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Lemen PM, Garrett DP, Thompson E, Aho M, Vasquez C, Park JN. High-dose naloxone formulations are not as essential as we thought. Harm Reduct J 2024; 21:93. [PMID: 38741224 PMCID: PMC11089786 DOI: 10.1186/s12954-024-00994-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 03/31/2024] [Indexed: 05/16/2024] Open
Abstract
Naloxone is an effective FDA-approved opioid antagonist for reversing opioid overdoses. Naloxone is available to the public and can be administered through intramuscular (IM), intravenous (IV), and intranasal spray (IN) routes. Our literature review investigates the adequacy of two doses of standard IM or IN naloxone in reversing fentanyl overdoses compared to newer high-dose naloxone formulations. Moreover, our initiative incorporates the experiences of people who use drugs, enabling a more practical and contextually-grounded analysis. The evidence indicates that the vast majority of fentanyl overdoses can be successfully reversed using two standard IM or IN dosages. Exceptions include cases of carfentanil overdose, which necessitates ≥ 3 doses for reversal. Multiple studies documented the risk of precipitated withdrawal using ≥ 2 doses of naloxone, notably including the possibility of recurring overdose symptoms after resuscitation, contingent upon the half-life of the specific opioid involved. We recommend distributing multiple doses of standard IM or IN naloxone to bystanders and educating individuals on the adequacy of two doses in reversing fentanyl overdoses. Individuals should continue administration until the recipient is revived, ensuring appropriate intervals between each dose along with rescue breaths, and calling emergency medical services if the individual is unresponsive after two doses. We do not recommend high-dose naloxone formulations as a substitute for four doses of IM or IN naloxone due to the higher cost, risk of precipitated withdrawal, and limited evidence compared to standard doses. Future research must take into consideration lived and living experience, scientific evidence, conflicts of interest, and the bodily autonomy of people who use drugs.
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Affiliation(s)
- Paige M Lemen
- Tennessee Harm Reduction, 1989 Madison Avenue, 7, Memphis, TN, 38104, USA.
- University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Daniel P Garrett
- Tennessee Harm Reduction, 1989 Madison Avenue, 7, Memphis, TN, 38104, USA
| | - Erin Thompson
- Harm Reduction Innovation Lab, Rhode Island Hospital, Providence, RI, USA
| | - Megan Aho
- Harm Reduction Innovation Lab, Rhode Island Hospital, Providence, RI, USA
| | - Christina Vasquez
- Harm Reduction Innovation Lab, Rhode Island Hospital, Providence, RI, USA
- The Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Ju Nyeong Park
- Harm Reduction Innovation Lab, Rhode Island Hospital, Providence, RI, USA
- The Warren Alpert Medical School, Brown University, Providence, RI, USA
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2
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Lemen PM, Garrett DP, Thompson E, Aho M, Vasquez C, Park JN. High-Dose Naloxone Formulations Are Not as Essential as We Thought. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.07.23293781. [PMID: 37645849 PMCID: PMC10462226 DOI: 10.1101/2023.08.07.23293781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Naloxone is a U.S. Food and Drug Administration (FDA) approved opioid antagonist for reversing opioid overdoses. Naloxone is available to the public, and can be administered through intramuscular (IM), intravenous (IV), and intranasal spray (IN) routes. Our literature review aimed to improve understanding regarding the adequacy of the regularly distributed two doses of low-dose IM or IN naloxone in effectively reversing fentanyl overdoses and whether high-dose naloxone formulations (HDNF) formulations are an optimal solution to this problem. Moreover, our initiative incorporated the perspectives and experiences of people who use drugs (PWUD), enabling a more practical and contextually-grounded analysis. We began by discussing the knowledge and perspectives of Tennessee Harm Reduction, a small peer-led harm reduction organization. A comprehensive literature review was then conducted to gather relevant scholarly works on the subject matter. The evidence indicates that, although higher doses of naloxone have been administered in both clinical and community settings, the vast majority of fentanyl overdoses can be successfully reversed using standard IM dosages with the exception of carfentanil overdoses and other more potent fentanyl analogs, which necessitate three or more doses for effective reversal. Multiple studies documented the risk of precipitated withdrawal using high doses of naloxone. Notably, the possibility of recurring overdose symptoms after resuscitation exists, contingent upon the half-life of the specific opioid. Considering these findings and the current community practice of distributing multiple doses, we recommend providing at least four standard doses of IN or IM naloxone to each potential bystander, and training them to continue administration until the recipient achieves stability, ensuring appropriate intervals between each dose. Based on the evidence, we do not recommend HDNF in the place of providing four doses of standard naloxone due to the higher cost, risk of precipitated withdrawal and limited evidence compared to standard IN and IM. All results must be taken into consideration with the inclusion of the lived experiences, individual requirements, and consent of PWUD as crucial factors. It is imperative to refrain from formulating decisions concerning PWUD in their absence, as their participation and voices should be integral to the decision-making process.
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3
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Edinoff AN, Martinez Garza D, Vining SP, Vasterling ME, Jackson ED, Murnane KS, Kaye AM, Fair RN, Torres YJL, Badr AE, Cornett EM, Kaye AD. New Synthetic Opioids: Clinical Considerations and Dangers. Pain Ther 2023; 12:399-421. [PMID: 36826742 PMCID: PMC9950705 DOI: 10.1007/s40122-023-00481-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/30/2023] [Indexed: 02/25/2023] Open
Abstract
Since the early 2010s, synthetic opioids have significantly contributed to overall opioid-related overdose mortalities. For point of reference, of the 68,630 opioid-related deaths recorded in 2020, 56,516 involved synthetic opioids. During much of this period, fentanyl has been the most commonly used synthetic opioid. This time when fentanyl was the most popular opioid has been called the "third wave" of the opioid crisis, partly because it led to a sharp rise in deaths from overdoses. Other synthetic opioids, such as carfentanil, protonitazene, and isotonitazene, have also become more widely diverted for nonmedical used. Carfentanil is an even more potent fentanyl derivative that was initially used in the mid-1980s as a general anesthetic for large animals such as elephants. Related to its strong affinity for mu opioid receptors, carfentanil is still utilized in medicine and science today as a radiotracer for positron emission tomography imaging. Protonitazene and isotonitazene belong to a novel class of synthetic opioids called benzimidazoles that were manufactured in the 1950s as novel analgesics. These agents have come under recent scrutiny as designer synthetic opioids becoming more prevalent. However, to date, there is incomplete data regarding the prevalence of synthetic opioids, as traditional toxicology screenings may not be sensitive to detect these compounds at such low doses post-mortem, particularly when blood is drawn from the periphery instead of central tissues such as the brain, lung, or heart. This narrative review aims to highlight the clinical challenges presented by these new synthetic opioids.
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Affiliation(s)
- Amber N Edinoff
- Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.
- Louisiana Addiction Research Center, Shreveport, LA, 71103, USA.
| | - David Martinez Garza
- Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Stephen P Vining
- Louisiana State University Health Science Center at Shreveport, School of Medicine, Shreveport, LA, 71103, USA
| | - Megan E Vasterling
- Louisiana State University Health at New Orleans, School of Medicine, New Orleans, LA, 70112, USA
| | - Eric D Jackson
- University of Arizona College of Medicine - Phoenix, Phoenix, AZ, 85004, USA
| | - Kevin S Murnane
- Louisiana Addiction Research Center, Shreveport, LA, 71103, USA
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Science Center at Shreveport, Shreveport, LA, 71130, USA
- Department of Pharmacology, Toxicology & Neuroscience, Louisiana State University Health Science Center at Shreveport, Shreveport, LA, 71103, USA
| | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA, 95211, USA
| | - Richard N Fair
- Department of Anesthesiology, Louisiana State University Health Science Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71130-3932, USA
| | - Yair Jose Lopez Torres
- Department of Anesthesiology, Louisiana State University Health Science Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71130-3932, USA
| | - Ahmed E Badr
- Department of Anesthesiology, Louisiana State University Health Science Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71130-3932, USA
| | - Elyse M Cornett
- Louisiana Addiction Research Center, Shreveport, LA, 71103, USA.
- Department of Anesthesiology, Louisiana State University Health Science Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71130-3932, USA.
- Department of Pharmacology, Toxicology & Neuroscience, Louisiana State University Health Science Center at Shreveport, Shreveport, LA, 71103, USA.
| | - Alan D Kaye
- Louisiana Addiction Research Center, Shreveport, LA, 71103, USA
- Department of Anesthesiology, Louisiana State University Health Science Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71130-3932, USA
- Department of Pharmacology, Toxicology & Neuroscience, Louisiana State University Health Science Center at Shreveport, Shreveport, LA, 71103, USA
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4
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Wei J, Lai M, Li F, Chen Y, Li X, Qiu Y, Shen H, Xu P, Di B. Assessment of abuse potential of carfentanil. Addict Biol 2023; 28:e13265. [PMID: 36692872 DOI: 10.1111/adb.13265] [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: 05/10/2022] [Revised: 11/30/2022] [Accepted: 12/09/2022] [Indexed: 01/09/2023]
Abstract
Carfentanil, as a fentanyl analogue, is a potent synthetic opioid. It has been controlled in many countries, and its emergence has been highlighted by many recent reports. However, although discriminative stimulus effects of carfentanil in rats had been reported, its abuse potential has not been fully evaluated. In this study, we evaluated the abuse potential of carfentanil via the tests of conditioned place preference (CPP), drug self-administration and naloxone-precipitated opioid withdrawal assay, compared with fentanyl and heroin. Carfentanil exhibited significant place preference at a minimum dose of 1 μg/kg in mice, whereas fentanyl and heroin induced significant place preference at the minimum doses of 100 μg/kg and 1000 μg/kg, respectively. In the drug-substitution test in heroin self-administered rats (50 μg/kg/infusion), carfentanil and fentanyl acquired significant self-administrations above saline levels from 0.05-0.1 and 0.1-10.0 μg/kg/infusion, respectively. Carfentanil induced the maximum number of infusions at 0.1 μg/kg, whereas fentanyl and heroin at 1 and 25 μg/kg, respectively. In short, carfentanil showed the highest potency to induce CPP and self-administration. Furthermore, repeated treatment with escalating doses of carfentanil, fentanyl or heroin induced typical withdrawal symptoms in mice, including a greater number of jumping and weight loss than saline group. This indicated that carfentanil could produce physical dependence similar to fentanyl and heroin. Taken together, the present study demonstrated the higher abuse potential of carfentanil compared with fentanyl and heroin. The rank order of abuse potential for these compounds is carfentanil > fentanyl > heroin.
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Affiliation(s)
- Jiayun Wei
- School of Pharmacy, China Pharmaceutical University, Nanjing, China.,Office of China National Narcotics Control Commission, China Pharmaceutical University Joint Laboratory on Key Technologies of Narcotics Control, Beijing, China.,Zhejiang Xiaoshan Hospital, Hangzhou, China
| | - Miaojun Lai
- Laboratory of Behavioral Neuroscience, Key Laboratory of Addiction Research of Zhejiang Province, Ningbo Kangning Hospital, Ningbo, China
| | - Feng Li
- School of Pharmacy, China Pharmaceutical University, Nanjing, China.,Office of China National Narcotics Control Commission, China Pharmaceutical University Joint Laboratory on Key Technologies of Narcotics Control, Beijing, China
| | - Yuanyuan Chen
- School of Pharmacy, China Pharmaceutical University, Nanjing, China.,Office of China National Narcotics Control Commission, China Pharmaceutical University Joint Laboratory on Key Technologies of Narcotics Control, Beijing, China
| | - Xiangyu Li
- Office of China National Narcotics Control Commission, China Pharmaceutical University Joint Laboratory on Key Technologies of Narcotics Control, Beijing, China.,Key Laboratory of Drug Monitoring and Control, Drug Intelligence and Forensic Center, Ministry of Public Security, Beijing, China
| | - Yi Qiu
- National Institute on Drug Dependence, Peking University, Beijing, China
| | - Haowei Shen
- Faculty of Physiology and Pharmacology, School of Medicine, Ningbo University, Ningbo, China
| | - Peng Xu
- School of Pharmacy, China Pharmaceutical University, Nanjing, China.,Office of China National Narcotics Control Commission, China Pharmaceutical University Joint Laboratory on Key Technologies of Narcotics Control, Beijing, China.,Key Laboratory of Drug Monitoring and Control, Drug Intelligence and Forensic Center, Ministry of Public Security, Beijing, China
| | - Bin Di
- School of Pharmacy, China Pharmaceutical University, Nanjing, China.,Office of China National Narcotics Control Commission, China Pharmaceutical University Joint Laboratory on Key Technologies of Narcotics Control, Beijing, China
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5
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Kong L, Walz AJ. Metabolism of the active carfentanil metabolite, 4-Piperidinecarboxylic acid, 1-(2-hydroxy-2-phenylethyl)-4-[(1-oxopropyl)phenylamino]-, methyl ester in vitro. Toxicol Lett 2022; 367:32-39. [PMID: 35835351 DOI: 10.1016/j.toxlet.2022.07.006] [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: 03/10/2022] [Revised: 07/05/2022] [Accepted: 07/11/2022] [Indexed: 10/17/2022]
Abstract
Carfentanil, a µ-opioid receptor (MOR) agonist with an analgesic potency 10,000 times that of morphine, is extensively metabolized to norcarfentanil (M1), 4-Piperidinecarboxylic acid, 1-(2-hydroxy-2-phenylethyl)-4-[(1-oxopropyl)phenylamino]-, methyl ester (M0 in this article), and other low abundant metabolites in human hepatocytes and liver/lung microsomes. M0 possessed comparable MOR activity to carfentanil, and accounted for approximately 12 % of the total carfentanil metabolite formation in human liver microsomes (HLMs). Little is known about the subsequent elimination of M0. This study investigated its metabolic pathway in HLMs, separation and preliminary identification of metabolites by liquid chromatography-tandem mass spectrometry, and possible involvement of cytochrome P450 enzymes in M0 metabolism with kinetic analysis. M0 produced 9 metabolites via N-dealkylation (M1), oxidation (M3, M6-9), N-dealkylation followed by oxidation (M2 and M4), and glucuronidation (M5). Formation of the major metabolite M1 fitted typical Michaelis-Menten kinetics. Recombinant human CYP3A5 showed the highest activity toward M1 formation followed by CYP3A4 and CYP2C8, while M8 was primarily formed by CYP3A4 followed by CYP2C19 and CYP2C8. These findings reveal the main involvement of CYP3A5 and 3A4 in human hepatic elimination of M0 with a kinetic profile similar to carfentanil which may inform development of treatment protocols for carfentanil exposure.
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Affiliation(s)
- Li Kong
- Research and Technology Directorate, Combat Capabilities Development Command Chemical Biological Center, U. S. Army, Aberdeen Proving Ground, MD 21010-5424, United States.
| | - Andrew J Walz
- Research and Technology Directorate, Combat Capabilities Development Command Chemical Biological Center, U. S. Army, Aberdeen Proving Ground, MD 21010-5424, United States
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6
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Abdelal R, Banerjee AR, Carlberg-Racich S, Cebollero C, Darwaza N, Kim C, Ito D, Epstein J. Real-world study of multiple naloxone administrations for opioid overdose reversal among emergency medical service providers. Subst Abus 2022; 43:1075-1084. [PMID: 35442869 DOI: 10.1080/08897077.2022.2060433] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background: The increasing rates of highly potent, illicit synthetic opioids (i.e., fentanyl) in the US is exacerbating the ongoing opioid epidemic. Multiple naloxone administrations (MNA) may be required to successfully reverse opioid overdoses. We conducted a real-world study to assess the rate of MNA for opioid overdose and identify factors associated with MNA. Methods: Data from the 2015-2020 National Emergency Medical Services Information System was examined to determine trends in events requiring MNA. Logistic regression analysis was performed to determine factors associated with MNA. Results: The percentage of individuals receiving MNA increased from 18.4% in 2015 to 28.4% in 2020. The odds of an event requiring MNA significantly increased by 11% annually. The adjusted odds ratio (aOR) for MNA were greatest among males, when advanced life support (ALS) was provided, and when the dispatch complaint indicated there was a drug poisoning event. Conclusions: The 54% increase in MNA since 2015 parallels the rise in overdose deaths attributable to synthetic opioids. This growth is visible in all regions of the country, including the West, where the prevalence of illicitly manufactured synthetic opioids is intensifying. Given this phenomenon, higher naloxone formulations may fulfill an unmet need in addressing the opioid overdose crisis.
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Affiliation(s)
- Randa Abdelal
- Hikma Pharmaceuticals USA Inc, Berkeley Heights, NJ, USA
| | | | | | | | | | - Chong Kim
- Stratevi, LLC, Santa Monica, CA, USA
| | - Diane Ito
- Stratevi, LLC, Santa Monica, CA, USA
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7
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Dale O. Pharmacokinetic considerations for community-based dosing of nasal naloxone in opioid overdose in adults. Expert Opin Drug Metab Toxicol 2022; 18:203-217. [PMID: 35500297 DOI: 10.1080/17425255.2022.2072728] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The administration of the opioid antagonist naloxone in the community is a measure to prevent death from opioid overdose. Approved nasal naloxone sprays deliver initial doses of 0.9 to 8 mg. The level of the initial community dose is controversial, as the scientific base is weak.In this review knowledge of the pharmacokinetics of nasal, both approved and improvised nasal sprays, and intramuscular naloxone will be utilized to evaluate dose-effect relationships in previous studies of opioid overdose outcomes. AREAS COVERED The aim was to present scientifically based considerations on the initial nasal naloxone doses currently available, which reasonably balances the effect and adverse outcomes, given that at least two doses are at hand. Also included in these considerations is the challenge by illicitly manufactured fentanyl and analogs.This paper is based on both peer-reviewed and grey literature identified by several searches, of such as naloxone pharmacokinetics/formulations/outcomes/emergency medical services, in PubMed and Embase. EXPERT OPINION There is little scientific evidence that supports the use of initial systemic dosing that exceeds 0.8 mg in the community. Higher doses increase the risk of withdrawal symptoms feared in people who use opioids. Many obstacles may reduce the potential of community-administered naloxone.
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Affiliation(s)
- Ola Dale
- Department of Circulation and Medical Imaging, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
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8
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Treatment of opioid overdose: current approaches and recent advances. Psychopharmacology (Berl) 2022; 239:2063-2081. [PMID: 35385972 PMCID: PMC8986509 DOI: 10.1007/s00213-022-06125-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 03/18/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The USA has recently entered the third decade of the opioid epidemic. Opioid overdose deaths reached a new record of over 74,000 in a 12-month period ending April 2021. Naloxone is the primary opioid overdose reversal agent, but concern has been raised that naloxone is not efficacious against the pervasive illicit high potency opioids (i.e., fentanyl and fentanyl analogs). METHODS This narrative review provides a brief overview of naloxone, including its history and pharmacology, and the evidence regarding naloxone efficacy against fentanyl and fentanyl analogs. We also highlight current advances in overdose treatments and technologies that have been tested in humans. RESULTS AND CONCLUSIONS The argument that naloxone is not efficacious against fentanyl and fentanyl analogs rests on case studies, retrospective analyses of community outbreaks, pharmacokinetics, and pharmacodynamics. No well-controlled studies have been conducted to test this argument, and the current literature provides limited evidence to suggest that naloxone is ineffective against fentanyl or fentanyl analog overdose. Rather a central concern for treating fentanyl/fentanyl analog overdose is the rapidity of overdose onset and the narrow window for treatment. It is also difficult to determine if other non-opioid substances are contributing to a drug overdose, for which naloxone is not an effective treatment. Alternative pharmacological approaches that are currently being studied in humans include other opioid receptor antagonists (e.g., nalmefene), respiratory stimulants, and buprenorphine. None of these approaches target polysubstance overdose and only one novel approach (a wearable naloxone delivery device) would address the narrow treatment window.
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9
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Flynn SM, France CP. Characterization of the discriminative stimulus effects of binary mixtures of mu opioid receptor agonists in rats discriminating fentanyl. J Pharmacol Exp Ther 2021; 380:171-179. [PMID: 34903563 DOI: 10.1124/jpet.121.000912] [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: 09/07/2021] [Accepted: 12/09/2021] [Indexed: 11/22/2022] Open
Abstract
Drug overdose deaths involving synthetic opioids, primarily fentanyl, have risen dramatically over the past decade and are currently the driving force of the opioid epidemic in the United States. Fentanyl analogs with greater potency than fentanyl (e.g., carfentanil) pose serious risk to public health. While fentanyl analogs are primarily encountered by humans as constituents of a mixture of drugs, research has primarily evaluated the effects of these drugs alone. The present study characterized interactions between mu opioid receptor agonists in seven male Sprague-Dawley rats trained to discriminate 10 µg/kg fentanyl from saline while responding under a fixed-ratio 10 schedule of food presentation. Dose-effect curves were determined for each drug alone and in binary mixtures (fentanyl:heroin, fentanyl:carfentanil, and heroin:carfentanil) at fixed-dose ratios of 3:1, 1:1, and 1:3 relative to the ED50 for each drug when given alone. Dose addition analyses were used to determine the nature of the drug-drug interaction for each mixture. Additive interactions were observed for all binary mixtures at each fixed dose ratio, except the 1:3 fentanyl:carfentanil mixture which exhibited supra-additive effects at the 80% effect level. These results suggest a lack of a significant interaction between the discriminative stimulus effects of these mu opioid receptor agonists at the doses tested in this study. Future studies expanding these findings to the respiratory depressant effects of these drugs are of significant importance to rule out possible interactions directly relevant to opioid overdose that occur at doses much larger than those tested in this study. Significance Statement In the United States, drug overdose deaths involving synthetic opioids, primarily fentanyls including superpotent fentanyl analogs (e.g., carfentanil), have increased 12-fold over the past decade. While previous studies have evaluated the effects of carfentanil alone, fentanyl analogs are encountered by humans as a mixture with other drugs; this study determined the effects of mixtures of carfentanil and other opioids (fentanyl and heroin) to characterize interactions between these drugs that might contribute to their apparent increased lethality in humans.
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Affiliation(s)
- Shawn M Flynn
- University of Texas Health Science Center, United States
| | - Charles P France
- Department of Pharmacology, University of Texas Health Science Center, United States
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10
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Vearrier D, Grundmann O. Clinical Pharmacology, Toxicity, and Abuse Potential of Opioids. J Clin Pharmacol 2021; 61 Suppl 2:S70-S88. [PMID: 34396552 DOI: 10.1002/jcph.1923] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/03/2021] [Indexed: 12/15/2022]
Abstract
Opioids were the most common drug class resulting in overdose deaths in the United States in 2019. Widespread clinical use of prescription opioids for moderate to severe pain contributed to the ongoing opioid epidemic with the subsequent emergence of fentanyl-laced heroin. More potent analogues of fentanyl and structurally diverse opioid receptor agonists such as AH-7921 and MT-45 are fueling an increasingly diverse illicit opioid supply. Overdose from synthetic opioids with high binding affinities may not respond to a typical naloxone dose, thereby rendering autoinjectors less effective, requiring higher antagonist doses or resulting in a confusing clinical picture for health care providers. Nonscheduled opioid drugs such as loperamide and dextromethorphan are associated with dependence and risk of overdose as easier access makes them attractive to opioid users. Despite a common opioid-mediated pathway, several opioids present with unique pharmacodynamic properties leading to acute toxicity and dependence development. Pharmacokinetic considerations involve half-life of the parent opioid and its metabolites as well as resulting toxicity, as is established for tramadol, codeine, and oxycodone. Pharmacokinetic considerations, toxicities, and treatment approaches for notable opioids are reviewed.
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Affiliation(s)
- David Vearrier
- Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Oliver Grundmann
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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11
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Bishop-Freeman SC, Young KA, Aurelius MB, Hudson JS. Pediatric opioid fatalities: What can we learn for prevention? J Forensic Sci 2021; 66:1410-1419. [PMID: 33893645 DOI: 10.1111/1556-4029.14725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/11/2021] [Accepted: 03/23/2021] [Indexed: 11/27/2022]
Abstract
The aim of this study was to highlight 19 cases investigated by the North Carolina Office of the Chief Medical Examiner over the last 12 years involving accidental or undetermined manner of death opioid ingestions leading to fatalities in young children. These pediatric ingestions have closely mirrored the opioid epidemic in adults transitioning from prescription medications to illicit drugs including fentanyl and fentanyl analogues. Unlike a typical adult ingestion for purposes of self-harm or pleasure, poisonings in toddlers and infants are usually the result of curiosity, exploration, a decreased sense of danger, or imitation of adult or older sibling behavior. Eleven of the decedents were between the ages of 8 and 24 months. Among the cases were 12 prescription opioid exposure deaths and 7 illicit drug poisonings. A majority of the decedents were found unresponsive in an unkept home and/or in unsafe sleeping spaces with easy access to drugs or drug materials, which stresses the importance of safe pediatric sleeping conditions. After a complete pathological investigation, several of the cases had physical or scene evidence demonstrating that foil, plastic, or paper small enough to be ingested can contain enough potent opioid to cause death. Details from the toxicological investigation are included for each case to provide postmortem whole blood drug concentrations for forensic practitioners. Accidental pediatric poisonings are preventable. Risk reduction through improving awareness and education of the dangers of opioids is a key factor in mitigating these tragedies.
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Affiliation(s)
- Sandra C Bishop-Freeman
- North Carolina Office of Chief Medical Examiner, Raleigh, NC, USA.,Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Kerry A Young
- North Carolina Office of Chief Medical Examiner, Raleigh, NC, USA
| | - Michelle B Aurelius
- North Carolina Office of Chief Medical Examiner, Raleigh, NC, USA.,Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Jason S Hudson
- North Carolina Office of Chief Medical Examiner, Raleigh, NC, USA
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12
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Flynn SM, France CP. Discriminative stimulus effects of carfentanil in rats discriminating fentanyl: Differential antagonism by naltrexone. Drug Alcohol Depend 2021; 221:108599. [PMID: 33631547 DOI: 10.1016/j.drugalcdep.2021.108599] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/17/2021] [Accepted: 01/21/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND A significant number of deaths caused by opioids involve fentanyl and/or one of its very potent analogs (e.g., carfentanil). Some clinical reports suggest larger doses of opioid receptor antagonists may be required to reverse the effects of carfentanil compared with other opioid receptor agonists, although this has not been examined extensively in vivo. The current study compared the discriminative stimulus effects of fentanyl, carfentanil, and heroin, and their antagonism by naltrexone. METHODS Eight male Sprague-Dawley rats were trained to discriminate 10.0 μg/kg fentanyl from saline while responding under a fixed-ratio 10 schedule of food presentation. Dose-effect curves were determined for the opioid receptor agonists fentanyl (1.0-32.0 μg/kg), carfentanil (0.1-3.2 μg/kg), and heroin (10.0-320.0 μg/kg), then redetermined following a 15-minute pretreatment with 0.1 mg/kg naltrexone. RESULTS Fentanyl, carfentanil, and heroin dose-dependently increased responding on the fentanyl-associated lever and decreased the rate of lever pressing. Carfentanil and heroin were approximately 10-fold more and less potent, respectively, than fentanyl at eliciting >80 % responding on the fentanyl-associated lever. Pretreatment with 0.1 mg/kg naltrexone resulted in a significant rightward shift in the fentanyl and heroin but not carfentanil dose-effect curves. CONCLUSIONS Differences in the effectiveness of naltrexone to attenuate the discriminative stimulus effects of carfentanil, compared with fentanyl and heroin, suggest that there may be differences in how carfentanil exerts its discriminative stimulus effects compared with other opioids. Further evaluation is needed of potential pharmacological and behavioral differences between carfentanil and other opioids, particularly in the context of toxicity.
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Affiliation(s)
- Shawn M Flynn
- Department of Pharmacology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive (Mail Code 7764), San Antonio, TX, 78229, USA; Addiction Research, Treatment and Training (ARTT) Center of Excellence, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Charles P France
- Department of Pharmacology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive (Mail Code 7764), San Antonio, TX, 78229, USA; Addiction Research, Treatment and Training (ARTT) Center of Excellence, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
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13
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Parkin S, Neale J, Brown C, Jones JD, Brandt L, Castillo F, Campbell ANC, Strang J, Comer SD. A qualitative study of repeat naloxone administrations during opioid overdose intervention by people who use opioids in New York City. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 87:102968. [PMID: 33096365 PMCID: PMC7940548 DOI: 10.1016/j.drugpo.2020.102968] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Take-home naloxone (THN) kits have been designed to provide community members (including people who use drugs, their families and/or significant others) with the necessary resources to address out-of-hospital opioid overdose events. Kits typically include two doses of naloxone. This 'twin-pack' format means that lay responders need information on how to use each dose. Advice given tends to be based on dosage algorithms used by medical personnel. However, little is currently known about how and why people who use drugs, acting as lay responders, decide to administer the second dose contained within single THN kits. The aim of this article is to explore this issue. METHODS Data were generated from a qualitative semi-structured interview study that was embedded within a randomised controlled trial examining the risks and benefits of Overdose Education and Naloxone Distribution (OEND) training in New York City (NYC). Analysis for this article focuses upon the experiences of 22 people who use(d) opioids and who provided repeat naloxone administrations (RNA) during 24 separate overdose events. The framework method of analysis was used to compare the time participants believed had passed between each naloxone dose administered ('subjective response interval') with the 'recommended response interval' (2-4 minutes) given during OEND training. Framework analysis also charted the various reasons and rationale for providing RNA during overdose interventions. RESULTS When participants' subjective response intervals were compared with the recommended response interval for naloxone dosing, three different time periods were reported for the 24 overdose events: i. 'two doses administered in under 2 minutes' (n = 10); ii. 'two doses administered within 2-4 minutes' (n = 7), and iii. 'two doses administered more than 4 minutes apart' (n = 7). A variety of reasons were identified for providing RNA within each of the three categories of response interval. Collectively, reasons for RNA included panic, recognition of urgency, delays in retrieving naloxone kit, perceptions of recipients' responsiveness/non-responsiveness to naloxone, and avoidance of Emergency Response Teams (ERT). CONCLUSION Findings suggest that decision-making processes by people who use opioids regarding how and when to provide RNA are influenced by factors that relate to the emergency event. In addition, the majority of RNA (17/24) occurred outside of the recommended response interval taught during OEND training. These findings are discussed in terms of evidence-based intervention and 'evidence-making intervention' with suggestions for how RNA guidance may be developed and included within future/existing models of OEND training.
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Affiliation(s)
- Stephen Parkin
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, SE5 8BB, United Kingdom.
| | - Joanne Neale
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, SE5 8BB, United Kingdom; South London and Maudsley NHS Foundation Trust, Maudsley Hospital, Denmark Hill, London; Centre for Social Research in Health, University of New South Wales, Sydney, NSW 2052, Australia
| | - Caral Brown
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, SE5 8BB, United Kingdom
| | - Jermaine D Jones
- Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States
| | - Laura Brandt
- Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States
| | - Felipe Castillo
- Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States
| | - Aimee N C Campbell
- Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States
| | - John Strang
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, SE5 8BB, United Kingdom; South London and Maudsley NHS Foundation Trust, Maudsley Hospital, Denmark Hill, London
| | - Sandra D Comer
- Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States
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Neale J, Kalk NJ, Parkin S, Brown C, Brandt L, Campbell ANC, Castillo F, Jones JD, Strang J, Comer SD. Factors associated with withdrawal symptoms and anger among people resuscitated from an opioid overdose by take-home naloxone: Exploratory mixed methods analysis. J Subst Abuse Treat 2020; 117:108099. [PMID: 32811629 DOI: 10.1016/j.jsat.2020.108099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/06/2020] [Accepted: 07/25/2020] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Take-home naloxone (THN) is a clinically effective and cost-effective means of reducing opioid overdose fatality. Nonetheless, naloxone administration that successfully saves a person's life can still produce undesirable and harmful effects. AIM To better understand factors associated with two widely reported adverse outcomes following naloxone administration; namely the person resuscitated displays: i. withdrawal symptoms and ii. anger. METHODS A mixed methods study combining a randomized controlled trial of overdose education and naloxone prescribing to people with opioid use disorder and semi-structured qualitative interviews with trial participants who had responded to an overdose whilst in the trial. All data were collected in New York City (2014-2019). A dataset (comprising demographic, pharmacological, situational, interpersonal, and overdose training related variables) was generated by transforming qualitative interview data from 47 overdose events into dichotomous variables and then combining these with quantitative demographic and overdose training related data from the main trial. Associations between variables within the dataset and reports of: i. withdrawal symptoms and ii. anger were explored using chi-squared tests, t-tests, and logistic regressions. RESULTS A multivariate logistic regression found that people who had overdosed were significantly more likely to display anger if the person resuscitating them criticized, berated or chastised them during resuscitation (adjusted OR = 27 [95% CI = 4.0-295]). In contrast, they were significantly less likely to display anger if the person resuscitating them communicated positively with them (OR = 0.10 [95% CI = 0.01-0.78]). Both positive and negative communication styles were independently associated with anger, and communication was associated with 59% of the variance in anger. There was no evidence that people who displayed withdrawal symptoms were more likely to display anger than those not displaying withdrawal symptoms, and neither displaying withdrawal symptoms nor displaying anger were associated with using more drugs after resuscitation. CONCLUSIONS Contrary to common assumptions, withdrawal symptoms and anger following naloxone administration may be unrelated phenomena. Findings are consistent with previous research that has suggested that a lay responder's positive or reassuring communication style may lessen anger post overdose. Implications for improving THN programmes and naloxone administration are discussed.
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Affiliation(s)
- Joanne Neale
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, London, SE5 8BB, United Kingdom; Centre for Social Research in Health, University of New South Wales, Sydney, NSW 2052, Australia; South London and Maudsley NHS Foundation Trust, Camberwell, London, SE5 8AZ, United Kingdom.
| | - Nicola J Kalk
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, London, SE5 8BB, United Kingdom; South London and Maudsley NHS Foundation Trust, Camberwell, London, SE5 8AZ, United Kingdom.
| | - Stephen Parkin
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, London, SE5 8BB, United Kingdom.
| | - Caral Brown
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, London, SE5 8BB, United Kingdom.
| | - Laura Brandt
- Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States.
| | - Aimee N C Campbell
- Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States.
| | - Felipe Castillo
- Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States.
| | - Jermaine D Jones
- Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States.
| | - John Strang
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, London, SE5 8BB, United Kingdom; South London and Maudsley NHS Foundation Trust, Camberwell, London, SE5 8AZ, United Kingdom.
| | - Sandra D Comer
- Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States.
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Ringuette AE, Spock M, Lindsley CW, Bender AM. DARK Classics in Chemical Neuroscience: Carfentanil. ACS Chem Neurosci 2020; 11:3955-3967. [PMID: 32786301 DOI: 10.1021/acschemneuro.0c00441] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Because of its remarkable potency and relative ease of synthesis, carfentanil (1) has recently emerged as a problematic contaminant in other drugs of abuse. Carfentanil and its close analogs, currently approved only for large animal veterinary medicine, have found use both as illicit additives to the clandestine manufacture of scheduled drugs and as chemical weapons. In this Review, the background, synthesis, manufacture, metabolism, pharmacology, approved indications, dosage, and adverse effects of carfentanil will be discussed along with its emergence as a key player in the ongoing opioid crisis.
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Affiliation(s)
- Anna E. Ringuette
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, , Vanderbilt University, Nashville, Tennessee 37232, United States
| | - Matthew Spock
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, , Vanderbilt University, Nashville, Tennessee 37232, United States
| | - Craig W. Lindsley
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, , Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Chemistry, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Biochemistry, Vanderbilt University, Nashville, Tennessee 37232, United States
| | - Aaron M. Bender
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Pharmacology, , Vanderbilt University, Nashville, Tennessee 37232, United States
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Parkin S, Neale J, Brown C, Campbell ANC, Castillo F, Jones JD, Strang J, Comer SD. Opioid overdose reversals using naloxone in New York City by people who use opioids: Implications for public health and overdose harm reduction approaches from a qualitative study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 79:102751. [PMID: 32304981 PMCID: PMC7572435 DOI: 10.1016/j.drugpo.2020.102751] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Adverse reactions to naloxone, such as withdrawal symptoms and aggression, are widely recognised in the literature by pharmaceutical manufacturers and clinical practitioners as standard reactions of individuals who are physically dependent upon opioid drugs following the reversal of potentially fatal opioid overdose. This paper seeks to provide a differentiated view on reactions to naloxone that may have important implications for public health and harm reduction approaches. METHODS Analyses from a qualitative investigation embedded within a 5-year Randomised Controlled Trial (RCT) examined the risks and benefits of Overdose Education and Naloxone Distribution (OEND) training models (brief or extended training) in various populations of people who use opioids in New York City. The qualitative experiences (obtained through semi-structured interviews) of 46 people who use opioids and who were each involved in the delivery of naloxone, during 56 separate overdose events that occurred throughout 2016-2018, were studied. Situational analysis and inductive content analysis of interview data focused upon overdose reversals in an attempt to provide understandings of the various adverse effects associated with naloxone from their perspective. These analyses were supplemented by data sessions within the research team during which the findings obtained from situational analysis and inductive content analysis were reviewed and complemented by deductive (clinical) appraisals of the various physical and psychological effects associated with the overdose reversals. RESULTS People who use opioids recognise three distinct and interconnected outcomes that may follow a successful opioid overdose reversal after intramuscular or intranasal administration of naloxone. These outcomes are here termed, (i) 'rage' (describing a wide range of angry, hostile and/or aggressive outbursts), (ii) 'withdrawal symptoms,' and (iii) 'not rage, not withdrawal' (i.e., a wide range of short-lived, 'harmless' conditions (such as temporary amnesia, mild emotional outbursts, or physical discomfort) that do not include rage or withdrawal symptoms). CONCLUSION Physical and psychological reactions to naloxone should not be understood exclusively as a consequence of acute, opioid-related, withdrawal symptoms. The three distinct and interconnected reversal outcomes identified in this study are considered from a harm reduction policy perspective and are further framed by concepts associated with 'mediated toxicity' (i.e., harm triggered by medicine). The overall conclusion is that harm reduction training programmes that are aligned to the policy and practice of take home naloxone may be strengthened by including awareness and training in how to best respond to 'rage' associated with overdose reversal following naloxone administration by people who use opioids and other laypersons.
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Affiliation(s)
- Stephen Parkin
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill SE5 8BB, United Kingdom.
| | - Joanne Neale
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill SE5 8BB, United Kingdom; Centre for Social Research in Health, University of New South Wales, Sydney, NSW 2052, Australia
| | - Caral Brown
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill SE5 8BB, United Kingdom
| | - Aimee N C Campbell
- Division on Substance Use Disorders, Columbia University Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 20, New York, NY 10032, United States
| | - Felipe Castillo
- Division on Substance Use Disorders, Columbia University Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 20, New York, NY 10032, United States
| | - Jermaine D Jones
- Division on Substance Use Disorders, Columbia University Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 20, New York, NY 10032, United States
| | - John Strang
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill SE5 8BB, United Kingdom; South London and Maudsley NHS Foundation Trust, Maudsley Hospital, London SE5 8AZ, United Kingdom
| | - Sandra D Comer
- Division on Substance Use Disorders, Columbia University Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 20, New York, NY 10032, United States
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Scott PJH, Koeppe RA, Shao X, Rodnick ME, Sowa AR, Henderson BD, Stauff J, Sherman PS, Arteaga J, Carlo DJ, Moss RB. The Effects of Intramuscular Naloxone Dose on Mu Receptor Displacement of Carfentanil in Rhesus Monkeys. Molecules 2020; 25:molecules25061360. [PMID: 32192089 PMCID: PMC7144122 DOI: 10.3390/molecules25061360] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 03/13/2020] [Accepted: 03/15/2020] [Indexed: 11/16/2022] Open
Abstract
Naloxone (NLX) is a mu receptor antagonist used to treat acute opioid overdoses. Currently approved doses of naloxone to treat opioid overdoses are 4 mg intranasal (IN) and 2 mg intramuscular (IM). However, higher mu receptor occupancy (RO) may be required to treat overdoses due to more potent synthetic opioids such as fentanyl and carfentanil that have entered the illicit drug market recently. To address this need, a higher dose of NLX has been investigated in a 5 mg IM formulation called ZIMHI but, while the effects of intravenous (IV) and IN administration of NLX on the opioid mu receptor occupancy (RO) have been studied, comparatively little is known about RO for IM administration of NLX. The goal of this study was to examine the effect of IM dosing of NLX on mu RO in rhesus macaques using [11C]carfentanil positron emission tomography (PET) imaging. The lowest dose of NLX (0.06 mg/kg) approximated 51% RO. Higher doses of NLX (0.14 mg/kg, 0.28 mg/kg) resulted in higher mu RO of 70% and 75%, respectively. Plasma levels were 4.6 ng/mL, 16.8 ng/mL, and 43.4 ng/mL for the three IM doses, and a significant correlation between percent RO and plasma NLX level was observed (r = 0.80). These results suggest that higher doses of IM NLX result in higher mu RO and could be useful in combating overdoses resulting from potent synthetic opioids.
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Affiliation(s)
- Peter J. H. Scott
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105, USA; (R.A.K.); (X.S.); (M.E.R.); (A.R.S.); (B.D.H.); (J.S.); (P.S.S.); (J.A.)
- Correspondence: (P.J.H.S.); (R.B.M.)
| | - Robert A. Koeppe
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105, USA; (R.A.K.); (X.S.); (M.E.R.); (A.R.S.); (B.D.H.); (J.S.); (P.S.S.); (J.A.)
| | - Xia Shao
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105, USA; (R.A.K.); (X.S.); (M.E.R.); (A.R.S.); (B.D.H.); (J.S.); (P.S.S.); (J.A.)
| | - Melissa E. Rodnick
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105, USA; (R.A.K.); (X.S.); (M.E.R.); (A.R.S.); (B.D.H.); (J.S.); (P.S.S.); (J.A.)
| | - Alexandra R. Sowa
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105, USA; (R.A.K.); (X.S.); (M.E.R.); (A.R.S.); (B.D.H.); (J.S.); (P.S.S.); (J.A.)
| | - Bradford D. Henderson
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105, USA; (R.A.K.); (X.S.); (M.E.R.); (A.R.S.); (B.D.H.); (J.S.); (P.S.S.); (J.A.)
| | - Jenelle Stauff
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105, USA; (R.A.K.); (X.S.); (M.E.R.); (A.R.S.); (B.D.H.); (J.S.); (P.S.S.); (J.A.)
| | - Phillip S. Sherman
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105, USA; (R.A.K.); (X.S.); (M.E.R.); (A.R.S.); (B.D.H.); (J.S.); (P.S.S.); (J.A.)
| | - Janna Arteaga
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105, USA; (R.A.K.); (X.S.); (M.E.R.); (A.R.S.); (B.D.H.); (J.S.); (P.S.S.); (J.A.)
| | - Dennis J. Carlo
- Adamis Pharmaceuticals, 11682 El Camino Real, Suite # 300, San Diego, CA 92130, USA;
| | - Ronald B. Moss
- Adamis Pharmaceuticals, 11682 El Camino Real, Suite # 300, San Diego, CA 92130, USA;
- Correspondence: (P.J.H.S.); (R.B.M.)
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