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Chiu CH, Ma KH, Huang EYK, Chang HW, Weng SJ, Yu TH, Farn SS, Kuo YY, Huang WS, Cheng CY, Tao PL, Yeh SHH. Dextromethorphan moderates reward deficiency associated with central serotonin transporter availability in 3,4-methylenedioxy-methamphetamine-treated animals. J Chin Med Assoc 2024; 87:538-549. [PMID: 38587377 DOI: 10.1097/jcma.0000000000001087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2024] Open
Abstract
BACKGROUND The neurotoxicity of 3,4-methylenedioxy-methamphetamine (MDMA) to the serotonergic system is well-documented. Dextromethorphan (DM), an antitussive drug, decreased morphine- or methamphetamine (MA)-induced reward in rats and may prevent MDMA-induced serotonergic deficiency in primates, as indicated by increased serotonin transporter (SERT) availability. We aimed to investigate the effects of DM on reward, behavioral sensitization, and neurotoxicity associated with loss of SERT induced by chronic MDMA administration in rats. METHODS Conditioned place preference (CPP) and locomotor activity tests were used to evaluate drug-induced reward and behavioral sensitization; 4-[ 18 F]-ADAM/animal-PET and immunohistochemistry were used to explore the effects of DM on MDMA-induced loss of SERT. RESULTS MDMA significantly reduced SERT binding in the rat brain; however, co-administration of DM significantly restored SERT, enhancing the recovery rate at day 14 by an average of ~23% compared to the MDMA group. In confirmation of the PET findings, immunochemistry revealed MDMA reduced SERT immunoactivity in all brain regions, whereas DM markedly increased the serotonergic fiber density after MDMA induction. CONCLUSION Behavioral tests and in vivo longitudinal PET imaging demonstrated the CPP indexes and locomotor activities of the reward system correlate negatively with PET 4-[ 18 F]ADAM SERT activity in the reward system. Our findings suggest MDMA induces functional abnormalities in a network of brain regions important to decision-making processes and the motivation circuit. DM may exert neuroprotective effects to reverse MDMA-induced neurotoxicity.
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Affiliation(s)
- Chuang-Hsin Chiu
- Department of Nuclear Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Kuo-Hsing Ma
- Department of Biology and Anatomy, National Defense Medical Center, Taipei, Taiwan, ROC
| | | | - Hsien-Wen Chang
- School of Pharmacy, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Shao-Ju Weng
- Department of Biology and Anatomy, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Tsung-Hsun Yu
- Brain Research Center, School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Shiou-Shiow Farn
- Isotope Application Division, Institute of Nuclear Energy Research, Taoyuan, Taiwan, ROC
| | - Yu-Yeh Kuo
- Department of Nursing, Hsin-Sheng College of Medical Care and Management, Taoyuan, Taiwan, ROC
| | - Wen-Sheng Huang
- Department of Nuclear Medicine, Cheng-Hsin General Hospital, Taipei, Taiwan, ROC
| | - Cheng-Yi Cheng
- Department of Nuclear Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Pao-Luh Tao
- Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan, ROC
| | - Skye Hsin-Hsien Yeh
- Brain Research Center, School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC
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Weber AN, Trebach J, Brenner MA, Thomas MM, Bormann NL. Managing Opioid Withdrawal Symptoms During the Fentanyl Crisis: A Review. Subst Abuse Rehabil 2024; 15:59-71. [PMID: 38623317 PMCID: PMC11016949 DOI: 10.2147/sar.s433358] [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: 02/07/2024] [Accepted: 04/05/2024] [Indexed: 04/17/2024] Open
Abstract
Illicitly manufactured fentanyl (IMF) is a significant contributor to the increasing rates of overdose-related deaths. Its high potency and lipophilicity can complicate opioid withdrawal syndromes (OWS) and the subsequent management of opioid use disorder (OUD). This scoping review aimed to collate the current OWS management of study populations seeking treatment for OWS and/or OUD directly from an unregulated opioid supply, such as IMF. Therefore, the focus was on therapeutic interventions published between January 2010 and November 2023, overlapping with the period of increasing IMF exposure. A health science librarian conducted a systematic search on November 13, 2023. A total of 426 studies were screened, and 173 studies were reviewed at the full-text level. Forty-nine studies met the inclusion criteria. Buprenorphine and naltrexone were included in most studies with the goal of transitioning to a long-acting injectable version. Various augmenting agents were tested (buspirone, memantine, suvorexant, gabapentin, and pregabalin); however, the liberal use of adjunctive medication and shortened timelines to initiation had the most consistently positive results. Outside of FDA-approved medications for OUD, lofexidine, gabapentin, and suvorexant have limited evidence for augmenting opioid agonist initiation. Trials often have low retention rates, particularly when opioid agonist washout is required. Neurostimulation strategies were promising; however, they were developed and studied early. Precipitated withdrawal is a concern; however, the rates were low and adequately mitigated or managed with low- or high-dose buprenorphine induction. Maintenance treatment continues to be superior to detoxification without continued management. Shorter induction protocols allow patients to initiate evidence-based treatment more quickly, reducing the use of illicit or non-prescribed substances.
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Affiliation(s)
| | - Joshua Trebach
- Department of Emergency Medicine, University of Iowa, Iowa City, IA, USA
| | - Marielle A Brenner
- Department of Emergency Medicine, University of Iowa, Iowa City, IA, USA
| | | | - Nicholas L Bormann
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
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Wang J, Deane FP, Kelly PJ, Robinson L. A narrative review of outcome measures used in drug and alcohol inpatient withdrawal treatment research. Drug Alcohol Rev 2023; 42:415-426. [PMID: 36633552 PMCID: PMC10108086 DOI: 10.1111/dar.13591] [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: 08/24/2022] [Revised: 11/20/2022] [Accepted: 11/28/2022] [Indexed: 01/13/2023]
Abstract
ISSUES Assessing drug and alcohol inpatient withdrawal treatment programs is important, as these represent a first step of treatment among people with alcohol and drug problems. However, there are many ways of measuring outcomes making it difficult for service providers to decide which domains and methods to use. This narrative review aims to clarify frequencies of the domains and methods used to assess withdrawal treatment outcomes. APPROACH We reviewed published studies that examined outcomes of inpatient drug and alcohol withdrawal treatment. The types of outcome measures used and the frequency of use were summarised. KEY FINDINGS The review showed that assessment of withdrawal treatment outcomes goes beyond traditional abstinence measures. Outcomes mainly focus on biological and psychological outcomes, with social outcomes rarely measured. Even within outcome domains (e.g., cravings), there were many assessment methods. IMPLICATIONS The review provides service providers with an outline of common outcome domains and measures. Given the importance of social functioning to recovery from alcohol and drug problems, greater emphasis on such measures is desirable. Future research could develop greater consensus on outcome measures for use in withdrawal management services to facilitate clarity around factors associated with treatment success. CONCLUSION Outcome assessment in withdrawal treatment goes beyond abstinence to include holistic measurement of biological, psychological and some social outcomes; but more work needs to be done to cohere the different assessment methods and broaden the scope to include social functioning.
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Affiliation(s)
- Jing Wang
- School of Psychology, University of Wollongong, Wollongong, Australia
- Illawarra Health and Medical Research Institute, Wollongong, Australia
| | - Frank P Deane
- School of Psychology, University of Wollongong, Wollongong, Australia
- Illawarra Health and Medical Research Institute, Wollongong, Australia
| | - Peter J Kelly
- School of Psychology, University of Wollongong, Wollongong, Australia
- Illawarra Health and Medical Research Institute, Wollongong, Australia
| | - Laura Robinson
- School of Psychology, University of Wollongong, Wollongong, Australia
- Illawarra Health and Medical Research Institute, Wollongong, Australia
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Huhn AS, Ellis JD, Dunn KE, Sholler DJ, Tabaschek P, Burns R, Strain EC. Patient-reported sleep outcomes in randomized-controlled trials in persons with substance use disorders: A systematic review. Drug Alcohol Depend 2022; 237:109508. [PMID: 35660223 DOI: 10.1016/j.drugalcdep.2022.109508] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 05/18/2022] [Accepted: 05/18/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Sleep disturbances and disorders are a common and sometimes recalcitrant problem in persons recovering from substance use disorders (SUDs). As such, several randomized-controlled trials (RCTs) have been conducted to address sleep disturbances in a variety of SUD subpopulations and clinical scenarios. The goal of this systematic review was to collate patient-reported sleep outcomes used in past SUD-related RCTs to provide guidance for future sleep research in persons with SUDs. METHODS This systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) on May 7th, 2020 (CRD42020182004). Studies were included if they were peer-reviewed manuscripts describing RCTs in an SUD population. RESULTS The initial search yielded 13,403 candidate articles, and 76 met a priori criteria and were included in this review. Thirty-five (46.1%) assessed sleep as a primary outcome (i.e., sleep improvement was the primary goal of the research) and 41 (53.9%) assessed sleep as a secondary outcome (i.e., sleep improvement was an important outcome, but not the primary outcome). The most commonly used measures included the Pittsburgh Sleep Quality Index, the Insomnia Severity Index, and sleep diaries. However, multiple additional sleep assessments were also used, including visual analogue and Likert scales. CONCLUSIONS The field of addiction medicine would benefit from a streamlined approach in assessing patient-reported sleep in RCTs, including commonly used and validated assessments of sleep quality, inserting daily or repeated measures into RCTs, and including questionnaires that assess clinically relevant insomnia or other sleep disorders.
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Affiliation(s)
- Andrew S Huhn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, USA.
| | - Jennifer D Ellis
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, USA
| | - Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, USA
| | - Dennis J Sholler
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, USA
| | - Paula Tabaschek
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, USA
| | - Rachel Burns
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, USA
| | - Eric C Strain
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, USA
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McGregor R, Thannickal TC, Siegel JM. Pleasure, addiction, and hypocretin (orexin). HANDBOOK OF CLINICAL NEUROLOGY 2021; 180:359-374. [PMID: 34225941 DOI: 10.1016/b978-0-12-820107-7.00022-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The hypocretins/orexins were discovered in 1998. Within 2 years, this led to the discovery of the cause of human narcolepsy, a 90% loss of hypothalamic neurons containing these peptides. Further work demonstrated that these neurons were not simply linked to waking. Rather these neurons were active during pleasurable behaviors in waking and were silenced by aversive stimulation. This was seen in wild-type mice, rats, cats, and dogs. It was also evident in humans, with increased Hcrt release during pleasurable activities and decreased release, to the levels seen in sleep, during pain. We found that human heroin addicts have, on average, an increase of 54% in the number of detectable Hcrt neurons compared to "control" human brains and that these Hcrt neurons are substantially smaller than those in control brains. We found that in mice, chronic morphine administration induced the same changes in Hcrt neuron number and size. Our studies in the mouse allowed us to determine the specificity, dose response relations, time course of the change in the number of Hcrt neurons, and that the increased number of Hcrt neurons after opiates was not due to neurogenesis. Furthermore, we found that it took a month or longer for these anatomical changes in the mouse brain to return to baseline. Human narcoleptics, despite their prescribed use of several commonly addictive drugs, do not show significant evidence of dose escalation or substance use disorder. Similarly, mice in which the peptide has been eliminated are resistant to addiction. These findings are consistent with the concept that an increased number of Hcrt neurons may underlie and maintain opioid or cocaine use disorders.
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Affiliation(s)
- Ronald McGregor
- Neuropsychiatric Institute and Brain Research Institute, University of California, Los Angeles, CA, United States; Neurobiology Research, Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, CA, United States
| | - Thomas C Thannickal
- Neuropsychiatric Institute and Brain Research Institute, University of California, Los Angeles, CA, United States; Neurobiology Research, Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, CA, United States
| | - Jerome M Siegel
- Neuropsychiatric Institute and Brain Research Institute, University of California, Los Angeles, CA, United States; Neurobiology Research, Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, CA, United States
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Fluyau D, Revadigar N, Pierre CG. Clinical benefits and risks of N-methyl-d-aspartate receptor antagonists to treat severe opioid use disorder: A systematic review. Drug Alcohol Depend 2020; 208:107845. [PMID: 31978670 DOI: 10.1016/j.drugalcdep.2020.107845] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 12/24/2019] [Accepted: 12/31/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Demand for treatments for severe opioid use disorder is increasing worldwide. The current pharmacotherapy is mainly focused on opioid and adrenergic receptors. The N-methyl-d-aspartate receptor (NMDAR) is among other receptors that can also be targeted to treat the disease. Findings from randomized controlled trials (RTCs) on NMDAR antagonists to treat severe opioid use disorder amply varied. This study aimed to evaluate the clinical benefits and assess the potential risks for adverse events or side effects of NMDAR antagonists that were investigated for the treatment of severe opioid use disorder. METHODS Articles were searched in PubMed, Scopus, Google Scholar, Proquest. Cochrane Review Database, Medline Ovid, and EMBASE from their inception to March 2019. RTCs on NMDAR antagonists for the treatment of severe opioid use disorder were independently screened and assessed by two authors. The results were synthesized qualitatively. RESULTS Nineteen RTCs of 1459 participants met the inclusion criteria. There is moderate evidence suggesting that ketamine, memantine, amantadine, and dextromethorphan may be able to manage opioid withdrawal symptoms. There is little evidence suggesting that memantine may be able to reduce methadone maintenance dose in participants on methadone, reduce opioid use, and reduce craving. Dropout is noticeable among dextromethorphan's participants. Safety concerns are more likely associated with dextromethorphan and ketamine. CONCLUSIONS NMDAR antagonists have the potentiality to treat severe opioid use disorder. There is insufficient evidence to recommend them for the treatment of severe opioid use disorder due to several limitations inherent to the RCTs reviewed. Further exploration is needed.
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Affiliation(s)
- Dimy Fluyau
- Emory University School of Medicine, 201 Dowman Dr, Atlanta, GA, 30322, United States.
| | - Neelambika Revadigar
- Columbia University School of Medicine, 630 W 168th St, New York, NY, 10032, United States.
| | - Christopher G Pierre
- Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States.
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Dunn KE, Huhn AS, Bergeria CL, Gipson CD, Weerts EM. Non-Opioid Neurotransmitter Systems that Contribute to the Opioid Withdrawal Syndrome: A Review of Preclinical and Human Evidence. J Pharmacol Exp Ther 2019; 371:422-452. [PMID: 31391211 PMCID: PMC6863456 DOI: 10.1124/jpet.119.258004] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 07/30/2019] [Indexed: 01/15/2023] Open
Abstract
Opioid misuse and abuse is a major international public health issue. Opioid use disorder (OUD) is largely maintained by a desire to suppress aversive opioid withdrawal symptoms. Opioid withdrawal in patients seeking abstinence from illicit or prescribed opioids is often managed by provision of a μ-opioid agonist/partial agonist in combination with concomitant medications. Concomitant medications are administered based on their ability to treat specific symptoms rather than a mechanistic understanding of the opioid withdrawal syndrome; however, their use has not been statistically associated with improved treatment outcomes. Understanding the central and/or peripheral mechanisms that underlie individual withdrawal symptom expression in humans will help promote medication development for opioid withdrawal management. To support focused examination of mechanistically supported concomitant medications, this review summarizes evidence from preclinical (N = 68) and human (N = 30) studies that administered drugs acting on the dopamine, serotonin, cannabinoid, orexin/hypocretin, and glutamate systems and reported outcomes related to opioid withdrawal. These studies provide evidence that each of these systems contribute to opioid withdrawal severity. The Food and Drug Administration has approved medications acting on these respective systems for other indications and research in this area could support the repurposing of these medications to enhance opioid withdrawal treatment. These data support a focused examination of mechanistically informed concomitant medications to help reduce opioid withdrawal severity and enhance the continuum of care available for persons with OUD.
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Affiliation(s)
- Kelly E Dunn
- Behavioral Pharmacology Research Unit, Johns Hopkins University School of Medicine, Baltimore, Maryland (K.D.E., A.S.H., C.L.B., E.M.W.); and Arizona State University, Tempe, Arizona (C.D.G.)
| | - Andrew S Huhn
- Behavioral Pharmacology Research Unit, Johns Hopkins University School of Medicine, Baltimore, Maryland (K.D.E., A.S.H., C.L.B., E.M.W.); and Arizona State University, Tempe, Arizona (C.D.G.)
| | - Cecilia L Bergeria
- Behavioral Pharmacology Research Unit, Johns Hopkins University School of Medicine, Baltimore, Maryland (K.D.E., A.S.H., C.L.B., E.M.W.); and Arizona State University, Tempe, Arizona (C.D.G.)
| | - Cassandra D Gipson
- Behavioral Pharmacology Research Unit, Johns Hopkins University School of Medicine, Baltimore, Maryland (K.D.E., A.S.H., C.L.B., E.M.W.); and Arizona State University, Tempe, Arizona (C.D.G.)
| | - Elise M Weerts
- Behavioral Pharmacology Research Unit, Johns Hopkins University School of Medicine, Baltimore, Maryland (K.D.E., A.S.H., C.L.B., E.M.W.); and Arizona State University, Tempe, Arizona (C.D.G.)
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9
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Gowing L, Farrell M, Ali R, White JM. Alpha₂-adrenergic agonists for the management of opioid withdrawal. Cochrane Database Syst Rev 2016; 2016:CD002024. [PMID: 27140827 PMCID: PMC7081129 DOI: 10.1002/14651858.cd002024.pub5] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Withdrawal is a necessary step prior to drug-free treatment or as the endpoint of long-term substitution treatment. OBJECTIVES To assess the effectiveness of interventions involving the use of alpha2-adrenergic agonists compared with placebo, reducing doses of methadone, symptomatic medications, or an alpha2-adrenergic agonist regimen different to the experimental intervention, for the management of the acute phase of opioid withdrawal. Outcomes included the withdrawal syndrome experienced, duration of treatment, occurrence of adverse effects, and completion of treatment. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1946 to November week 2, 2015), EMBASE (January 1985 to November week 2, 2015), PsycINFO (1806 to November week 2, 2015), Web of Science, and reference lists of articles. SELECTION CRITERIA Randomised controlled trials comparing alpha2-adrenergic agonists (clonidine, lofexidine, guanfacine, tizanidine) with reducing doses of methadone, symptomatic medications or placebo, or comparing different alpha2-adrenergic agonists to modify the signs and symptoms of withdrawal in participants who were opioid dependent. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS We included 26 randomised controlled trials involving 1728 participants. Six studies compared an alpha2-adrenergic agonist with placebo, 12 with reducing doses of methadone, four with symptomatic medications, and five compared different alpha2-adrenergic agonists. We assessed 10 studies as having a high risk of bias in at least one of the methodological domains that were considered.We found moderate-quality evidence that alpha2-adrenergic agonists were more effective than placebo in ameliorating withdrawal in terms of the likelihood of severe withdrawal (risk ratio (RR) 0.32, 95% confidence interval (CI) 0.18 to 0.57; 3 studies; 148 participants). We found moderate-quality evidence that completion of treatment was significantly more likely with alpha2-adrenergic agonists compared with placebo (RR 1.95, 95% CI 1.34 to 2.84; 3 studies; 148 participants).Peak withdrawal severity may be greater with alpha2-adrenergic agonists than with reducing doses of methadone, as measured by the likelihood of severe withdrawal (RR 1.18, 95% CI 0.81 to 1.73; 5 studies; 340 participants; low quality), and peak withdrawal score (standardised mean difference (SMD) 0.22, 95% CI -0.02 to 0.46; 2 studies; 263 participants; moderate quality), but these differences were not significant and there is no significant difference in severity when considered over the entire duration of the withdrawal episode (SMD 0.13, 95% CI -0.24 to 0.49; 3 studies; 119 participants; moderate quality). The signs and symptoms of withdrawal occurred and resolved earlier with alpha2-adrenergic agonists. The duration of treatment was significantly longer with reducing doses of methadone (SMD -1.07, 95% CI -1.31 to -0.83; 3 studies; 310 participants; low quality). Hypotensive or other adverse effects were significantly more likely with alpha2-adrenergic agonists (RR 1.92, 95% CI 1.19 to 3.10; 6 studies; 464 participants; low quality), but there was no significant difference in rates of completion of withdrawal treatment (RR 0.85, 95% CI 0.69 to 1.05; 9 studies; 659 participants; low quality).There were insufficient data for quantitative comparison of different alpha2-adrenergic agonists. Available data suggest that lofexidine does not reduce blood pressure to the same extent as clonidine, but is otherwise similar to clonidine. AUTHORS' CONCLUSIONS Clonidine and lofexidine are more effective than placebo for the management of withdrawal from heroin or methadone. We detected no significant difference in efficacy between treatment regimens based on clonidine or lofexidine and those based on reducing doses of methadone over a period of around 10 days, but methadone was associated with fewer adverse effects than clonidine, and lofexidine has a better safety profile than clonidine.
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Affiliation(s)
- Linda Gowing
- University of AdelaideDiscipline of PharmacologyFrome RoadAdelaideSouth AustraliaAustralia5005
| | - Michael Farrell
- University of New South WalesNational Drug and Alcohol Research Centre36 King StreetRandwickSydneyNSWAustraliaNSW 2025
| | - Robert Ali
- University of AdelaideDiscipline of PharmacologyFrome RoadAdelaideSouth AustraliaAustralia5005
| | - Jason M White
- University of South AustraliaSchool of Pharmacy and Medical SciencesGPO Box 2471AdelaideAustraliaSA 5001
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Arout CA, Edens E, Petrakis IL, Sofuoglu M. Targeting Opioid-Induced Hyperalgesia in Clinical Treatment: Neurobiological Considerations. CNS Drugs 2015; 29:465-86. [PMID: 26142224 DOI: 10.1007/s40263-015-0255-x] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Opioid analgesics have become a cornerstone in the treatment of moderate to severe pain, resulting in a steady rise of opioid prescriptions. Subsequently, there has been a striking increase in the number of opioid-dependent individuals, opioid-related overdoses, and fatalities. Clinical use of opioids is further complicated by an increasingly deleterious profile of side effects beyond addiction, including tolerance and opioid-induced hyperalgesia (OIH), where OIH is defined as an increased sensitivity to already painful stimuli. This paradoxical state of increased nociception results from acute and long-term exposure to opioids, and appears to develop in a substantial subset of patients using opioids. Recently, there has been considerable interest in developing an efficacious treatment regimen for acute and chronic pain. However, there are currently no well-established treatments for OIH. Several substrates have emerged as potential modulators of OIH, including the N-methyl-D-aspartate and γ-aminobutyric acid receptors, and most notably, the innate neuroimmune system. This review summarizes the neurobiology of OIH in the context of clinical treatment; specifically, we review evidence for several pathways that show promise for the treatment of pain going forward, as prospective adjuvants to opioid analgesics. Overall, we suggest that this paradoxical state be considered an additional target of clinical treatment for chronic pain.
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Affiliation(s)
- Caroline A Arout
- Department of Psychiatry, Yale University School of Medicine, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA,
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Lee SY, Chen SL, Chang YH, Chu CH, Chen SH, Chen PS, Huang SY, Tzeng NS, Wang LJ, Lee IH, Wang TY, Chen KC, Yang YK, Hong JS, Lu RB. A placebo-controlled trial of dextromethorphan as an adjunct in opioid-dependent patients undergoing methadone maintenance treatment. Int J Neuropsychopharmacol 2015; 18:pyv008. [PMID: 25716777 PMCID: PMC4540107 DOI: 10.1093/ijnp/pyv008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 01/16/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Low-dose dextromethorphan (DM) might have anti-inflammatory and neurotrophic effects mechanistically remote from an NMDA receptor. In a randomized, double-blind, controlled 12 week study, we investigated whether add-on dextromethorphan reduced cytokine levels and benefitted opioid-dependent patients undergoing methadone maintenance therapy (MMT). METHODS Patients were randomly assigned to a group: DM60 (60mg/day dextromethorphan; n = 65), DM120 (120mg/day dextromethorphan; n = 65), or placebo (n = 66). Primary outcomes were the methadone dose required, plasma morphine level, and retention in treatment. Plasma tumor necrosis factor (TNF)-α, C-reactive protein, interleukin (IL)-6, IL-8, transforming growth factor-β1, and brain-derived neurotrophic factor (BDNF) levels were examined during weeks 0, 1, 4, 8, and 12. Multiple linear regressions with generalized estimating equation methods were used to examine the therapeutic effect. RESULTS After 12 weeks, the DM60 group had significantly longer treatment retention and lower plasma morphine levels than did the placebo group. Plasma TNF-α was significantly decreased in the DM60 group compared to the placebo group. However, changes in plasma cytokine levels, BDNF levels, and the methadone dose required in the three groups were not significantly different. CONCLUSIONS We provide evidence-decreased concomitant heroin use-of low-dose add-on DM's efficacy for treating opioid-dependent patients undergoing MMT.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ru-Band Lu
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Dr S-Y Lee); Department of Psychiatry, National Cheng Kung University, Tainan, Taiwan (Drs S-Y Lee, P Chen, I Lee, T-Y Wang, K Chen, Yang, and Lu); Department of Neurology, School of medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (Dr S-L Chen); Institute of Allied Health Sciences, National Cheng Kung University, Tainan, Taiwan (Drs Chang and Lu); Laboratory of Neurobiology, NIH/NIEHS, Research Triangle Park, NC (Drs Chu and S-H Chen); Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (Drs Huang and Tzeng); Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (Drs L-J Wang, T-Y Wang, and Hong); Institute of Behavioral Medicine, College of Medicine and Hospital, National Cheng Kung University, Tainan, Taiwan (Dr Lu); Addiction Research Center, National Cheng Kung University, Tainan, Taiwan (Dr Lu); Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan (Dr Lu).
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