painter NA, Smith MA, Stranges PM, Tran TH, McFee Winans AR, Bratberg JP. Mobilizing pharmacists to address the opioid crisis: A joint opinion of the ambulatory care and adult medicine practice and research networks of the American College of Clinical Pharmacy. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1331] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Scott A. Coon
- Department of Pharmacotherapeutics & Clinical Research University of South Florida, Taneja College of Pharmacy, Morsani College of Medicine Tampa Florida USA
| | - Lucas G. Hill
- Division of Pharmacy Practice The University of Texas at Austin College of Pharmacy Austin Texas USA
| | - Robert W. Hutchison
- Department of Pharmacy Practice Texas A&M Irma Lerma Rangel College of Pharmacy Round Rock Texas USA
| | - Lindsay M. Arnold
- Department of Pharmacy Services St. Elizabeth's Medical Center Brighton Massachusetts USA
| | - Jennie B. Jarrett
- Department of Pharmacy Practice University of Illinois at Chicago, College of Pharmacy Chicago Illinois USA
| | - Anne R. Ottney
- Department of Pharmacy Practice Ferris State University, College of Pharmacy Big Rapids Michigan USA
| | - Alvin B. Oung
- Department of Pharmacy Practice University of Wyoming School of Pharmacy Laramie Wyoming USA
| | - Nathan A. Painter
- Division of Clinical Pharmacy University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences San Diego California USA
| | - Michael A. Smith
- Department of Clinical Pharmacy University of Michigan College of Pharmacy Ann Arbor Michigan USA
| | - Paul M. Stranges
- Department of Pharmacy Practice University of Illinois at Chicago, College of Pharmacy Chicago Illinois USA
| | - Tran H. Tran
- Department of Pharmacy Practice Midwestern University Chicago College of Pharmacy Downers Grove Illinois USA
| | - Amanda R. McFee Winans
- Section of Clinical Pharmacy, Department of Pharmaceutical Care Services Bassett Medical Center Cooperstown New York USA
| | - Jeffrey P. Bratberg
- Department of Pharmacy Practice University of Rhode Island College of Pharmacy Kingston Rhode Island USA
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Wolff C, Dowd WN, Ali MM, McClellan C, Meinhofer A, Glos L, Mutter R, Rosenberg M, Schick A. The impact of the abuse-deterrent reformulation of extended-release OxyContin on prescription pain reliever misuse and heroin initiation. Addict Behav 2020; 105:106268. [PMID: 32036188 DOI: 10.1016/j.addbeh.2019.106268] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/20/2019] [Accepted: 12/17/2019] [Indexed: 10/25/2022]
Abstract
The introduction of abuse-deterrent OxyContin in 2010 was intended to reduce its misuse by making it more tamper resistant. However, some studies have suggested that this reformulation might have had unintended consequences, such as increases in heroin-related deaths. We used the 2005-2014 cross-sectional U.S. National Survey on Drug Use and Health to explore the impact of this reformulation on intermediate outcomes that precede heroin-related deaths for individuals with a history of OxyContin misuse. Our study sample consisted of adults who misused any prescription pain reliever prior to the reformulation of OxyContin (n = 81,400). Those who misused OxyContin prior to the reformulation were considered the exposed group and those who misused other prescription pain relievers prior to the reformulation were considered the unexposed group. We employed multivariate logistic regression under a difference-in-differences framework to examine the effect of the reformulation on five dichotomous outcomes: prescription pain reliever misuse; prescription pain reliever use disorder; heroin use; heroin use disorder; and heroin initiation. We found a net reduction in the odds of prescription pain reliever misuse (OR:0.791, p < 0.001) and heroin initiation (OR:0.422, p = 0.011) after the reformulation for the exposed group relative to the unexposed group. We found no statistically significant effects of the reformulation on prescription pain reliever use disorder (OR: 0.934, p = 0.524), heroin use (OR: 1.014p = 0.941), and heroin use disorder (OR: 1.063, p = 0.804). Thus, the reformulation of OxyContin appears to have reduced prescription pain reliever misuse without contributing to relatively greater new heroin use among those who misused OxyContin prior to the reformulation.
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Guenther S, Mickle TC, Barrett AC, Smith A, Braeckman R, Kelsh D, Vince B. Pharmacokinetics and Abuse Potential of Asalhydromorphone, a Novel Prodrug of Hydromorphone, After Intranasal Administration in Recreational Drug Users. PAIN MEDICINE 2020; 21:511-520. [PMID: 30986302 DOI: 10.1093/pm/pnz066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Hydromorphone (HM) is a potent μ-opioid receptor agonist with high susceptibility for abuse. A prodrug of hydromorphone, asalhydromorphone (ASAL-HM), has been designed to deter nonoral forms of abuse associated with hydromorphone. This study evaluated the intranasal (IN) pharmacokinetics and exploratory abuse potential of ASAL-HM compared with HM. DESIGN Single-center, randomized, double-blind, crossover study. SETTING Clinical research site. SUBJECTS Healthy adult, nondependent recreational opioid users. METHODS Subjects (N = 26) were randomized to receive IN administration of 16.1 mg of ASAL-HM and 8.0 mg of HM (molar-equivalent with respect to hydromorphone). Blood samples were taken through 24 hours postdose, and pharmacodynamic end points (Drug Liking, Feeling High, Take Drug Again, Overall Drug Liking) were assessed through eight hours postdose. Nasal irritation and safety were also assessed. RESULTS Relative to IN HM, the rate (Cmax) and extent (area under the curve [AUC0-last, AUC0-inf]) of exposure to hydromorphone following IN ASAL-HM were reduced by ≥50%. Consistent with these findings, scores on "at-the-moment" (i.e., Drug Liking Emax, High Emax) and retrospective (i.e., Take Drug Again, Overall Drug Liking) end points were statistically significantly lower for IN ASAL-HM, with mean/median differences ranging from 11.4 to 25.0 points. ASAL-HM produced greater nasal-related effects, such as nasal burning and facial pain, and a lower incidence of typical opioid-related adverse events such as euphoria, pruritus, and somnolence. CONCLUSIONS The novel hydromorphone prodrug ASAL-HM produced marked reductions in hydromorphone exposure and abuse-related effects following IN administration compared with HM. ASAL-HM has desirable molecular features for incorporation into putative abuse-deterrent immediate-release and extended-release hydromorphone products.
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Affiliation(s)
| | | | | | | | | | - Debra Kelsh
- Vince & Associates, Overland Park, Kansas, USA
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11
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Smart R, Kase CA, Taylor EA, Lumsden S, Smith SR, Stein BD. Strengths and weaknesses of existing data sources to support research to address the opioids crisis. Prev Med Rep 2020; 17:101015. [PMID: 31993300 PMCID: PMC6971390 DOI: 10.1016/j.pmedr.2019.101015] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 10/22/2019] [Accepted: 11/02/2019] [Indexed: 12/18/2022] Open
Abstract
Better opioid prescribing practices, promoting effective opioid use disorder treatment, improving naloxone access, and enhancing public health surveillance are strategies central to reducing opioid-related morbidity and mortality. Successfully advancing and evaluating these strategies requires leveraging and linking existing secondary data sources. We conducted a scoping study in Fall 2017 at RAND, including a literature search (updated in December 2018) complemented by semi-structured interviews with policymakers and researchers, to identify data sources and linking strategies commonly used in opioid studies, describe data source strengths and limitations, and highlight opportunities to use data to address high-priority public health research questions. We identified 306 articles, published between 2005 and 2018, that conducted secondary analyses of existing data to examine one or more public health strategies. Multiple secondary data sources, available at national, state, and local levels, support such research, with substantial breadth in data availability, data contents, and the data's ability to support multi-level analyses over time. Interviewees identified opportunities to expand existing capabilities through systematic enhancements, including greater support to states for creating and facilitating data use, as well as key data challenges, such as data availability lags and difficulties matching individual-level data over time or across datasets. Multiple secondary data sources exist that can be used to examine the impact of public health approaches to addressing the opioid crisis. Greater data access, improved usability for research purposes, and data element standardization can enhance their value, as can improved data availability timeliness and better data comparability across jurisdictions.
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Affiliation(s)
| | | | | | - Susan Lumsden
- Office of Health Policy, Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, United States
| | - Scott R. Smith
- Office of Health Policy, Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, United States
| | - Bradley D. Stein
- RAND Corporation, Pittsburgh, PA, United States
- University of Pittsburgh School of Medicine, Pittsburgh PA, United States
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Balyan R, Hahn D, Huang H, Chidambaran V. Pharmacokinetic and pharmacodynamic considerations in developing a response to the opioid epidemic. Expert Opin Drug Metab Toxicol 2020; 16:125-141. [PMID: 31976778 PMCID: PMC7199505 DOI: 10.1080/17425255.2020.1721458] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/22/2020] [Indexed: 12/14/2022]
Abstract
Introduction: Opioids continue to be used widely for pain management. Widespread availability of prescription opioids has led to opioid abuse and addiction. Besides steps to reduce inappropriate prescribing, exploiting opioid pharmacology to make their use safer is important.Areas covered: This article discusses the pathology and factors underlying opioid abuse. Pharmacokinetic and pharmacodynamic properties affecting abuse liability of commonly abused opioids have been highlighted. These properties inform the development of ideal abuse deterrent products. Mechanisms and cost-effectiveness of available abuse deterrent products have been reviewed in addition to the pharmacology of medications used to treat addiction.Expert opinion: The opioid crisis presents unique challenges to managing pain effectively given the limited repertoire of strong analgesics. The 5-point strategy to combat the opioid crisis calls for better preventive, treatment, and recovery services, better data, better pain management, better availability of overdose-reversing drugs and better research. There is an urgent need to decrease the cost of abuse deterrent opioids which deters their cost-effectiveness. In addition, discovery of novel analgesics, further insight into central and peripheral pain mechanisms, understanding genomic risk profiles for efficient targeted efforts, and education will be key to winning this fight against the opioid crisis.
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Affiliation(s)
- Rajiv Balyan
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA
| | - David Hahn
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA
| | - Henry Huang
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA
| | - Vidya Chidambaran
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, USA
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Ge X, Henningfield JE, Siddhanti S, Jobes J, Lu L, Xie S, Ziola M, Kelsh D, Vince B, Di Fonzo CJ, Tagliaferri M, Zalevsky J, Doberstein SK, Hoch U, Eldon MA. Human Abuse Potential of Oral NKTR-181 in Recreational Opioid Users: A Randomized, Double-Blind, Crossover Study. PAIN MEDICINE 2020; 21:e114-e126. [PMID: 31553457 DOI: 10.1093/pm/pnz232] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To evaluate the human abuse potential, pharmacokinetics, pharmacodynamics, and safety of oral NKTR-181 (oxycodegol), a novel full mu-opioid receptor agonist, relative to oral oxycodone. DESIGN This double-blind, randomized, single-dose, crossover human abuse potential study was conducted in healthy, adult, non-physically dependent recreational opioid users. SETTING Inpatient clinical research site. SUBJECTS Seventy-one subjects randomized (95.7% male, 65.2% African American, mean age = 31.7 years). METHODS The primary objective was to compare two therapeutic doses of NKTR-181 (400 and 600 mg) with 40 and 60 mg of oxycodone and a supratherapeutic dose (1200 mg) of NKTR-181 with 60 mg of oxycodone using visual analog scale (VAS) ratings for Drug Liking "at this moment" (Drug Liking). Secondary objectives included VAS ratings for other subjective measures, and central nervous system (CNS) mu-opioid effects were assessed using pupillometry. Each subject received single oral doses of five treatments and matching placebo. RESULTS Compared with 40 and 60 mg of oxycodone, the maximum mean Drug Liking score at 400 and 600 mg NKTR-181 was significantly lower, and the rate of onset and extent of Drug Liking for all NKTR-181 doses in the first two hours postdose were also significantly lower. Delayed attenuated Drug Liking and pupillary miosis response following administration of NKTR-181 vs oxycodone were consistent with slower NKTR-181 CNS entry kinetics and mu-opioid receptor binding. No adverse events were rated as severe, and somnolence and dizziness occurred more frequently when subjects received oxycodone. CONCLUSIONS NKTR-181 at oral doses of 400 and 600 mg showed significantly fewer and less severe subjective effects accepted as representative of opioid abuse potential, such as lower peak Drug Liking in recreational opioid users, than 40 and 60 mg of oxycodone.
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Affiliation(s)
- Xue Ge
- Nektar Therapeutics, San Francisco, California
| | - Jack E Henningfield
- The Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Baltimore, Maryland.,Pinney Associates, Bethesda, Maryland
| | | | - Janet Jobes
- Nektar Therapeutics, San Francisco, California
| | - Lin Lu
- Nektar Therapeutics, San Francisco, California
| | - Sunny Xie
- Nektar Therapeutics, San Francisco, California
| | | | - Debra Kelsh
- Altasciences Clinical Research, Overland Park, Kansas, USA
| | - Bradley Vince
- Altasciences Clinical Research, Overland Park, Kansas, USA
| | | | | | | | | | - Ute Hoch
- Nektar Therapeutics, San Francisco, California
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14
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Beheshti D. Adverse health effects of abuse-deterrent opioids: Evidence from the reformulation of OxyContin. HEALTH ECONOMICS 2019; 28:1449-1461. [PMID: 31715653 DOI: 10.1002/hec.3944] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/22/2019] [Accepted: 07/28/2019] [Indexed: 05/26/2023]
Abstract
The United States is currently in the midst of the worst drug epidemic in its history, with nearly 64,000 overdose deaths in 2016. In response, pharmaceutical companies have begun introducing abuse-deterrent painkillers, pills with properties that make the drug more difficult to misuse. The first such painkiller, a reformulated version of OxyContin, was released in 2010. Previous research has found no net effect on opioid mortality, with users substituting from OxyContin toward heroin. This paper explores health effects of the reformulation beyond mortality. In particular, I show that heroin is substantially more likely to be injected than OxyContin, increasing exposure to blood-borne diseases. Exploiting variation across states in OxyContin misuse prior to the reformulation, I find relative increases in the spread of hepatitis B and C in states most likely to be affected by the reformulation. In aggregate, the estimates suggest that absent the reformulation, we would have observed approximately 76% fewer cases of hepatitis C and 53% fewer cases of hepatitis B from 2011 to 2015. I find some suggestive evidence that the reformulation also lead to increases in HIV and hepatitis A, although these findings are less robust. These findings have important implications for future policies addressing the opioid crisis.
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Affiliation(s)
- David Beheshti
- Department of Economics, University of Texas at Austin, Austin, Texas
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15
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Butler SF, Black RA, Fleming AB. Relative Abuse of Crush-Resistant Prescription Opioid Tablets via Alternative Oral Modes of Administration. PAIN MEDICINE 2019; 19:1613-1627. [PMID: 29016905 PMCID: PMC6084581 DOI: 10.1093/pm/pnx151] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective Some crush-resistant tablet formulations (CRTs) reduce prescription opioid abuse by nonoral routes of administration (ROAs), especially insufflation and injection, while oral abuse increases. Oral abuse involving product manipulation vs swallowing whole for CRTs and comparators was examined. Methods Abuse by oral modes of administration (e.g., swallowing whole, chewing, dissolving in the mouth), was examined using the ASI-MV, a computerized, clinical interview for adults in substance abuse treatment from January 2009 to March 2015. CRTs (reformulated oxycodone extended-release [ER], reformulated oxymorphone ER, and tapentadol ER) were compared with non-CRT versions, morphine ER, and oxycodone immediate-release single entity. Analyses employed descriptive statistics and logistic regression. Results Among 364,329 unique assessments, 18,135 patients reported oral abuse of the CRTs and comparators examined. CRTs had a higher prevalence of oral abuse involving product manipulation than comparators (P < 0.0001) among all abusers of product. Oral abuse involving product manipulation for CRTs was greater among the subset of patients reporting oral abuse and significantly higher than comparators (P < 0.003). CRTs were significantly less likely than comparators to be swallowed whole (P < 0.0001) and significantly more likely to be chewed (P < 0.003). CRTs were more likely to be dissolved in the mouth than most comparators. Conclusions Results suggest the need for abuse-deterrent formulations designed to reduce abuse by oral administration with product manipulation, such as chewing. Advances in this area may reduce the overall abuse of prescription opioids and interrupt the progression from abuse by swallowing whole to oral administration involving product manipulation and other ROAs.
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16
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Green CA, Perrin NA, Hazlehurst B, Janoff SL, DeVeaugh‐Geiss A, Carrell DS, Grijalva CG, Liang C, Enger CL, Coplan PM. Identifying and classifying opioid-related overdoses: A validation study. Pharmacoepidemiol Drug Saf 2019; 28:1127-1137. [PMID: 31020755 PMCID: PMC6767606 DOI: 10.1002/pds.4772] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 02/23/2019] [Accepted: 02/25/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE The study aims to develop and validate algorithms to identify and classify opioid overdoses using claims and other coded data, and clinical text extracted from electronic health records using natural language processing (NLP). METHODS Primary data were derived from Kaiser Permanente Northwest (2008-2014), an integrated health care system (~n > 475 000 unique individuals per year). Data included International Classification of Diseases, Ninth Revision (ICD-9) codes for nonfatal diagnoses, International Classification of Diseases, Tenth Revision (ICD-10) codes for fatal events, clinical notes, and prescription medication records. We assessed sensitivity, specificity, positive predictive value, and negative predictive value for algorithms relative to medical chart review and conducted assessments of algorithm portability in Kaiser Permanente Washington, Tennessee State Medicaid, and Optum. RESULTS Code-based algorithm performance was excellent for opioid-related overdoses (sensitivity = 97.2%, specificity = 84.6%) and classification of heroin-involved overdoses (sensitivity = 91.8%, specificity = 99.0%). Performance was acceptable for code-based suicide/suicide attempt classifications (sensitivity = 70.7%, specificity = 90.5%); sensitivity improved with NLP (sensitivity = 78.7%, specificity = 91.0%). Performance was acceptable for the code-based substance abuse-involved classification (sensitivity = 75.3%, specificity = 79.5%); sensitivity improved with the NLP-enhanced algorithm (sensitivity = 80.5%, specificity = 76.3%). The opioid-related overdose algorithm performed well across portability assessment sites, with sensitivity greater than 96% and specificity greater than 84%. Cross-site sensitivity for heroin-involved overdose was greater than 87%, specificity greater than or equal to 99%. CONCLUSIONS Code-based algorithms developed to detect opioid-related overdoses and classify them according to heroin involvement perform well. Algorithms for classifying suicides/attempts and abuse-related opioid overdoses perform adequately for use for research, particularly given the complexity of classifying such overdoses. The NLP-enhanced algorithms for suicides/suicide attempts and abuse-related overdoses perform significantly better than code-based algorithms and are appropriate for use in settings that have data and capacity to use NLP.
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Affiliation(s)
- Carla A. Green
- Center for Health Research, Kaiser Permanente NorthwestPortlandOregon
| | - Nancy A. Perrin
- Center for Health Research, Kaiser Permanente NorthwestPortlandOregon
- Johns Hopkins School of NursingJohns Hopkins UniversityBaltimoreMaryland
| | - Brian Hazlehurst
- Center for Health Research, Kaiser Permanente NorthwestPortlandOregon
| | - Shannon L. Janoff
- Center for Health Research, Kaiser Permanente NorthwestPortlandOregon
| | | | - David S. Carrell
- Health Research Institute, Kaiser Permanente WashingtonSeattleWashington
| | - Carlos G. Grijalva
- Department of Health PolicyVanderbilt University Medical CenterNashvilleTennessee
| | - Caihua Liang
- EpidemiologyOptumBostonMassachusetts
- EpidemiologyOptumAnn ArborMichigan
| | - Cheryl L. Enger
- EpidemiologyOptumBostonMassachusetts
- EpidemiologyOptumAnn ArborMichigan
| | - Paul M. Coplan
- Epidemiology, Johnson & JohnsonNew BrunswickNew Jersey
- Adjunct, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvania
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Schaffer AL, Buckley NA, Degenhardt L, Larance B, Cairns R, Dobbins TA, Pearson SA. Person-level changes in oxycodone use after the introduction of a tamper-resistant formulation in Australia. CMAJ 2019; 190:E355-E362. [PMID: 29581162 DOI: 10.1503/cmaj.170666] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Australia introduced tamper-resistant controlled-release (CR) oxycodone in April 2014. We quantified the impact of the reformulation on dispensing, switching and poisonings. METHODS We performed interrupted time-series analyses using population-representative national dispensing data from 2012 to 2016. We measured dispensing of oxycodone CR (≥ 10 mg), discontinuation of use of strong opioids and switching to other strong opioids after the reformulation compared with a historical control period. Similarly, we compared calls about intentional opioid poisoning using data from a regional poisons information centre. RESULTS After the reformulation, dispensing decreased for 10-30 mg (total level shift -11.1%, 95% confidence interval [CI], -17.2% to -4.6%) and 40-80 mg oxycodone CR (total level shift -31.5%, 95% CI -37.5% to -24.9%) in participants less than 65 years of age but was unchanged in people 65 years of age or older. Compared with the previous year, discontinuation of use of strong opioids did not increase (adjusted hazard ratio [HR] 0.95, 95% CI 0.91 to 1.00), but switching to oxycodone/naloxone did increase (adjusted HR 1.54, 95% CI 1.32 to 1.79). Switching to morphine varied by age (p < 0.001), and the greatest increase was in participants less than 45 years of age (adjusted HR 4.33, 95% CI 2.13 to 8.80). Participants switching after the reformulation were more likely to be dispensed a tablet strength of 40 mg or more (adjusted odds ratio [OR] 1.40, 95% CI 1.09 to 1.79). Calls for intentional poisoning that involved oxycodone taken orally increased immediately after the reformulation (incidence rate ratio (IRR) 1.31, 95% CI 1.05-1.64), but there was no change for injected oxycodone. INTERPRETATION The reformulation had a greater impact on opioid access patterns of people less than 65 years of age who were using higher strengths of oxycodone CR. This group has been identified as having an increased risk of problematic opioid use and warrants closer monitoring in clinical practice.
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Affiliation(s)
- Andrea L Schaffer
- Centre for Big Data Research in Health (Schaffer, Pearson), University of New South Wales; School of Medical Sciences (Buckley), University of Sydney; National Drug and Alcohol Research Centre (Degenhardt, Larance, Dobbins), University of New South Wales, Sydney, AU; New South Wales Poisons Information Centre (Cairns), Children's Hospital at Westmead, Westmead, AU
| | - Nicholas A Buckley
- Centre for Big Data Research in Health (Schaffer, Pearson), University of New South Wales; School of Medical Sciences (Buckley), University of Sydney; National Drug and Alcohol Research Centre (Degenhardt, Larance, Dobbins), University of New South Wales, Sydney, AU; New South Wales Poisons Information Centre (Cairns), Children's Hospital at Westmead, Westmead, AU
| | - Louisa Degenhardt
- Centre for Big Data Research in Health (Schaffer, Pearson), University of New South Wales; School of Medical Sciences (Buckley), University of Sydney; National Drug and Alcohol Research Centre (Degenhardt, Larance, Dobbins), University of New South Wales, Sydney, AU; New South Wales Poisons Information Centre (Cairns), Children's Hospital at Westmead, Westmead, AU
| | - Briony Larance
- Centre for Big Data Research in Health (Schaffer, Pearson), University of New South Wales; School of Medical Sciences (Buckley), University of Sydney; National Drug and Alcohol Research Centre (Degenhardt, Larance, Dobbins), University of New South Wales, Sydney, AU; New South Wales Poisons Information Centre (Cairns), Children's Hospital at Westmead, Westmead, AU
| | - Rose Cairns
- Centre for Big Data Research in Health (Schaffer, Pearson), University of New South Wales; School of Medical Sciences (Buckley), University of Sydney; National Drug and Alcohol Research Centre (Degenhardt, Larance, Dobbins), University of New South Wales, Sydney, AU; New South Wales Poisons Information Centre (Cairns), Children's Hospital at Westmead, Westmead, AU
| | - Timothy A Dobbins
- Centre for Big Data Research in Health (Schaffer, Pearson), University of New South Wales; School of Medical Sciences (Buckley), University of Sydney; National Drug and Alcohol Research Centre (Degenhardt, Larance, Dobbins), University of New South Wales, Sydney, AU; New South Wales Poisons Information Centre (Cairns), Children's Hospital at Westmead, Westmead, AU
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health (Schaffer, Pearson), University of New South Wales; School of Medical Sciences (Buckley), University of Sydney; National Drug and Alcohol Research Centre (Degenhardt, Larance, Dobbins), University of New South Wales, Sydney, AU; New South Wales Poisons Information Centre (Cairns), Children's Hospital at Westmead, Westmead, AU
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18
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Park K, Otte A. Prevention of Opioid Abuse and Treatment of Opioid Addiction: Current Status and Future Possibilities. Annu Rev Biomed Eng 2019; 21:61-84. [PMID: 30786212 DOI: 10.1146/annurev-bioeng-060418-052155] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Prescription opioid medications have seen a dramatic rise in misuse and abuse, leading regulators and scientists to develop policies and abuse-deterrent technologies to combat the current opioid epidemic. These abuse-deterrent formulations (ADFs) are intended to deter physical and chemical tampering of opioid-based products, while still providing safe and effective delivery for therapeutic purposes. Even though formulations with varying abuse-deterrent technologies have been approved, questions remain about their effectiveness. While these formulations provide a single means to combat the epidemic, a greater emphasis should be placed on formulations for treatment of addiction and overdose to help those struggling with opioid dependence. This article analyzes various ADFs currently in clinical use and explores potential novel systems for treatment of addiction and prevention of overdose.
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Affiliation(s)
- Kinam Park
- Weldon School of Biomedical Engineering and College of Pharmacy, Purdue University, West Lafayette, Indiana 47907, USA
| | - Andrew Otte
- Weldon School of Biomedical Engineering and College of Pharmacy, Purdue University, West Lafayette, Indiana 47907, USA
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19
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Cicero TJ, Mendoza M, Cattaneo M, Dart RC, Mardekian J, Polson M, Roland CL, Schnoll SH, Webster LR, Park PW. Real-world misuse, abuse, and dependence of abuse-deterrent versus non-abuse-deterrent extended-release morphine in Medicaid non-cancer patients. Postgrad Med 2019; 131:225-229. [DOI: 10.1080/00325481.2019.1585688] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Theodore J. Cicero
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
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20
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Peacock A, Larance B, Bruno R, Pearson SA, Buckley NA, Farrell M, Degenhardt L. Post-marketing studies of pharmaceutical opioid abuse-deterrent formulations: a framework for research design and reporting. Addiction 2019; 114:389-399. [PMID: 29989247 PMCID: PMC6599581 DOI: 10.1111/add.14380] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 02/12/2018] [Accepted: 07/04/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND AIMS Opioid formulations with properties to deter abuse (abuse-deterrent formulations; ADFs) have been developed as one response to the prescription opioid 'epidemic'. As for all medicines, ADFs undergo evaluation of safety and efficacy prior to registration for marketing. However, reduced extra-medical use (the primary intended outcome of ADFs and reason for their introduction) can only be established in post-marketing observational studies, comparing them to opioid formulations without abuse-deterrent properties. This has implications for various features of study design and analysis. We discuss proposals for the design, conduct, governance and reporting of post-marketing studies on the effectiveness of pharmaceutical and opioid ADFs. METHODS A review of current guidance documents, public work-shops and forums and our own experience with post-marketing studies of ADFs. RESULTS AND CONCLUSIONS Research questions for post-marketing studies on ADFs of opioids should reasonably be framed around detecting any probable intended or unintended clinical and/or meaningful changes in specific aspects of extra-medical use (e.g. injection use) and harms. Outcomes reported by prevalence and frequency of occurrence and disaggregated by specific product and route of administration can illustrate the magnitude of ADF impact. We argue that a multi-faceted approach is required, using data from both general population and sentinel high-risk cohorts and from primary and secondary data sources. The comparator (historical non-ADF formulation of that opioid, equivalent current generic or similar opioid product), duration of monitoring and analytical approach require justification and should be sufficient to add weight to conclusions of causality. To maximize transparency, we recommend explicit declarations of funding and conflict of interest, establishment of an advisory committee, publication of study protocol and access to study results.
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Affiliation(s)
- Amy Peacock
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney NSW 2052 Australia
- School of Medicine, University of Tasmania, TAS 7001, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney NSW 2052 Australia
| | - Raimondo Bruno
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney NSW 2052 Australia
- School of Medicine, University of Tasmania, TAS 7001, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, University of New South Wales, Australia
| | | | - Michael Farrell
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney NSW 2052 Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney NSW 2052 Australia
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21
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Rauck RL. Mitigation of IV Abuse Through the Use of Abuse-Deterrent Opioid Formulations: An Overview of Current Technologies. Pain Pract 2019; 19:443-454. [PMID: 30597739 PMCID: PMC6849554 DOI: 10.1111/papr.12760] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 11/19/2018] [Accepted: 12/09/2018] [Indexed: 12/19/2022]
Abstract
Providers who treat patients with chronic pain face a dual challenge: providing adequate access to opioid therapies for appropriate pain management while adopting strategies to minimize the risk for abuse. Commonly prescribed opioids have substantial abuse potential when administered intravenously, and extended‐release (ER)/long‐acting (LA) opioids may be targeted for intravenous (IV) abuse because of the higher per‐dose medication level. The consequences of IV opioid abuse are severe and increase the risks for adverse outcomes, including mortality due to acute health events, serious infections, and deep vein thrombosis, to name a few. To reduce the potential for abuse of prescription opioids by both recreational and experienced drug abusers, abuse‐deterrent formulations (ADFs) of opioid medications employ either physical/chemical barriers or agonist‐antagonist combinations. Here we review the development and use of opioid ADFs as a harm‐reduction strategy, and their potential for mitigating IV opioid abuse. The approved ER/LA opioids with ADF labeling in the United States include formulations of oxycodone, hydrocodone, and morphine. Findings from in vitro laboratory tests of abuse deterrence for opioid ADFs are described herein, as are data from human abuse potential studies for IV abuse of those ADF products, for which such studies are feasible (ie, abuse‐deterrent agonist‐antagonist formulations). The available ADF opioids may decrease both the attractiveness and the feasibility of IV abuse. The adoption of ADF opioids represents one tactic for providing access to needed medication for patients with chronic pain, while potentially reducing the risk for opioid abuse, in a comprehensive effort to combat the opioid epidemic.
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Affiliation(s)
- Richard L Rauck
- Carolinas Pain Institute, The Center for Clinical Research, Winston-Salem, North Carolina, U.S.A
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22
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Dasgupta N, Schwarz J, Hennessy S, Ertefaie A, Dart RC. Causal inference for evaluating prescription opioid abuse using trend-in-trend design. Pharmacoepidemiol Drug Saf 2019; 28:716-725. [PMID: 30714239 DOI: 10.1002/pds.4736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/20/2018] [Accepted: 12/26/2018] [Indexed: 11/06/2022]
Abstract
PURPOSE One response to the opioid crisis in the United States has been the development of opioid analgesics with properties intended to reduce non-oral use. Previous evaluations of abuse in the community have relied on population averaged interrupted time series Poisson models with utilization offsets. However, competing interventions and secular trends complicate interpretation of time-series analyses. An alternative research design, trend-in-trend, accounts for heterogeneity in per capita opioid dispensing and unmeasured time-varying confounding, which provides a causal evaluation, provided that underlying assumptions are met. METHODS Trend-in-trend can be modeled using a logistic regression framework. In logistic regression, exposure was any product-specific outpatient dispensing by three-digit ZIP code and calendar quarter, for 22 opioids. The outcome was any product-specific abuse case ascertained from poison centers and drug treatment programs, covering 94% of the US population, between July 2009 and December 2016. Product-specific odds ratios compared places without dispensing with places with any dispensing; the causal contrast represents the odds of product-specific abuse in the community given exposure. RESULTS Dispensing of new and low-volume opioids varied considerably across the country, with no region showing high of all products. Of 22 opioids analyzed, the three with approved labeling as intended to deter abuse ranked near the lowest in both absolute (population-adjusted rates: 1.7, 0.9, and 8.2 per million people per quarter, respectively) and relative measures (trend-in-trend ORs: 1.96, 1.79, 1.69, respectively). CONCLUSIONS Postmarketing studies of prescription opioid abuse may benefit by evolving from unadjusted surveillance rates to a causal inference approach.
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Affiliation(s)
- Nabarun Dasgupta
- Rocky Mountain Poison and Drug Center, Denver Health, Denver, CO, USA.,Injury Prevention Research Center and Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - John Schwarz
- Rocky Mountain Poison and Drug Center, Denver Health, Denver, CO, USA
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training and Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Askhan Ertefaie
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, USA
| | - Richard C Dart
- Rocky Mountain Poison and Drug Center, Denver Health, Denver, CO, USA.,Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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23
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Loeser KC, Rodriguez R. Regulatory and evidence-based considerations for abuse-deterrent opioids. Am J Health Syst Pharm 2019; 76:114-118. [DOI: 10.1093/ajhp/zxy013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Ryan Rodriguez
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL
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24
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Dalal S, Bruera E. Pain Management for Patients With Advanced Cancer in the Opioid Epidemic Era. Am Soc Clin Oncol Educ Book 2019; 39:24-35. [PMID: 31099619 DOI: 10.1200/edbk_100020] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Use of opioids for the treatment of pain is necessary for the majority of patients with advanced cancer, however its use has become challenging in the face of the opioid epidemic and the emerging evidence that patients with cancer are also at risk for nonmedical opioid use. This article proposes an assessment and treatment plan that incorporates universal screening with monitoring for all patients with cancer who are considered for opioid treatment to assess their risk for opioid misuse and harm. Timely identification with appropriate management, including referral of at-risk patients, will allow oncology professionals to optimize the risk-to-benefit and support the safe use of opioids for patients with cancer.
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Affiliation(s)
- Shalini Dalal
- 1 From the Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eduardo Bruera
- 1 From the Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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25
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Burtner J, Behling M, Cassidy T, Butler SF. Prevalence of nonmedical use and routes of administration for prescription stimulant medications among adults in a substance abuse treatment population. J Addict Dis 2018; 37:34-45. [PMID: 30592231 DOI: 10.1080/10550887.2018.1512825] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The aim was to examine prevalence of past 30-day prescription stimulant nonmedical use (NMU) by adults assessed for substance use problems and to better understand patterns of route of administration (ROA) and drug problem severity. Data were collected from a computer administered assessment of substance use problems completed by adults (age ≥ 18) using the Addiction Severity Index-Multimedia Version (ASI-MV®) as part of the clinical intake process between January 2013 and March 2016. A cross-sectional observational study examined prevalence and prescription-adjusted prevalence of past 30-day NMU of prescription stimulants and compound-specific use by ROA (oral, snort, smoke, inject, other oral, and alternate ROA). Compounds of interest were amphetamine extended-release (ER), amphetamine immediate-release (IR), amphetamine mixed salts, methylphenidate ER, and methylphenidate IR. Of 198,411 respondents, 4,185 reported prescription stimulant NMU, prevalence ranged from 0.33% for methylphenidate IR to 1.61% for amphetamine mixed salts. Prescription-adjusted prevalence of NMU was highest for methylphenidate IR (0.51%) and lowest for amphetamine ER (0.28%). The most common ROA was oral, swallowed whole followed by snorting. There was a greater probability of nonmedical prescription stimulant use among respondents with higher drug severity ratings. Results suggest that one should not overlook the impact of prescription stimulant NMU in adults in treatment for substance use problems. NMU of prescription stimulants was associated with riskier routes of administration than reported for college student samples. A pattern of high-risk alternate ROA and increasing drug problem severity has important implications of substance use evaluation.
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26
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Ahmad R, Alaei S, Omidian H. Safety and performance of current abuse-deterrent formulations. Expert Opin Drug Metab Toxicol 2018; 14:1255-1271. [DOI: 10.1080/17425255.2018.1546289] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Rand Ahmad
- College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Samaneh Alaei
- College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Hamid Omidian
- College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL, USA
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Fanelli A, Sorella MC, Ghisi D. Morphine sulfate abuse-deterrent formulations for the treatment of chronic pain. Expert Rev Clin Pharmacol 2018; 11:1157-1162. [DOI: 10.1080/17512433.2018.1545573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Andrea Fanelli
- Anesthesia e Pain Therapy Unit, Policlinico S.Orsola-Malpighi, Bologna, Italy
| | | | - Daniela Ghisi
- Anesthesia, Intensive Care and Pain Therapy, Istituto Ortopedico Rizzoli, Bologna, Italy
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Alpert A, Powell D, Pacula RL. Supply-Side Drug Policy in the Presence of Substitutes: Evidence from the Introduction of Abuse-Deterrent Opioids. AMERICAN ECONOMIC JOURNAL. ECONOMIC POLICY 2018; 10:1-35. [PMID: 34326924 PMCID: PMC8317673 DOI: 10.1257/pol.20170082] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Overdose deaths from prescription opioid pain relievers nearly quadrupled between 1999 and 2010. We study the consequences of one of the largest supply disruptions to date to abusable opioids - the introduction of an abuse-deterrent version of OxyContin in 2010. Supply-side interventions which limit access to opioids may have the unintended consequence of increasing use of substitute drugs, including heroin. Exploiting cross-state variation in OxyContin exposure, we find that states with the highest initial rates of OxyContin misuse experienced the largest increases in heroin deaths. Our results imply that the recent heroin epidemic is largely due to the reformulation of OxyContin.
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Affiliation(s)
- Abby Alpert
- The Wharton School; University of Pennsylvania; Philadelphia, PA 19104
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Bond M, Schoedel KA, Rabinovich-Guilatt L, Gasior M, Tracewell W, Malamut R, Ma Y, Webster LR. Evaluation of the Relative Intranasal Abuse Potential of a Hydrocodone Extended-Release Tablet Formulated with Abuse-Deterrence Technology in Nondependent, Recreational Opioid Users. PAIN MEDICINE 2018; 19:1597-1612. [PMID: 29016880 PMCID: PMC6084602 DOI: 10.1093/pm/pnx133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Objective To assess the intranasal abuse potential of hydrocodone extended-release (ER) tablets developed with CIMA Abuse-Deterrence Technology compared with hydrocodone powder and hydrocodone bitartrate ER capsules (Zohydro ER, original formulation [HYD-OF]). Design Single-dose, randomized, double-blind, quadruple-dummy, active- and placebo-controlled, crossover study. Setting One US site. Subjects Healthy, adult, nondependent, recreational opioid users. Methods Subjects able to tolerate intranasal hydrocodone and discriminate hydrocodone from placebo were eligible for study enrollment. Eligible participants randomly received intranasal hydrocodone ER, intranasal hydrocodone powder, intranasal HYD-OF, intact oral hydrocodone ER, and placebo. Coprimary pharmacodynamic end points were a maximum effect on “at the moment” Drug Liking visual analog scale and Overall Drug Liking visual analog scale. Pharmacokinetics and safety were assessed. Results Mean maximum effect for “at the moment” Drug Liking was significantly (P < 0.01) lower for intranasal hydrocodone ER (72.8) compared with hydrocodone powder (80.2) and HYD-OF (83.2). Similar results were observed for Overall Drug Liking maximum effect (68.5 vs 77.1 and 79.8, respectively; P < 0.01). Secondary end points, including balance of effects and positive, sedative, and other effects, were consistent with these results. Intranasal treatments showed significantly greater effects vs placebo, while intact oral hydrocodone ER was similar to placebo. For each treatment, plasma concentration-time profiles paralleled “at the moment” Drug Liking over time. Incidences of adverse events for intranasal treatments were 52% for hydrocodone ER, 53% for hydrocodone powder, and 61% for HYD-OF. Conclusions The statistically significant differences between hydrocodone ER vs hydrocodone powder and HYD-OF for the primary drug liking end points indicate a lower intranasal abuse potential with hydrocodone ER in healthy, nondependent, recreational opioid users.
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Affiliation(s)
- Mary Bond
- Teva Pharmaceuticals, Inc., Malvern, Pennsylvania, USA
| | | | | | - Maciej Gasior
- Teva Pharmaceuticals, Inc., Frazer, Pennsylvania, USA
| | | | | | - Yuju Ma
- Teva Pharmaceuticals, Inc., Frazer, Pennsylvania, USA
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Kinzler ER, Pantaleon C, Aigner S. Relative Oral Bioavailability of an Abuse-deterrent, Extended-release Formulation of Morphine Versus Extended-release Morphine: A 2-period, Single-dose, Randomized Crossover Study in Healthy Subjects. Clin Ther 2018; 40:1357-1365. [PMID: 30049503 DOI: 10.1016/j.clinthera.2018.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 06/07/2018] [Accepted: 06/13/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE Morphine ARER is a novel oral, abuse-deterrent, extended-release (ER) formulation of morphine sulfate with physical and chemical properties that deter misuse and abuse by nonoral routes of administration. Here we evaluate the relative bioavailability of morphine ARER and extended-release morphine. METHODS This single-dose, 2-treatment, 2-period, 2-sequence, randomized crossover study in healthy adult subjects compared the relative bioavailability of morphine ARER 100 mg to that of ER morphine 100 mg in the fasted condition. At 12 and 1.5 hours before dosing and 12 hours after dosing, all subjects received a 50-mg oral naltrexone tablet to minimize opioid-related side effects. Pharmacokinetic parameters including the AUC0-t, AUC0-∞, and Cmax of morphine and its metabolite morphine-6-glucuronide (M6G) were determined at various times up to 48 hours postdose. The bioequivalence of morphine ARER and ER morphine was determined using an ANOVA of the least-squares mean values of morphine and M6G bioavailability. FINDINGS Forty-nine subjects completed the study. Both morphine ARER and ER morphine exhibited peak plasma morphine and M6G concentrations of ∼30 ng/mL and ∼200 ng/mL, respectively, at 3 hours postdose. The 90% CIs of the ln-transformed values of morphine AUC0-t, AUC0-∞, and Cmax were within the 80% to 125% range for bioequivalence. M6G values also indicated bioequivalence of morphine ARER and ER morphine. The most common adverse events were nausea and somnolence. IMPLICATIONS These data show that, in these subjects, morphine ARER was bioequivalent to ER morphine, a treatment for pain with well-established efficacy and safety profiles.
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Affiliation(s)
- Eric R Kinzler
- Inspirion Delivery Sciences LLC, Morristown, New Jersey.
| | | | - Stefan Aigner
- Inspirion Delivery Sciences LLC, Morristown, New Jersey
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Evaluation of the Relative Abuse of an OROS Extended-release Hydromorphone HCI Product. Clin J Pain 2018; 34:618-628. [DOI: 10.1097/ajp.0000000000000585] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Webster LR, Smith MD, Lawler J, Lindhardt K, Dayno JM. Human Abuse Potential of an Abuse-Deterrent (AD), Extended-Release (ER) Morphine Product Candidate (Morphine-ADER Injection-Molded Tablets) vs Extended-Release Morphine Administered Intranasally in Nondependent Recreational Opioid Users. PAIN MEDICINE 2018; 18:1695-1705. [PMID: 27651510 PMCID: PMC5939830 DOI: 10.1093/pm/pnw219] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective. To compare the relative human abuse potential after insufflation of manipulated morphine abuse-deterrent, extended-release injection-molded tablets (morphine-ADER-IMT) with that of marketed morphine ER tablets. Methods. A randomized, double-blind, double-dummy, active- and placebo-controlled five-way crossover study was performed with adult volunteers who were experienced, nondependent, recreational opioid users. After intranasal (IN) administration of manipulated high-volume (HV) morphine-ADER-IMT (60 mg), participants were randomized (1:1:1:1) to receive IN manipulated low-volume (LV) morphine ER (60 mg), IN manipulated LV morphine-ADER-IMT, intact oral morphine-ADER-IMT (60 mg), and placebo in crossover fashion. Pharmacodynamic and pharmacokinetic assessments included peak effect of drug liking (Emax; primary endpoint) using drug liking visual analog scale (VAS) score, Emax using overall drug liking, and take drug again (TDA) VASs scores, and mean abuse quotient (AQ), a pharmacokinetic parameter associated with drug liking. Results. Forty-six participants completed the study. After insufflation of HV morphine-ADER-IMT and LV morphine-ADER-IMT, drug liking Emax was significantly lower (P < 0.0001) compared with IN morphine ER. Overall drug liking and TDA Emax values were significantly lower (P < 0.0001) after insufflation of HV morphine-ADER-IMT and LV morphine-ADER-IMT compared with IN morphine ER. Mean AQ was lower after insufflation of HV (9.2) and LV (2.3) morphine-ADER-IMT or ingestion of oral morphine-ADER-IMT (5.5) compared with insufflation of LV morphine ER (37.2). Conclusions. All drug liking, take drug again, and abuse quotient endpoints support a significantly lower abuse potential with insufflation of manipulated morphine-ADER-IMT compared with manipulated and insufflated non-AD ER morphine.
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Affiliation(s)
| | | | - John Lawler
- Egalet Corporation, Wayne, Pennsylvania, USA
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Webster LR, Pantaleon C, Shah MS, DiFalco R, Iverson M, Smith MD, Kinzler ER, Aigner S. A Randomized, Double-Blind, Double-Dummy, Placebo-Controlled, Intranasal Drug Liking Study on a Novel Abuse-Deterrent Formulation of Morphine-Morphine ARER. PAIN MEDICINE 2018; 18:1303-1313. [PMID: 27651506 DOI: 10.1093/pm/pnw213] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective Misuse and abuse of prescription opioids remains a major healthcare concern despite considerable efforts to increase public awareness. Abuse-deterrent formulations of prescription opioids are designed to reduce intentional misuse, abuse, and prescription opioid-related death. A novel extended-release (ER) formulation of morphine (Morphine ARER; MorphaBond™) resists physical manipulation and retains the drug's ER characteristics, even if attempts are made to manipulate the formulation. Design This randomized, double-blind, double-dummy, placebo-controlled, four-way crossover study investigated the abuse potential and safety of crushed intranasal and intact oral Morphine ARER compared with commercially available crushed intranasal ER morphine sulfate (ER morphine). Outcome Measures Endpoints included maximum mean drug liking (E max ) as measured by subjects on a bipolar 100 mm visual analog scale (primary), a subject's desire to take the drug again, good effects of the drug, and drug high. Results Twenty-five subjects completed the treatment phase. There was a 40% reduction in E max for crushed intranasal Morphine ARER compared with crushed intranasal ER morphine ( P < .0001). There was no significant difference when comparing the E max for crushed intranasal vs intact Morphine ARER. When comparing crushed intranasal Morphine ARER with ER morphine, subjects reported lower mean scores for good effects of the drug, drug high, and overall drug liking, as well as a lower desire to use Morphine ARER again. Other than adverse events associated with intranasal administration of a drug, all adverse events were typical of those reported for opioid-containing drugs. Conclusions Overall, these data suggest that Morphine ARER has a lower abuse potential via the intranasal route of administration when compared with ER morphine.
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Affiliation(s)
| | | | | | - Ray DiFalco
- Cerovene, Inc., Valley Cottage, New York, USA
| | - Matthew Iverson
- Inspirion Delivery Technologies, LLC, Valley Cottage, New York
| | | | - Eric R Kinzler
- Inspirion Delivery Technologies, LLC, Valley Cottage, New York
| | - Stefan Aigner
- Inspirion Delivery Technologies, LLC, Valley Cottage, New York
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Webster LR, Viscusi ER, Brown C, Dayno JM. Human abuse potential studies of abuse-deterrent opioids: lessons from oral and intranasal studies with morphine abuse-deterrent, extended-release, injection-molded tablets. Curr Med Res Opin 2018; 34:893-901. [PMID: 29368961 DOI: 10.1080/03007995.2018.1433144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The development and use of abuse-deterrent (AD) opioids is part of a multifaceted strategy to reduce misuse, abuse, and diversion, while maintaining access for patients with severe pain who may benefit from their analgesic efficacy. Morphine AD, extended-release (ER), injection-molded tablets (morphine-ADER-IMT; ARYMO ER; Egalet US Inc., Wayne, PA) is approved by the FDA as an AD opioid. As part of the characterization of AD opioids, assessments of their human abuse potential (HAP) are required. Evidence from HAP studies can guide clinicians on the use of AD opioids in clinical practice. Herein, we describe HAP study design, and how specific AD features can impact the conduct of a study and interpretation of its results. OBJECTIVES To review the design features and results of the oral and intranasal HAP studies with morphine-ADER-IMT in order to improve the understanding of key elements of HAP studies of AD opioids. CONCLUSIONS Results from HAP studies with morphine-ADER-IMT and other AD opioids suggest that key study design features include the release profile (immediate-release vs extended-release) of the positive control, study drug doses, and the way the products are manipulated. These elements can directly impact the outcomes of the pharmacokinetic and pharmacodynamic (e.g. Maximum Drug Liking, Overall Drug Liking, and Take Drug Again) results. When evaluating HAP studies, it is important to understand study design features to assist in the interpretation of the results and understand the clinical relevance of the data to help guide clinical decision-making about the use of AD opioids.
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Abstract
Abstract
Abuse-deterrent opioid formulations have been suggested as one way to decrease the abuse, addiction, and overdose of orally prescribed opioids. Ten oral opioid formulations have received abuse-deterrent labeling by the U.S. Food and Drug Administration (FDA). Their properties consist of physical and/or chemical means by which the pills resist manipulation and create a barrier to unintended administration, such as chewing, nasal snorting, smoking, and intravenous injection. In this review, we describe the mechanisms of abuse-deterrent technology, the types of premarketing studies required for FDA approval, the pharmacology of the currently approved abuse-deterrent opioid formulations, and the evidence for and against their influence on opioid abuse. We conclude that there is currently insufficient evidence to indicate that the availability of abuse-deterrent opioid formulations has altered the trajectory of opioid overdose and addiction; however, postmarketing studies are in their infancy, and novel deterrent formulations are continually being developed and submitted for marketing approval.
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Intranasal Pharmacokinetics of Morphine ARER, a Novel Abuse-Deterrent Formulation: Results from a Randomized, Double-Blind, Four-Way Crossover Study in Nondependent, Opioid-Experienced Subjects. Pain Res Manag 2018; 2018:7276021. [PMID: 29849845 PMCID: PMC5937443 DOI: 10.1155/2018/7276021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/01/2018] [Accepted: 03/25/2018] [Indexed: 11/17/2022]
Abstract
Objective To investigate the pharmacokinetics (PK) of Morphine ARER, an extended-release (ER), abuse-deterrent formulation of morphine sulfate after oral and intranasal administration. Methods This randomized, double-blind, double-dummy, placebo-controlled, four-way crossover study assessed the PK of morphine and its active metabolite, M6G, from crushed intranasal Morphine ARER and intact oral Morphine ARER compared with crushed intranasal ER morphine following administration to nondependent, recreational opioid users. The correlation between morphine PK and the pharmacodynamic parameter of drug liking, a measure of abuse potential, was also evaluated. Results Mean maximum observed plasma concentration (Cmax) for morphine was lower with crushed intranasal Morphine ARER (26.2 ng/mL) and intact oral Morphine ARER (18.6 ng/mL), compared with crushed intranasal ER morphine (49.5 ng/mL). The time to Cmax (Tmax) was the same for intact oral and crushed intranasal Morphine ARER (1.6 hours) and longer for crushed intranasal morphine ER (1.1 hours). Higher mean maximum morphine Cmax, Tmax, and abuse quotient (Cmax/Tmax) were positively correlated with maximum effect for drug liking (R2 ≥ 0.9795). Conclusion These data suggest that Morphine ARER maintains its ER profile despite physical manipulation and intranasal administration, which may be predictive of a lower intranasal abuse potential compared with ER morphine.
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Setnik B, Bass A, Bramson C, Levy-Cooperman N, Malhotra B, Matschke K, Geoffroy P, Sommerville KW, Wolfram G. Abuse Potential Study of ALO-02 (Extended-Release Oxycodone Surrounding Sequestered Naltrexone) Compared with Immediate-Release Oxycodone Administered Orally to Nondependent Recreational Opioid Users. PAIN MEDICINE 2018; 18:1077-1088. [PMID: 27550954 PMCID: PMC5914361 DOI: 10.1093/pm/pnw178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective. To evaluate the abuse potential of ALO-02, an abuse-deterrent formulation comprising pellets of extended-release oxycodone hydrochloride surrounding sequestered naltrexone hydrochloride. Design. Randomized, double-blind, placebo-/active-controlled, 6-way crossover study, with naloxone challenge, drug discrimination, and treatment phases. Subjects. Nondependent, recreational opioid users. Methods. Oral administration of crushed and intact ALO-02, crushed immediate-release (IR) oxycodone, and placebo. Primary endpoints were Drug Liking and High measured on visual analog scales and reported as maximum effect (Emax) and area-under-the-effect-curve from 0 to 2 hours (AUE0-2h). Other pharmacodynamic, pharmacokinetic and safety assessments were included. Results. Drug Liking and High (Emax) for crushed oxycodone IR 40 mg were significantly higher compared with placebo, confirming study validity (P < 0.0001). Drug Liking and High (Emax, AUE0-2h) for crushed ALO-02 (40 mg/4.8 mg and 60 mg/7.2 mg) were significantly lower compared to corresponding doses of crushed oxycodone IR (40 and 60 mg; P < 0.0001). Likewise, Drug Liking and High (Emax and AUE0-2h) for intact ALO-02 60 mg/7.2 mg were significantly lower compared with crushed oxycodone IR 60 mg (P < 0.0001). Secondary pharmacodynamic endpoints and plasma concentrations of oxycodone and naltrexone were consistent with these results. Fewer participants experienced adverse events (AEs) after ALO-02 (crushed or intact: 71.1–91.9%) compared with crushed oxycodone IR (100%). Most common AEs following crushed ALO-02 and oxycodone IR were euphoric mood, pruritus, somnolence, and dizziness. Conclusions. The results suggest that ALO-02 (crushed or intact) has lower abuse potential than crushed oxycodone IR when administered orally in nondependent, recreational opioid users.
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Affiliation(s)
- Beatrice Setnik
- Global Product Development, Global Innovative Pharma - Neuroscience & Pain, Pfizer Inc, Durham, NC, USA
| | - Almasa Bass
- Global Product Development, Global Innovative Pharma - Clinical Sciences, Pfizer Inc, Durham, NC, USA
| | - Candace Bramson
- Global Product Development, Global Innovative Pharma - Clinical Sciences, Pfizer Inc, Groton, CT, USA
| | | | - Bimal Malhotra
- Global Product Development, Global Innovative Pharma - Clinical Pharmacology, Pfizer Inc, New York, NY, USA
| | - Kyle Matschke
- Global Product Development, Global Innovative Pharma - Statistics, Pfizer Inc., Collegeville, PA, USA
| | | | - Kenneth W Sommerville
- Global Product Development, Global Innovative Pharma - Neuroscience & Pain, Pfizer Inc, Durham, NC, USA.,Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Gernot Wolfram
- Global Product Development, Global Innovative Pharma - Neuroscience & Pain, Pfizer Inc, Durham, NC, USA
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Vosburg SK, Severtson SG, Dart RC, Cicero TJ, Kurtz SP, Parrino MW, Green JL. Assessment of Tapentadol API Abuse Liability With the Researched Abuse, Diversion and Addiction-Related Surveillance System. THE JOURNAL OF PAIN 2018; 19:439-453. [DOI: 10.1016/j.jpain.2017.11.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 10/18/2017] [Accepted: 11/29/2017] [Indexed: 11/15/2022]
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Pergolizzi JV, Raffa RB, Taylor R, Vacalis S. Abuse-deterrent opioids: an update on current approaches and considerations. Curr Med Res Opin 2018; 34:711-723. [PMID: 29262730 DOI: 10.1080/03007995.2017.1419171] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Abuse and misuse of prescription opioids is a significant public health concern. This review examines the strategies used to confer abuse-deterrent properties on opioid abuse-deterrent formulations (ADFs), the characteristics and supporting data for each of the available ADFs, and the role of opioid ADFs as part of a comprehensive opioid risk management plan. METHODS A PubMed search was performed for articles published within the last 10 years using the search terms "abuse deterrent opioids". Articles were limited to clinical studies and reviews focusing on United States (US) Food and Drug Administration (FDA)-approved opioid ADFs in the US. RESULTS There are currently nine extended-release and one immediate-release opioid pain medications with US FDA-approved ADF labelling. All use either physical and chemical barriers or agonist/antagonist combinations to deter manipulation and abuse. Evidence is mounting that introduction of opioid ADFs has been associated with decreased rates of abuse and diversion of opioids in the US. CONCLUSIONS Although not sufficient by themselves to prevent prescription opioid abuse and misuse, opioid ADFs are an important component of a healthcare provider's comprehensive opioid risk management plan (along with utilization of prescription drug monitoring programs, clinical assessment tools, urine tests, co-prescribing of naloxone to patients at risk of an overdose, access to non-pharmacological treatments and addiction/mental health resources, among others). Adoption of opioid ADFs should be considered as part of an overall public health opioid risk management plan involving all stakeholders to balance legitimate safe and effective use of opioids against misuse and abuse.
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Affiliation(s)
| | - Robert B Raffa
- b University of Arizona College of Pharmacy , Tucson , AZ , USA
- c Temple University School of Pharmacy , Philadelphia , PA , USA
| | | | - Steven Vacalis
- d CaroMont Family Medicine-Gastonia , Gastonia , NC , USA
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Bluthenthal RN, Chu D, Wenger LD, Bourgois P, Valente T, Kral AH. Differences in time to injection onset by drug in California: Implications for the emerging heroin epidemic. Drug Alcohol Depend 2018; 185:253-259. [PMID: 29477084 PMCID: PMC5889717 DOI: 10.1016/j.drugalcdep.2018.01.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Revised: 01/02/2018] [Accepted: 01/04/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Heroin use is increasing in the US. Heroin use may predispose users towards injection routes of drug administration as compared to other illicit substances. OBJECTIVE To explore the relationship between heroin use and drug injection, we compared time from first use to first injection (referred to as time to injection onset by drug [TTIOD]) of heroin, methamphetamine/speed, cocaine, and crack cocaine among people who inject drugs (PWID). METHODS Age of first use and first injection by drug was collected from 776 PWID. Survival analyses were used to determine TTIOD and to examine demographic factors associated with TTIOD. Cox regression analysis was used to determine demographic factors associated with drug-specific injection onset. RESULTS The eventual injection onset rate by the drug was 99% for participants who used heroin, 85% for participants who used methamphetamine/speed, 80% for participants who used powder cocaine, and 38% for participants who used crack cocaine. Hazard ratios for injection use within one year of first use by drug were: 1.37 (median survival time [MST] = 0.61 years) for heroin, 0.66 (MST = 1.10 years) for methamphetamine/speed, 0.50 (MST = 2.93 years) for powder cocaine, and 0.12 (MST = 39.59 years) for crack cocaine. Demographic differences in TTIOD were found for each drug. Demographic differences were found for eventual injection by drug for all substances except heroin. CONCLUSION Among PWID, heroin use was associated with a more rapid transition to injection and a higher rate of eventual heroin injection regardless of demographics. More robust, innovative efforts to reduce heroin use and prevent injection initiation are urgently needed.
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Affiliation(s)
- Ricky N Bluthenthal
- Department of Preventive Medicine, Institute for Prevention Research, Keck School of Medicine, University of Southern California, 2001 N. Soto Street, Los Angeles, CA, United States.
| | - Daniel Chu
- Department of Preventive Medicine, Institute for Prevention Research, Keck School of Medicine, University of Southern California, 2001 N. Soto Street, Los Angeles, CA, United States
| | - Lynn D Wenger
- Behavioral and Urban Health Program, RTI International, 351 California St., San Francisco, CA, United States
| | - Philippe Bourgois
- Department of Psychiatry and Biobehavioral Sciences, UCLA Center for Social Medicine and the Humanities, Semel Institute, 760 Westwood Plaza, Los Angeles, CA, United States
| | - Thomas Valente
- Department of Preventive Medicine, Institute for Prevention Research, Keck School of Medicine, University of Southern California, 2001 N. Soto Street, Los Angeles, CA, United States
| | - Alex H Kral
- Behavioral and Urban Health Program, RTI International, 351 California St., San Francisco, CA, United States
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Smith MD, Webster LR, Lawler J, Lindhardt K, Dayno JM. Human Abuse Potential of an Abuse-Deterrent (AD), Extended-Release (ER) Morphine Product Candidate (Morphine-ADER Injection-Molded Tablets) versus Extended-Release Morphine Administered Orally in Nondependent Recreational Opioid Users. PAIN MEDICINE 2018; 18:898-907. [PMID: 27633773 PMCID: PMC5431384 DOI: 10.1093/pm/pnw174] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objective. To compare the relative human abuse potential of intact and manipulated morphine abuse-deterrent, extended-release injection-molded tablets (morphine-ADER-IMT) with that of marketed morphine sulfate ER tablets Methods. This randomized, double-blind, triple-dummy, active- and placebo-controlled, 4-way crossover, single-center study included adult volunteers who were experienced, nondependent, recreational opioid users. Participants were randomized 1:1:1:1 to placebo, morphine-ADER-IMT (60 mg, intact), morphine-ADER-IMT (60 mg, manipulated), and morphine ER (60 mg, manipulated) and received 1 dose of each oral agent in crossover fashion, separated by ≥5 days. Pharmacodynamic and pharmacokinetic endpoints were assessed, including the primary endpoint of peak effect of Drug Liking (Emax) via Drug Liking Visual Analog Scale (VAS) score and the secondary endpoints of time to Emax (TEmax) and mean abuse quotient (AQ; a pharmacokinetic parameter associated with drug liking). Results. Thirty-eight participants completed the study. Median Drug Liking VAS Emax was significantly lower after treatment with manipulated morphine-ADER-IMT (67) compared with manipulated morphine ER (74; P = 0.007). TEmax was significantly shorter after treatment with manipulated morphine ER compared with intact (P < 0.0001) or manipulated (P = 0.004) morphine-ADER-IMT. Mean AQ was lower after treatment with intact (5.7) or manipulated (16.4) morphine-ADER-IMT compared with manipulated morphine ER (45.9). Conclusions. Manipulated morphine-ADER-IMT demonstrated significantly lower Drug Liking Emax compared with manipulated morphine ER when administered orally. Morphine-ADER-IMT would be an important new AD, ER morphine product with lower potential for unintentional misuse by chewing or intentional manipulation for oral abuse than currently available non-AD morphine ER products.
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Affiliation(s)
| | | | - John Lawler
- Egalet Corporation, Wayne, Pennsylvania, USA
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Challenges Involved in the Development and Delivery of Abuse-deterrent Formulations of Opioid Analgesics. Clin Ther 2018; 40:334-344. [PMID: 29398162 DOI: 10.1016/j.clinthera.2018.01.003] [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] [Received: 10/29/2017] [Revised: 12/20/2017] [Accepted: 01/02/2018] [Indexed: 11/22/2022]
Abstract
PURPOSE This commentary examines the development, regulatory, and reimbursement challenges facing abuse-deterrent formulation (ADF) products. METHODS In January 2017, the Tufts Center for the Study of Drug Development convened a roundtable to explore clinical development, regulatory, and reimbursement challenges with respect to ADFs of opioid analgesics. Roundtable participants, who included a range of pharmaceutical industry and other experts, discussed multiple challenges. FINDINGS First, several key clinical development challenges were identified and discussed. These challenges pertain to prodrug development and development of deterrents against oral abuse. Second, experts suggested that more clarity is needed from regulatory authorities regarding standards for proving ADF labeling claims and for being rewarded with 3-year data exclusivity. Similarly, given the substantial burdens associated with the development of postapproval evidence generation, experts raised the need for a consistent regulatory policy related to postapproval evidence generation for all ADFs (branded and generic). Third, despite the public health benefits of certain ADF products, current coverage and access policies impede patient access. Payer justification for restrictive policies appears to be based more on budget impact considerations than cost-effectiveness. Fourth, there remains a need to further expand the evidence base regarding clinical and cost-effectiveness as well as abuse deterrence in a real-world setting for all ADF products. IMPLICATIONS Clinical development challenges need to be overcome with respect to novel ADF technologies, such as prodrugs and deterrents against oral abuse. More clarity is needed from regulatory authorities on labeling claims and data exclusivity eligibility with respect to ADFs. Ensuring prescriber training and awareness of various options for treating pain, including ADF products, is an important step, as is educating payers about the public health benefits of ADFs in appropriate subpopulations of pain patients. In addition, physicians may need to incorporate appropriate risk stratification methods. Finally, it is important to establish a level playing field between coverage of ADF and non-ADF products so that non-ADF products are not given preferred formulary placement.
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Larance B, Dobbins T, Peacock A, Ali R, Bruno R, Lintzeris N, Farrell M, Degenhardt L. The effect of a potentially tamper-resistant oxycodone formulation on opioid use and harm: main findings of the National Opioid Medications Abuse Deterrence (NOMAD) study. Lancet Psychiatry 2018; 5:155-166. [PMID: 29336948 DOI: 10.1016/s2215-0366(18)30003-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 11/20/2017] [Accepted: 11/22/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND Escalation of pharmaceutical opioid use and harm in North America is well-documented, with similar issues emerging in Australia. One response is the development of tamper-resistant formulations of opioids. A potentially tamper-resistant formulation of controlled-release oxycodone was introduced in Australia in April, 2014, rapidly replacing the non-tamper-resistant formulation. Our study is the most systematic and comprehensive examination of the impact of a new opioid formulation to date, assessing the effect of tamper-resistant formulation of controlled-release oxycodone on population-level opioid use and opioid-related harm (ie, overdose, help-seeking, and treatment-seeking); and opioid use, tampering, and preference for the tamper-resistant formulation of controlled-release oxycodone compared with other drugs or formulations among sentinel populations likely to tamper with pharmaceutical opioids. METHODS We conducted interrupted time-series analyses of opioid sales data and multiple routinely collected health datasets, followed up a cohort of people who tamper with pharmaceutical opioids before and after the introduction of the tamper-resistant formulation of controlled-release oxycodone, and analysed annual surveys of people who inject drugs. Data were collected from several Australian states: New South Wales, South Australia, and Tasmania. Meta-analyses (weighted Z tests) were conducted to synthesise across data sources providing evidence for a given indicator. FINDINGS At the population level, we found reduced sales of higher strengths of controlled-release oxycodone and increased sales of other oxycodone formulations. No significant effect was observed among population-level indicators of opioid overdose, or help or treatment-seeking. Mortality data were not available for inclusion at the time of our study. Meta-analyses across sentinel populations (ie, prospective cohort, surveys of people who inject drugs, and clients of supervised injecting facilities or needle and syringe programmes) indicated reduced controlled-release oxycodone use via tampering (mainly injection), with no evidence of switching to heroin or other drug use. INTERPRETATION This formulation of controlled-release oxycodone reduced tampering with pharmaceutical opioids among people who inject drugs, but did not affect population-level opioid use or harm. FUNDING Mundipharma Australia, the Australian Government, and the National Health and Medical Research Council.
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Affiliation(s)
- Briony Larance
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.
| | - Timothy Dobbins
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Amy Peacock
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Robert Ali
- Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Raimondo Bruno
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia; School of Medicine, University of Tasmania, Hobart, TAS, Australia
| | - Nicholas Lintzeris
- Sydney Medical School, Sydney University, Sydney, NSW, Australia; The Langton Centre, South East Sydney Local Health District Drug and Alcohol Services, Sydney, NSW, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia; School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Global Health, School of Public Health, University of Washington, Washington, DC, USA
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Mayock SP, Saim S, Fleming AB. In Vitro Drug Release After Crushing: Evaluation of Xtampza ® ER and Other ER Opioid Formulations. Clin Drug Investig 2018; 37:1117-1124. [PMID: 28940174 PMCID: PMC5684282 DOI: 10.1007/s40261-017-0561-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background and Objective Extended-release (ER) opioids are associated with high rates of abuse. Recreational opioid users often manipulate ER formulations to achieve a high plasma concentration in a short amount of time, resulting in a more rapid and intense high. Patients may also manipulate ER tablets to facilitate swallowing, without recognizing that manipulation could increase release rate. The goal of this study was to assess the ability of oxycodone DETERx (Xtampza® ER, Collegium Pharmaceutical, Inc., Canton, MA, USA) and other commercially available ER opioid formulations with and without physicochemical abuse-deterrent characteristics to be manipulated by crushing in an in vitro setting. Methods In vitro dissolution techniques were used to compare the opioid release from a variety of ER opioid formulations. Dissolution was assessed for intact and crushed dosage forms. Opioid release was quantified using high-performance liquid chromatography. Results Intact formulations exhibited drug release rates characteristic of 12- or 24-h dosage forms. After crushing using commonly available household tools, only Xtampza ER maintained ER of opioid. Conclusions Xtampza ER maintained its ER characteristics after crushing, unlike many other commercially available opioid formulations, including some formulated with abuse-deterrent properties. As such, Xtampza ER may be less appealing to abusers and offer a margin of safety for patients who manipulate dosage forms to facilitate swallowing.
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Affiliation(s)
- Stephen P Mayock
- Collegium Pharmaceutical, Inc., 780 Dedham St, Ste 800, Canton, MA, 02021, USA
| | - Said Saim
- Collegium Pharmaceutical, Inc., 780 Dedham St, Ste 800, Canton, MA, 02021, USA
| | - Alison B Fleming
- Collegium Pharmaceutical, Inc., 780 Dedham St, Ste 800, Canton, MA, 02021, USA.
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Understanding abuse of buprenorphine/naloxone film versus tablet products using data from ASI-MV® substance use disorder treatment centers and RADARS® System Poison Centers. J Subst Abuse Treat 2018; 84:42-49. [DOI: 10.1016/j.jsat.2017.10.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 10/23/2017] [Accepted: 10/25/2017] [Indexed: 11/18/2022]
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Ladegaard I. Instantly Hooked? Freebies and Samples of Opioids, Cannabis, MDMA, and Other Drugs in an Illicit E-Commerce Market. JOURNAL OF DRUG ISSUES 2017. [DOI: 10.1177/0022042617746975] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Do drug dealers entice nonusers with free samples? Police, the popular press, and social media users say so, but crime researchers have found little support for this theory and argue instead that sample distribution is an unsound strategy for illegal market business. But what about in digital drug markets, where operational logics are based on sophisticated anonymization technology and reputation systems? The author collected data from a large e-commerce website for drugs over 305 days in 2014 and 2015 and documents that (a) drug dealers give away samples of all major substance categories and (b) sample distribution increases vendor sales for prescription drugs and opioid-based painkillers. To explore possible explanations of these findings, the author collected data from the market’s online forum and analyzed 175 discussions (2,218 posts) about samples. Among the findings is that samples are preferably given to reputable review writers, or “drug critics.”
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Cepeda MS, Coplan PM, Kopper NW, Maziere JY, Wedin GP, Wallace LE. ER/LA Opioid Analgesics REMS: Overview of Ongoing Assessments of Its Progress and Its Impact on Health Outcomes. PAIN MEDICINE 2017; 18:78-85. [PMID: 27373304 PMCID: PMC5283702 DOI: 10.1093/pm/pnw129] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objective. Opioid abuse is a serious public health concern. In response, the Food and Drug Administration (FDA) determined that a risk evaluation and mitigation strategy (REMS) for extended-release and long-acting (ER/LA) opioids was necessary to ensure that the benefits of these analgesics continue to outweigh the risks. Key components of the REMS are training for prescribers through accredited continuing education (CE), and providing patient educational materials. Methods. The impact of this REMS has been assessed using diverse metrics including evaluation of prescriber and patient understanding of the risks associated with opioids; patient receipt and comprehension of the medication guide and patient counseling document; patient satisfaction with access to opioids; drug utilization and changes in prescribing patterns; and surveillance of ER/LA opioid misuse, abuse, overdose, addiction, and death. Results and Conclusions. The results of these assessments indicate that the increasing rates of opioid abuse, addiction, overdose, and death observed prior to implementation of the REMS have since leveled off or started to decline. However, these benefits cannot be attributed solely to the ER/LA opioid analgesics REMS since many other initiatives to prevent abuse occurred contemporaneously. These improvements occurred while preserving patient access to opioids as a large majority of patients surveyed expressed satisfaction with their access to opioids.
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Affiliation(s)
- M Soledad Cepeda
- Department of Epidemiology, Janssen Research and Development, Titusville, New Jersey, NJ, USA
| | - Paul M Coplan
- Department of Risk Management and Epidemiology, Purdue Pharma L.P., Stamford, Connecticut, CT, USA.,Adjunct, Department of Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Nathan W Kopper
- Department of Drug Safety, Mallinckrodt Pharmaceuticals, Inc., Hazelwood, Missouri, MO, USA
| | - Jean-Yves Maziere
- REMS, Labeling, Drug Safety, Boehringer Ingelheim Roxane, Inc./Roxane Laboratories, Inc. Columbus, Ohio, OH, USA
| | - Gregory P Wedin
- Department of Drug Safety, Upsher-Smith Laboratories, Inc., Maple Grove, Minnesota, USA
| | - Laura E Wallace
- Department of Risk Management and Epidemiology, Purdue Pharma L.P., Stamford, Connecticut, CT, USA
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Darwish M, Bond M, Ma Y, Tracewell W, Robertson P, Webster LR. Abuse Potential with Oral Route of Administration of a Hydrocodone Extended-Release Tablet Formulated with Abuse-Deterrence Technology in Nondependent, Recreational Opioid Users. PAIN MEDICINE 2017; 18:61-77. [PMID: 27330154 PMCID: PMC5283701 DOI: 10.1093/pm/pnw122] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective. To compare the oral abuse potential of hydrocodone extended-release (ER) tablet developed with CIMA® Abuse-Deterrence Technology with that of hydrocodone immediate release (IR). Design. Randomized, double-blind, placebo-controlled, crossover study. Setting and Patients. One study site in the United States; adult nondependent, recreational opioid users. Methods. After confirming their ability to tolerate and discriminate hydrocodone IR 45 mg from placebo, eligible participants were randomized to receive each of the following oral treatments once: finely crushed placebo, hydrocodone IR 45-mg powder, intact hydrocodone ER 45-mg tablet, and finely crushed hydrocodone ER 45-mg tablet. Primary pharmacodynamic measure was “at the moment” drug liking. Secondary measures included overall drug liking, drug effects (e.g., balance, positive, negative, sedative), pupillometry, pharmacokinetics, and safety. Results. Mean maximum effect (Emax) for “at the moment” drug liking was significantly lower for intact (53.9) and finely crushed hydrocodone ER (66.9) vs. hydrocodone IR (85.2; P < 0.001). Drug liking for intact hydrocodone ER was comparable to placebo (Emax: 53.9 vs. 53.2). Secondary measures were consistent with these results, indicating that positive, negative, and sedative drug effects were diminished with intact and crushed hydrocodone ER tablet vs. hydrocodone IR. The 72-hour plasma concentration-time profile for each treatment mimicked its respective “at the moment” drug-liking-over-time profile. Incidence of adverse events was lower with intact hydrocodone ER (53%) vs. hydrocodone IR (79%) and finely crushed hydrocodone ER (73%). Conclusions. The oral abuse potential of hydrocodone ER (intact and finely crushed) was significantly lower than hydrocodone IR in healthy, nondependent, recreational opioid users. Hydrocodone ER was generally well tolerated.
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Affiliation(s)
- Mona Darwish
- Department of Clinical Pharmacology (Teva), Sci-Med Bridge, LLC, Malvern, Pennsylvania, USA
| | - Mary Bond
- Departments of Clinical Pharmacology, Teva Pharmaceuticals, Frazer, PA, USA
| | - Yuju Ma
- Biometrics, Teva Pharmaceuticals, Frazer, Pennsylvania, USA
| | | | | | - Lynn R Webster
- Department of Scientific Affairs, PRA Health Sciences, Raleigh, North Carolina, USA
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