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Laffont CM, Purohit P, Delcamp N, Gonzalez-Garcia I, Skolnick P. Comparison of intranasal naloxone and intranasal nalmefene in a translational model assessing the impact of synthetic opioid overdose on respiratory depression and cardiac arrest. Front Psychiatry 2024; 15:1399803. [PMID: 38952632 PMCID: PMC11215134 DOI: 10.3389/fpsyt.2024.1399803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 05/10/2024] [Indexed: 07/03/2024] Open
Abstract
Introduction Using a validated translational model that quantitatively predicts opioid-induced respiratory depression and cardiac arrest, we compared cardiac arrest events caused by synthetic opioids (fentanyl, carfentanil) following rescue by intranasal (IN) administration of the μ-opioid receptor antagonists naloxone and nalmefene. Methods This translational model was originally developed by Mann et al. (Clin Pharmacol Ther 2022) to evaluate the effectiveness of intramuscular (IM) naloxone. We initially implemented this model using published codes, reproducing the effects reported by Mann et al. on the incidence of cardiac arrest events following intravenous doses of fentanyl and carfentanil as well as the reduction in cardiac arrest events following a standard 2 mg IM dose of naloxone. We then expanded the model in terms of pharmacokinetic and µ-opioid receptor binding parameters to simulate effects of 4 mg naloxone hydrochloride IN and 3 mg nalmefene hydrochloride IN, both FDA-approved for the treatment of opioid overdose. Model simulations were conducted to quantify the percentage of cardiac arrest in 2000 virtual patients in both the presence and absence of IN antagonist treatment. Results Following simulated overdoses with both fentanyl and carfentanil in chronic opioid users, IN nalmefene produced a substantially greater reduction in the incidence of cardiac arrest compared to IN naloxone. For example, following a dose of fentanyl (1.63 mg) producing cardiac arrest in 52.1% (95% confidence interval, 47.3-56.8) of simulated patients, IN nalmefene reduced this rate to 2.2% (1.0-3.8) compared to 19.2% (15.5-23.3) for IN naloxone. Nalmefene also produced large and clinically meaningful reductions in the incidence of cardiac arrests in opioid naïve subjects. Across dosing scenarios, simultaneous administration of four doses of IN naloxone were needed to reduce the percentage of cardiac arrest events to levels that approached those produced by a single dose of IN nalmefene. Conclusion Simulations using this validated translational model of opioid overdose demonstrate that a single dose of IN nalmefene produces clinically meaningful reductions in the incidence of cardiac arrest compared to IN naloxone following a synthetic opioid overdose. These findings are especially impactful in an era when >90% of all opioid overdose deaths are linked to synthetic opioids such as fentanyl.
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Affiliation(s)
- Celine M. Laffont
- Research and Development, Indivior, Inc., Richmond, VA, United States
| | - Prasad Purohit
- Research and Development, Indivior, Inc., Richmond, VA, United States
| | - Nash Delcamp
- Clinical Pharmacology and Pharmacometrics Solutions, Simulations Plus, Buffalo, NY, United States
| | - Ignacio Gonzalez-Garcia
- Clinical Pharmacology and Pharmacometrics Solutions, Simulations Plus, Buffalo, NY, United States
| | - Phil Skolnick
- Research and Development, Indivior, Inc., Richmond, VA, United States
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Baird A, White SA, Das R, Tatum N, Bisgaard EK. Whole body physiology model to simulate respiratory depression of fentanyl and associated naloxone reversal. COMMUNICATIONS MEDICINE 2024; 4:114. [PMID: 38866911 PMCID: PMC11169242 DOI: 10.1038/s43856-024-00536-5] [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: 10/31/2023] [Accepted: 05/31/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND Opioid use in the United States and abroad is an endemic part of society with yearly increases in overdose rates and deaths. In response, the use of the safe and effective reversal agent, naloxone, is being fielded and used by emergency medical technicians at a greater rate. There is evidence that repeated dosing of a naloxone nasal spray is becoming more common. Despite this we lack repeated dosing guidelines as a function of the amount of opiate the patient has taken. METHODS To measure repeat dosing guidelines, we construct a whole-body model of the pharmacokinetics and dynamics of an opiate, fentanyl on respiratory depression. We then construct a model of nasal deposition and administration of naloxone to investigate repeat dosing requirements for large overdose scenarios. We run a single patient through multiple goal directed resuscitation protocols and measure total naloxone administered. RESULTS Here we show that naloxone is highly effective at reversing the respiratory symptoms of the patient and recommend dosing requirements as a function of the fentanyl amount administered. We show that for increasing doses of fentanyl, naloxone requirements also increase. The rescue dose displays a nonlinear response to the initial opioid dose. This nonlinear response is largely logistic with three distinct phases: onset, rapid acceleration, and a plateau period for doses above 1.2 mg. CONCLUSIONS This paper investigates the total naloxone dose needed to properly reverse respiratory depression associated with fentanyl overdose. We show that the current guidelines for a rescue dose may be much lower than required.
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Affiliation(s)
- Austin Baird
- University of Washington Department of Surgery, Division of Healthcare Simulation Sciences, Seattle, WA, USA.
| | - Steven A White
- Applied Research Associated Southeast Division, Raleigh, NC, USA
| | - Rishi Das
- Applied Research Associated Southeast Division, Raleigh, NC, USA
| | - Nathan Tatum
- Applied Research Associated Southeast Division, Raleigh, NC, USA
| | - Erika K Bisgaard
- University of Washington Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, Seattle, WA, USA
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3
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Allen DZ, Talmadge J, Yen D, Bedrosian JC, Frost M, Wang T, Mathai A, Jarecki-Smith J, Citardi MJ. Bystander-application of a novel nasal swab optimized for drug delivery is safe and non-traumatic for the general population. Drug Alcohol Depend 2024; 259:111289. [PMID: 38643531 DOI: 10.1016/j.drugalcdep.2024.111289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/24/2024] [Accepted: 03/28/2024] [Indexed: 04/23/2024]
Abstract
OBJECTIVE The PN Naloxone Nasal Swab (Pocket Naloxone Corp., Bethesda, MD) is a swab optimized for drug delivery and intended for use by non-medical personnel for the emergency treatment of opioid overdose. The aim of this study (PNC-20-003) is to determine the safety of this nasal swab in a real-world environment. METHODS This was a single-institution, quantitative-qualitative prospective trial performed at an outpatient clinic. Patients with normal or abnormal nasal structure were recruited. A non-medically trained individual placed the nasal (soaked in fluorescein dye) on each side of the patient's nose. Endoscopy with recording was performed before and after swab placement. An independent reviewer rated degree of staining, mucosal bleeding, and trauma at nasal subsites. RESULTS Videos from 32 nasal cavities (16 participants) were reviewed. All cavities had high intensity staining at the septum and the inferior turbinate. No patients had staining within the middle meatus, agger nasi, or olfactory regions. In patients with normal anatomy, obstructive nasal anatomy or prior nasal surgery, all cavities had staining near the nasal septum. Only 7 cavities (22 %) had minor bleeding defined as ooze that stopped in 1-2min, and 3 (9 %) had minor trauma defined as mucosal disruption less than 5mm. There were no significant differences in comparing pre- and post-swab nasal cavity, trauma, or bleeding exams. CONCLUSIONS These study results showed that this swab is atraumatic to the nasal mucosal membranes when administered by non-medical personnel. Analysis suggests contact with targeted sites for drug absorption regardless of anatomy.
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Affiliation(s)
- David Z Allen
- Department of Otorhinolaryngology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, United States
| | | | - David Yen
- Specialty Physician Associates, Bethlehem, PA 18017, United States
| | | | - Michael Frost
- Pocket Naloxone Corp., Bethesda, MD 20816, United States
| | - Tao Wang
- Pocket Naloxone Corp., Bethesda, MD 20816, United States
| | | | | | - Martin J Citardi
- Department of Otorhinolaryngology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, United States.
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4
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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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Mu RJ, Liu TL, Liu XD, Liu L. PBPK-PD model for predicting morphine pharmacokinetics, CNS effects and naloxone antagonism in humans. Acta Pharmacol Sin 2024:10.1038/s41401-024-01255-2. [PMID: 38570601 DOI: 10.1038/s41401-024-01255-2] [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: 12/21/2023] [Accepted: 02/27/2024] [Indexed: 04/05/2024] Open
Abstract
Morphine and morphine-6-glucuronide (M6G) produce central nervous system (CNS) effects by activating mu-opioid receptors, while naloxone is used mainly for the reversal of opioid overdose, specifically for the fatal complication of respiratory depression, but also for alleviating opioid-induced side effects. In this study we developed a physiologically-based pharmacokinetic-pharmacodynamic (PBPK-PD) model to simultaneously predict pharmacokinetics and CNS effects (miosis, respiratory depression and analgesia) of morphine as well as antagonistic effects of naloxone against morphine. The pharmacokinetic and pharmacodynamic parameters were obtained from in vitro data, in silico, or animals. Pharmacokinetic and pharmacodynamic simulations were conducted using 39 and 36 clinical reports, respectively. The pharmacokinetics of morphine and M6G following oral or intravenous administration were simulated, and the PBPK-PD model was validated using clinical observations. The Emax model correlated CNS effects with free concentrations of morphine and M6G in brain parenchyma. The predicted CNS effects were compared with observations. Most clinical observations fell within the 5th-95th percentiles of simulations based on 1000 virtual individuals. Most of the simulated area under the concentration-time curve or peak concentrations also fell within 0.5-2-fold of observations. The contribution of morphine to CNS effects following intravenous or oral administration was larger than that of M6G. Pharmacokinetics and antagonistic effects of naloxone on CNS effects were also successfully predicted using the developed PBPK-PD model. In conclusion, the pharmacokinetics and pharmacodynamics of morphine and M6G, antagonistic effects of naloxone against morphine-induced CNS effects may be successfully predicted using the developed PBPK-PD model based on the parameters derived from in vitro, in silico, or animal studies.
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Affiliation(s)
- Rui-Jing Mu
- Department of Pharmacology, College of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Tian-Lei Liu
- Department of Pharmacology, College of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Xiao-Dong Liu
- Department of Pharmacology, College of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China.
| | - Li Liu
- Department of Pharmacology, College of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China.
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6
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Saari TI, Strang J, Dale O. Clinical Pharmacokinetics and Pharmacodynamics of Naloxone. Clin Pharmacokinet 2024; 63:397-422. [PMID: 38485851 PMCID: PMC11052794 DOI: 10.1007/s40262-024-01355-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 04/29/2024]
Abstract
Naloxone is a World Health Organization (WHO)-listed essential medicine and is the first choice for treating the respiratory depression of opioids, also by lay-people witnessing an opioid overdose. Naloxone acts by competitive displacement of opioid agonists at the μ-opioid receptor (MOR). Its effect depends on pharmacological characteristics of the opioid agonist, such as dissociation rate from the MOR receptor and constitution of the victim. Aim of treatment is a balancing act between restoration of respiration (not consciousness) and avoidance of withdrawal, achieved by titration to response after initial doses of 0.4-2 mg. Naloxone is rapidly eliminated [half-life (t1/2) 60-120 min] due to high clearance. Metabolites are inactive. Major routes for administration are intravenous, intramuscular, and intranasal, the latter primarily for take-home naloxone. Nasal bioavailability is about 50%. Nasal uptake [mean time to maximum concentration (Tmax) 15-30 min] is likely slower than intramuscular, as reversal of respiration lag behind intramuscular naloxone in overdose victims. The intraindividual, interindividual and between-study variability in pharmacokinetics in volunteers are large. Variability in the target population is unknown. The duration of action of 1 mg intravenous (IV) is 2 h, possibly longer by intramuscular and intranasal administration. Initial parenteral doses of 0.4-0.8 mg are usually sufficient to restore breathing after heroin overdose. Fentanyl overdoses likely require higher doses of naloxone. Controlled clinical trials are feasible in opioid overdose but are absent in cohorts with synthetic opioids. Modeling studies provide valuable insight in pharmacotherapy but cannot replace clinical trials. Laypeople should always have access to at least two dose kits for their interim intervention.
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Affiliation(s)
- Teijo I Saari
- Department of Anaesthesiology and Intensive Care, University of Turku, Turku, Finland
- Division of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland
| | - John Strang
- National Addiction Centre, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, SE5 8BB, UK
| | - Ola Dale
- Department of Circulation and Medical Imaging, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.
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7
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Feasel MG, Moran TS, Cheng BC, Averick S. Are carfentanil and acrylfentanyl naloxone resistant? Front Psychiatry 2024; 15:1359851. [PMID: 38445085 PMCID: PMC10912486 DOI: 10.3389/fpsyt.2024.1359851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 01/25/2024] [Indexed: 03/07/2024] Open
Abstract
The rapid rise in deaths since 2012 due to opioid poisoning is correlated with the proliferation of potent synthetic opioid agonists such as fentanyl, acrylfentanyl, and carfentanil. The efficacy of frontline antidotes such as naloxone in reversing such poisoning events has been questioned, and the possibility of naloxone-resistant synthetic opioids has been raised. In this manuscript, we applied in vitro techniques to establish the median effective inhibitory concentrations for fentanyl, acrylfentanyl, and carfentanil and subsequently evaluate naloxone's ability to reverse agonist-receptor interactions.
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Affiliation(s)
- Michael G. Feasel
- Defense Advanced Research Projects Agency (DARPA), Biological Technologies Office (BTO), Arlington, VA, United States
| | - Theodore S. Moran
- U.S. Army DEVCOM Chemical and Biological Center, Aberdeen, MD, United States
| | - Boyle C. Cheng
- Neuroscience Institute, Allegheny Health Network, Pittsburgh, PA, United States
| | - Saadyah Averick
- Neuroscience Institute, Allegheny Health Network, Pittsburgh, PA, United States
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8
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Kusic DM, Heil J, Zajic S, Brangan A, Dairo O, Heil S, Feigin G, Kacinko S, Buono RJ, Ferraro TN, Rafeq R, Haroz R, Baston K, Bodofsky E, Sabia M, Salzman M, Resch A, Madzo J, Scheinfeldt LB, Issa JPJ, Jelinek J. Postmortem toxicology findings from the Camden Opioid Research Initiative. PLoS One 2023; 18:e0292674. [PMID: 37910493 PMCID: PMC10619848 DOI: 10.1371/journal.pone.0292674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 09/26/2023] [Indexed: 11/03/2023] Open
Abstract
The United States continues to be impacted by decades of an opioid misuse epidemic, worsened by the COVID-19 pandemic and by the growing prevalence of highly potent synthetic opioids (HPSO) such as fentanyl. In instances of a toxicity event, first-response administration of reversal medications such as naloxone can be insufficient to fully counteract the effects of HPSO, particularly when there is co-occurring substance use. In an effort to characterize and study this multi-faceted problem, the Camden Opioid Research Initiative (CORI) has been formed. The CORI study has collected and analyzed post-mortem toxicology data from 42 cases of decedents who expired from opioid-related toxicity in the South New Jersey region to characterize substance use profiles. Co-occurring substance use, whether by intent or through possible contamination of the illicit opioid supply, is pervasive among deaths due to opioid toxicity, and evidence of medication-assisted treatment is scarce. Nearly all (98%) of the toxicology cases show the presence of the HPSO, fentanyl, and very few (7%) results detected evidence of medication-assisted treatment for opioid use disorder, such as buprenorphine or methadone, at the time of death. The opioid toxicity reversal drug, naloxone, was detected in 19% of cases, but 100% of cases expressed one or more stimulants, and sedatives including xylazine were detected in 48% of cases. These results showing complex substance use profiles indicate that efforts at mitigating the opioid misuse epidemic must address the complications presented by co-occurring stimulant and other substance use, and reduce barriers to and stigmas of seeking effective medication-assisted treatments.
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Affiliation(s)
- Dara M. Kusic
- Research, Coriell Institute for Medical Research, Camden, New Jersey, United States of America
| | - Jessica Heil
- Clinical Research Office, Cooper University Health Care, Camden, New Jersey, United States of America
| | - Stefan Zajic
- Research, Coriell Institute for Medical Research, Camden, New Jersey, United States of America
| | - Andrew Brangan
- Coriell Institute for Medical Research, Camden, New Jersey, United States of America
| | - Oluseun Dairo
- Coriell Institute for Medical Research, Camden, New Jersey, United States of America
| | - Stacey Heil
- Coriell Institute for Medical Research, Camden, New Jersey, United States of America
| | - Gerald Feigin
- Office of the Medical Examiner, Gloucester County Health Department, Sewell, New Jersey, United States of America
| | - Sherri Kacinko
- Forensic Toxicology, NMS Labs, Horsham, Pennsylvania, United States of America
| | - Russell J. Buono
- Biomedical Sciences, Cooper Medical School of Rowan University, Camden, New Jersey, United States of America
| | - Thomas N. Ferraro
- Biomedical Sciences, Cooper Medical School of Rowan University, Camden, New Jersey, United States of America
| | - Rachel Rafeq
- Department of Emergency Medicine, Cooper University Health Care, Camden, New Jersey, United States of America
| | - Rachel Haroz
- Department of Emergency Medicine, Cooper University Health Care, Camden, New Jersey, United States of America
| | - Kaitlan Baston
- Cooper Medical School of Rowan University, Camden, New Jersey, United States of America
| | - Elliot Bodofsky
- Neurological Institute, Cooper University Health Care, Camden, New Jersey, United States of America
| | - Michael Sabia
- Anesthesiology, Cooper University Health Care, Camden, New Jersey, United States of America
| | - Matthew Salzman
- Department of Emergency Medicine, Cooper University Health Care, Camden, New Jersey, United States of America
| | - Alissa Resch
- Research, Coriell Institute for Medical Research, Camden, New Jersey, United States of America
| | - Jozef Madzo
- Research, Coriell Institute for Medical Research, Camden, New Jersey, United States of America
- Biomedical Sciences, Cooper Medical School of Rowan University, Camden, New Jersey, United States of America
| | - Laura B. Scheinfeldt
- Research, Coriell Institute for Medical Research, Camden, New Jersey, United States of America
- Biomedical Sciences, Cooper Medical School of Rowan University, Camden, New Jersey, United States of America
| | - Jean-Pierre J. Issa
- Research, Coriell Institute for Medical Research, Camden, New Jersey, United States of America
- Biomedical Sciences, Cooper Medical School of Rowan University, Camden, New Jersey, United States of America
| | - Jaroslav Jelinek
- Research, Coriell Institute for Medical Research, Camden, New Jersey, United States of America
- Biomedical Sciences, Cooper Medical School of Rowan University, Camden, New Jersey, United States of America
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Ferguson M, Rittenbach K, Leece P, Adams A, Ali F, Elton-Marshall T, Burmeister C, Brothers TD, Medley A, Choisil P, Strike C, Ng J, Lorenzetti DL, Gallant K, Buxton JA. Document d’orientation sur la distribution et l’utilisation de trousses de naloxone à emporter par les intervenants et intervenantes communautaires en cas de surdose au Canada. CMAJ 2023; 195:E1312-E1325. [PMID: 37788838 PMCID: PMC10637331 DOI: 10.1503/cmaj.230128-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Affiliation(s)
- Max Ferguson
- Centre de contrôle des maladies de la Colombie-Britannique (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, C.-B.; Département de psychiatrie (Rittenbach), Université de Calgary, Calgary, Alb.; Département de psychiatrie (Rittenbach), Université de l'Alberta, Edmonton, Alb.; Santé publique Ontario (Leece); École Dalla Lana de santé publique (Leece, Elton-Marshall, Strike) et Département de médecine familiale et communautaire (Leece), Université de Toronto; Institut de recherche sur les politiques de santé mentale (Ali, Elton-Marshall), Centre de toxicomanie et de santé mentale, Toronto, Ont.; École d'épidémiologie et de santé publique (Elton-Marshall), Université d'Ottawa, Ottawa, Ont.; Département de médecine (Brothers), Université Dalhousie, Halifax, N.-É.; Centre collaboratif pour la santé inclusive UCL (Brothers), Collège universitaire de Londres, Londres, Royaume-Uni; Centre de santé des Autochtones (Medley), École de santé publique Johns Hopkins Bloomberg, Baltimore, Md.; Programme d'interventions d'urgence en cas de surdose et de toxicomanie (Medley), Régie de la santé du littoral de Vancouver, Vancouver, C.-B.; Bibliothèque des sciences de la santé (Lorenzetti), Université de Calgary; Département des sciences de la santé communautaire (Lorenzetti), École de médecine Cumming, Université de Calgary; Institut O'Brien de santé publique (Lorenzetti), Université de Calgary, Calgary, Alb.; Centre de traitement de la toxicomanie de la Colombie-Britannique (Gallant); École de santé des populations et de santé publique (Buxton), Université de Colombie-Britannique, Vancouver, C.-B
| | - Katherine Rittenbach
- Centre de contrôle des maladies de la Colombie-Britannique (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, C.-B.; Département de psychiatrie (Rittenbach), Université de Calgary, Calgary, Alb.; Département de psychiatrie (Rittenbach), Université de l'Alberta, Edmonton, Alb.; Santé publique Ontario (Leece); École Dalla Lana de santé publique (Leece, Elton-Marshall, Strike) et Département de médecine familiale et communautaire (Leece), Université de Toronto; Institut de recherche sur les politiques de santé mentale (Ali, Elton-Marshall), Centre de toxicomanie et de santé mentale, Toronto, Ont.; École d'épidémiologie et de santé publique (Elton-Marshall), Université d'Ottawa, Ottawa, Ont.; Département de médecine (Brothers), Université Dalhousie, Halifax, N.-É.; Centre collaboratif pour la santé inclusive UCL (Brothers), Collège universitaire de Londres, Londres, Royaume-Uni; Centre de santé des Autochtones (Medley), École de santé publique Johns Hopkins Bloomberg, Baltimore, Md.; Programme d'interventions d'urgence en cas de surdose et de toxicomanie (Medley), Régie de la santé du littoral de Vancouver, Vancouver, C.-B.; Bibliothèque des sciences de la santé (Lorenzetti), Université de Calgary; Département des sciences de la santé communautaire (Lorenzetti), École de médecine Cumming, Université de Calgary; Institut O'Brien de santé publique (Lorenzetti), Université de Calgary, Calgary, Alb.; Centre de traitement de la toxicomanie de la Colombie-Britannique (Gallant); École de santé des populations et de santé publique (Buxton), Université de Colombie-Britannique, Vancouver, C.-B
| | - Pamela Leece
- Centre de contrôle des maladies de la Colombie-Britannique (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, C.-B.; Département de psychiatrie (Rittenbach), Université de Calgary, Calgary, Alb.; Département de psychiatrie (Rittenbach), Université de l'Alberta, Edmonton, Alb.; Santé publique Ontario (Leece); École Dalla Lana de santé publique (Leece, Elton-Marshall, Strike) et Département de médecine familiale et communautaire (Leece), Université de Toronto; Institut de recherche sur les politiques de santé mentale (Ali, Elton-Marshall), Centre de toxicomanie et de santé mentale, Toronto, Ont.; École d'épidémiologie et de santé publique (Elton-Marshall), Université d'Ottawa, Ottawa, Ont.; Département de médecine (Brothers), Université Dalhousie, Halifax, N.-É.; Centre collaboratif pour la santé inclusive UCL (Brothers), Collège universitaire de Londres, Londres, Royaume-Uni; Centre de santé des Autochtones (Medley), École de santé publique Johns Hopkins Bloomberg, Baltimore, Md.; Programme d'interventions d'urgence en cas de surdose et de toxicomanie (Medley), Régie de la santé du littoral de Vancouver, Vancouver, C.-B.; Bibliothèque des sciences de la santé (Lorenzetti), Université de Calgary; Département des sciences de la santé communautaire (Lorenzetti), École de médecine Cumming, Université de Calgary; Institut O'Brien de santé publique (Lorenzetti), Université de Calgary, Calgary, Alb.; Centre de traitement de la toxicomanie de la Colombie-Britannique (Gallant); École de santé des populations et de santé publique (Buxton), Université de Colombie-Britannique, Vancouver, C.-B
| | - Alison Adams
- Centre de contrôle des maladies de la Colombie-Britannique (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, C.-B.; Département de psychiatrie (Rittenbach), Université de Calgary, Calgary, Alb.; Département de psychiatrie (Rittenbach), Université de l'Alberta, Edmonton, Alb.; Santé publique Ontario (Leece); École Dalla Lana de santé publique (Leece, Elton-Marshall, Strike) et Département de médecine familiale et communautaire (Leece), Université de Toronto; Institut de recherche sur les politiques de santé mentale (Ali, Elton-Marshall), Centre de toxicomanie et de santé mentale, Toronto, Ont.; École d'épidémiologie et de santé publique (Elton-Marshall), Université d'Ottawa, Ottawa, Ont.; Département de médecine (Brothers), Université Dalhousie, Halifax, N.-É.; Centre collaboratif pour la santé inclusive UCL (Brothers), Collège universitaire de Londres, Londres, Royaume-Uni; Centre de santé des Autochtones (Medley), École de santé publique Johns Hopkins Bloomberg, Baltimore, Md.; Programme d'interventions d'urgence en cas de surdose et de toxicomanie (Medley), Régie de la santé du littoral de Vancouver, Vancouver, C.-B.; Bibliothèque des sciences de la santé (Lorenzetti), Université de Calgary; Département des sciences de la santé communautaire (Lorenzetti), École de médecine Cumming, Université de Calgary; Institut O'Brien de santé publique (Lorenzetti), Université de Calgary, Calgary, Alb.; Centre de traitement de la toxicomanie de la Colombie-Britannique (Gallant); École de santé des populations et de santé publique (Buxton), Université de Colombie-Britannique, Vancouver, C.-B
| | - Farihah Ali
- Centre de contrôle des maladies de la Colombie-Britannique (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, C.-B.; Département de psychiatrie (Rittenbach), Université de Calgary, Calgary, Alb.; Département de psychiatrie (Rittenbach), Université de l'Alberta, Edmonton, Alb.; Santé publique Ontario (Leece); École Dalla Lana de santé publique (Leece, Elton-Marshall, Strike) et Département de médecine familiale et communautaire (Leece), Université de Toronto; Institut de recherche sur les politiques de santé mentale (Ali, Elton-Marshall), Centre de toxicomanie et de santé mentale, Toronto, Ont.; École d'épidémiologie et de santé publique (Elton-Marshall), Université d'Ottawa, Ottawa, Ont.; Département de médecine (Brothers), Université Dalhousie, Halifax, N.-É.; Centre collaboratif pour la santé inclusive UCL (Brothers), Collège universitaire de Londres, Londres, Royaume-Uni; Centre de santé des Autochtones (Medley), École de santé publique Johns Hopkins Bloomberg, Baltimore, Md.; Programme d'interventions d'urgence en cas de surdose et de toxicomanie (Medley), Régie de la santé du littoral de Vancouver, Vancouver, C.-B.; Bibliothèque des sciences de la santé (Lorenzetti), Université de Calgary; Département des sciences de la santé communautaire (Lorenzetti), École de médecine Cumming, Université de Calgary; Institut O'Brien de santé publique (Lorenzetti), Université de Calgary, Calgary, Alb.; Centre de traitement de la toxicomanie de la Colombie-Britannique (Gallant); École de santé des populations et de santé publique (Buxton), Université de Colombie-Britannique, Vancouver, C.-B
| | - Tara Elton-Marshall
- Centre de contrôle des maladies de la Colombie-Britannique (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, C.-B.; Département de psychiatrie (Rittenbach), Université de Calgary, Calgary, Alb.; Département de psychiatrie (Rittenbach), Université de l'Alberta, Edmonton, Alb.; Santé publique Ontario (Leece); École Dalla Lana de santé publique (Leece, Elton-Marshall, Strike) et Département de médecine familiale et communautaire (Leece), Université de Toronto; Institut de recherche sur les politiques de santé mentale (Ali, Elton-Marshall), Centre de toxicomanie et de santé mentale, Toronto, Ont.; École d'épidémiologie et de santé publique (Elton-Marshall), Université d'Ottawa, Ottawa, Ont.; Département de médecine (Brothers), Université Dalhousie, Halifax, N.-É.; Centre collaboratif pour la santé inclusive UCL (Brothers), Collège universitaire de Londres, Londres, Royaume-Uni; Centre de santé des Autochtones (Medley), École de santé publique Johns Hopkins Bloomberg, Baltimore, Md.; Programme d'interventions d'urgence en cas de surdose et de toxicomanie (Medley), Régie de la santé du littoral de Vancouver, Vancouver, C.-B.; Bibliothèque des sciences de la santé (Lorenzetti), Université de Calgary; Département des sciences de la santé communautaire (Lorenzetti), École de médecine Cumming, Université de Calgary; Institut O'Brien de santé publique (Lorenzetti), Université de Calgary, Calgary, Alb.; Centre de traitement de la toxicomanie de la Colombie-Britannique (Gallant); École de santé des populations et de santé publique (Buxton), Université de Colombie-Britannique, Vancouver, C.-B
| | - Charlene Burmeister
- Centre de contrôle des maladies de la Colombie-Britannique (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, C.-B.; Département de psychiatrie (Rittenbach), Université de Calgary, Calgary, Alb.; Département de psychiatrie (Rittenbach), Université de l'Alberta, Edmonton, Alb.; Santé publique Ontario (Leece); École Dalla Lana de santé publique (Leece, Elton-Marshall, Strike) et Département de médecine familiale et communautaire (Leece), Université de Toronto; Institut de recherche sur les politiques de santé mentale (Ali, Elton-Marshall), Centre de toxicomanie et de santé mentale, Toronto, Ont.; École d'épidémiologie et de santé publique (Elton-Marshall), Université d'Ottawa, Ottawa, Ont.; Département de médecine (Brothers), Université Dalhousie, Halifax, N.-É.; Centre collaboratif pour la santé inclusive UCL (Brothers), Collège universitaire de Londres, Londres, Royaume-Uni; Centre de santé des Autochtones (Medley), École de santé publique Johns Hopkins Bloomberg, Baltimore, Md.; Programme d'interventions d'urgence en cas de surdose et de toxicomanie (Medley), Régie de la santé du littoral de Vancouver, Vancouver, C.-B.; Bibliothèque des sciences de la santé (Lorenzetti), Université de Calgary; Département des sciences de la santé communautaire (Lorenzetti), École de médecine Cumming, Université de Calgary; Institut O'Brien de santé publique (Lorenzetti), Université de Calgary, Calgary, Alb.; Centre de traitement de la toxicomanie de la Colombie-Britannique (Gallant); École de santé des populations et de santé publique (Buxton), Université de Colombie-Britannique, Vancouver, C.-B
| | - Thomas D Brothers
- Centre de contrôle des maladies de la Colombie-Britannique (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, C.-B.; Département de psychiatrie (Rittenbach), Université de Calgary, Calgary, Alb.; Département de psychiatrie (Rittenbach), Université de l'Alberta, Edmonton, Alb.; Santé publique Ontario (Leece); École Dalla Lana de santé publique (Leece, Elton-Marshall, Strike) et Département de médecine familiale et communautaire (Leece), Université de Toronto; Institut de recherche sur les politiques de santé mentale (Ali, Elton-Marshall), Centre de toxicomanie et de santé mentale, Toronto, Ont.; École d'épidémiologie et de santé publique (Elton-Marshall), Université d'Ottawa, Ottawa, Ont.; Département de médecine (Brothers), Université Dalhousie, Halifax, N.-É.; Centre collaboratif pour la santé inclusive UCL (Brothers), Collège universitaire de Londres, Londres, Royaume-Uni; Centre de santé des Autochtones (Medley), École de santé publique Johns Hopkins Bloomberg, Baltimore, Md.; Programme d'interventions d'urgence en cas de surdose et de toxicomanie (Medley), Régie de la santé du littoral de Vancouver, Vancouver, C.-B.; Bibliothèque des sciences de la santé (Lorenzetti), Université de Calgary; Département des sciences de la santé communautaire (Lorenzetti), École de médecine Cumming, Université de Calgary; Institut O'Brien de santé publique (Lorenzetti), Université de Calgary, Calgary, Alb.; Centre de traitement de la toxicomanie de la Colombie-Britannique (Gallant); École de santé des populations et de santé publique (Buxton), Université de Colombie-Britannique, Vancouver, C.-B
| | - Andrea Medley
- Centre de contrôle des maladies de la Colombie-Britannique (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, C.-B.; Département de psychiatrie (Rittenbach), Université de Calgary, Calgary, Alb.; Département de psychiatrie (Rittenbach), Université de l'Alberta, Edmonton, Alb.; Santé publique Ontario (Leece); École Dalla Lana de santé publique (Leece, Elton-Marshall, Strike) et Département de médecine familiale et communautaire (Leece), Université de Toronto; Institut de recherche sur les politiques de santé mentale (Ali, Elton-Marshall), Centre de toxicomanie et de santé mentale, Toronto, Ont.; École d'épidémiologie et de santé publique (Elton-Marshall), Université d'Ottawa, Ottawa, Ont.; Département de médecine (Brothers), Université Dalhousie, Halifax, N.-É.; Centre collaboratif pour la santé inclusive UCL (Brothers), Collège universitaire de Londres, Londres, Royaume-Uni; Centre de santé des Autochtones (Medley), École de santé publique Johns Hopkins Bloomberg, Baltimore, Md.; Programme d'interventions d'urgence en cas de surdose et de toxicomanie (Medley), Régie de la santé du littoral de Vancouver, Vancouver, C.-B.; Bibliothèque des sciences de la santé (Lorenzetti), Université de Calgary; Département des sciences de la santé communautaire (Lorenzetti), École de médecine Cumming, Université de Calgary; Institut O'Brien de santé publique (Lorenzetti), Université de Calgary, Calgary, Alb.; Centre de traitement de la toxicomanie de la Colombie-Britannique (Gallant); École de santé des populations et de santé publique (Buxton), Université de Colombie-Britannique, Vancouver, C.-B
| | - Paul Choisil
- Centre de contrôle des maladies de la Colombie-Britannique (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, C.-B.; Département de psychiatrie (Rittenbach), Université de Calgary, Calgary, Alb.; Département de psychiatrie (Rittenbach), Université de l'Alberta, Edmonton, Alb.; Santé publique Ontario (Leece); École Dalla Lana de santé publique (Leece, Elton-Marshall, Strike) et Département de médecine familiale et communautaire (Leece), Université de Toronto; Institut de recherche sur les politiques de santé mentale (Ali, Elton-Marshall), Centre de toxicomanie et de santé mentale, Toronto, Ont.; École d'épidémiologie et de santé publique (Elton-Marshall), Université d'Ottawa, Ottawa, Ont.; Département de médecine (Brothers), Université Dalhousie, Halifax, N.-É.; Centre collaboratif pour la santé inclusive UCL (Brothers), Collège universitaire de Londres, Londres, Royaume-Uni; Centre de santé des Autochtones (Medley), École de santé publique Johns Hopkins Bloomberg, Baltimore, Md.; Programme d'interventions d'urgence en cas de surdose et de toxicomanie (Medley), Régie de la santé du littoral de Vancouver, Vancouver, C.-B.; Bibliothèque des sciences de la santé (Lorenzetti), Université de Calgary; Département des sciences de la santé communautaire (Lorenzetti), École de médecine Cumming, Université de Calgary; Institut O'Brien de santé publique (Lorenzetti), Université de Calgary, Calgary, Alb.; Centre de traitement de la toxicomanie de la Colombie-Britannique (Gallant); École de santé des populations et de santé publique (Buxton), Université de Colombie-Britannique, Vancouver, C.-B
| | - Carol Strike
- Centre de contrôle des maladies de la Colombie-Britannique (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, C.-B.; Département de psychiatrie (Rittenbach), Université de Calgary, Calgary, Alb.; Département de psychiatrie (Rittenbach), Université de l'Alberta, Edmonton, Alb.; Santé publique Ontario (Leece); École Dalla Lana de santé publique (Leece, Elton-Marshall, Strike) et Département de médecine familiale et communautaire (Leece), Université de Toronto; Institut de recherche sur les politiques de santé mentale (Ali, Elton-Marshall), Centre de toxicomanie et de santé mentale, Toronto, Ont.; École d'épidémiologie et de santé publique (Elton-Marshall), Université d'Ottawa, Ottawa, Ont.; Département de médecine (Brothers), Université Dalhousie, Halifax, N.-É.; Centre collaboratif pour la santé inclusive UCL (Brothers), Collège universitaire de Londres, Londres, Royaume-Uni; Centre de santé des Autochtones (Medley), École de santé publique Johns Hopkins Bloomberg, Baltimore, Md.; Programme d'interventions d'urgence en cas de surdose et de toxicomanie (Medley), Régie de la santé du littoral de Vancouver, Vancouver, C.-B.; Bibliothèque des sciences de la santé (Lorenzetti), Université de Calgary; Département des sciences de la santé communautaire (Lorenzetti), École de médecine Cumming, Université de Calgary; Institut O'Brien de santé publique (Lorenzetti), Université de Calgary, Calgary, Alb.; Centre de traitement de la toxicomanie de la Colombie-Britannique (Gallant); École de santé des populations et de santé publique (Buxton), Université de Colombie-Britannique, Vancouver, C.-B
| | - Justin Ng
- Centre de contrôle des maladies de la Colombie-Britannique (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, C.-B.; Département de psychiatrie (Rittenbach), Université de Calgary, Calgary, Alb.; Département de psychiatrie (Rittenbach), Université de l'Alberta, Edmonton, Alb.; Santé publique Ontario (Leece); École Dalla Lana de santé publique (Leece, Elton-Marshall, Strike) et Département de médecine familiale et communautaire (Leece), Université de Toronto; Institut de recherche sur les politiques de santé mentale (Ali, Elton-Marshall), Centre de toxicomanie et de santé mentale, Toronto, Ont.; École d'épidémiologie et de santé publique (Elton-Marshall), Université d'Ottawa, Ottawa, Ont.; Département de médecine (Brothers), Université Dalhousie, Halifax, N.-É.; Centre collaboratif pour la santé inclusive UCL (Brothers), Collège universitaire de Londres, Londres, Royaume-Uni; Centre de santé des Autochtones (Medley), École de santé publique Johns Hopkins Bloomberg, Baltimore, Md.; Programme d'interventions d'urgence en cas de surdose et de toxicomanie (Medley), Régie de la santé du littoral de Vancouver, Vancouver, C.-B.; Bibliothèque des sciences de la santé (Lorenzetti), Université de Calgary; Département des sciences de la santé communautaire (Lorenzetti), École de médecine Cumming, Université de Calgary; Institut O'Brien de santé publique (Lorenzetti), Université de Calgary, Calgary, Alb.; Centre de traitement de la toxicomanie de la Colombie-Britannique (Gallant); École de santé des populations et de santé publique (Buxton), Université de Colombie-Britannique, Vancouver, C.-B
| | - Diane L Lorenzetti
- Centre de contrôle des maladies de la Colombie-Britannique (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, C.-B.; Département de psychiatrie (Rittenbach), Université de Calgary, Calgary, Alb.; Département de psychiatrie (Rittenbach), Université de l'Alberta, Edmonton, Alb.; Santé publique Ontario (Leece); École Dalla Lana de santé publique (Leece, Elton-Marshall, Strike) et Département de médecine familiale et communautaire (Leece), Université de Toronto; Institut de recherche sur les politiques de santé mentale (Ali, Elton-Marshall), Centre de toxicomanie et de santé mentale, Toronto, Ont.; École d'épidémiologie et de santé publique (Elton-Marshall), Université d'Ottawa, Ottawa, Ont.; Département de médecine (Brothers), Université Dalhousie, Halifax, N.-É.; Centre collaboratif pour la santé inclusive UCL (Brothers), Collège universitaire de Londres, Londres, Royaume-Uni; Centre de santé des Autochtones (Medley), École de santé publique Johns Hopkins Bloomberg, Baltimore, Md.; Programme d'interventions d'urgence en cas de surdose et de toxicomanie (Medley), Régie de la santé du littoral de Vancouver, Vancouver, C.-B.; Bibliothèque des sciences de la santé (Lorenzetti), Université de Calgary; Département des sciences de la santé communautaire (Lorenzetti), École de médecine Cumming, Université de Calgary; Institut O'Brien de santé publique (Lorenzetti), Université de Calgary, Calgary, Alb.; Centre de traitement de la toxicomanie de la Colombie-Britannique (Gallant); École de santé des populations et de santé publique (Buxton), Université de Colombie-Britannique, Vancouver, C.-B
| | - Kat Gallant
- Centre de contrôle des maladies de la Colombie-Britannique (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, C.-B.; Département de psychiatrie (Rittenbach), Université de Calgary, Calgary, Alb.; Département de psychiatrie (Rittenbach), Université de l'Alberta, Edmonton, Alb.; Santé publique Ontario (Leece); École Dalla Lana de santé publique (Leece, Elton-Marshall, Strike) et Département de médecine familiale et communautaire (Leece), Université de Toronto; Institut de recherche sur les politiques de santé mentale (Ali, Elton-Marshall), Centre de toxicomanie et de santé mentale, Toronto, Ont.; École d'épidémiologie et de santé publique (Elton-Marshall), Université d'Ottawa, Ottawa, Ont.; Département de médecine (Brothers), Université Dalhousie, Halifax, N.-É.; Centre collaboratif pour la santé inclusive UCL (Brothers), Collège universitaire de Londres, Londres, Royaume-Uni; Centre de santé des Autochtones (Medley), École de santé publique Johns Hopkins Bloomberg, Baltimore, Md.; Programme d'interventions d'urgence en cas de surdose et de toxicomanie (Medley), Régie de la santé du littoral de Vancouver, Vancouver, C.-B.; Bibliothèque des sciences de la santé (Lorenzetti), Université de Calgary; Département des sciences de la santé communautaire (Lorenzetti), École de médecine Cumming, Université de Calgary; Institut O'Brien de santé publique (Lorenzetti), Université de Calgary, Calgary, Alb.; Centre de traitement de la toxicomanie de la Colombie-Britannique (Gallant); École de santé des populations et de santé publique (Buxton), Université de Colombie-Britannique, Vancouver, C.-B
| | - Jane A Buxton
- Centre de contrôle des maladies de la Colombie-Britannique (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, C.-B.; Département de psychiatrie (Rittenbach), Université de Calgary, Calgary, Alb.; Département de psychiatrie (Rittenbach), Université de l'Alberta, Edmonton, Alb.; Santé publique Ontario (Leece); École Dalla Lana de santé publique (Leece, Elton-Marshall, Strike) et Département de médecine familiale et communautaire (Leece), Université de Toronto; Institut de recherche sur les politiques de santé mentale (Ali, Elton-Marshall), Centre de toxicomanie et de santé mentale, Toronto, Ont.; École d'épidémiologie et de santé publique (Elton-Marshall), Université d'Ottawa, Ottawa, Ont.; Département de médecine (Brothers), Université Dalhousie, Halifax, N.-É.; Centre collaboratif pour la santé inclusive UCL (Brothers), Collège universitaire de Londres, Londres, Royaume-Uni; Centre de santé des Autochtones (Medley), École de santé publique Johns Hopkins Bloomberg, Baltimore, Md.; Programme d'interventions d'urgence en cas de surdose et de toxicomanie (Medley), Régie de la santé du littoral de Vancouver, Vancouver, C.-B.; Bibliothèque des sciences de la santé (Lorenzetti), Université de Calgary; Département des sciences de la santé communautaire (Lorenzetti), École de médecine Cumming, Université de Calgary; Institut O'Brien de santé publique (Lorenzetti), Université de Calgary, Calgary, Alb.; Centre de traitement de la toxicomanie de la Colombie-Britannique (Gallant); École de santé des populations et de santé publique (Buxton), Université de Colombie-Britannique, Vancouver, C.-B.
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Ferguson M, Rittenbach K, Leece P, Adams A, Ali F, Elton-Marshall T, Burmeister C, Brothers TD, Medley A, Choisil P, Strike C, Ng J, Lorenzetti DL, Gallant K, Buxton JA. Guidance on take-home naloxone distribution and use by community overdose responders in Canada. CMAJ 2023; 195:E1112-E1123. [PMID: 37640401 PMCID: PMC10462409 DOI: 10.1503/cmaj.230128] [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: 08/31/2023] Open
Abstract
BACKGROUND The increasing toxicity of opioids in the unregulated drug market has led to escalating numbers of overdoses in Canada and worldwide; takehome naloxone (THN) is an evidence-based intervention that distributes kits containing naloxone to people in the community who may witness an overdose. The purpose of this guidance is to provide policy recommendations for territorial, provincial and federal THN programs, using evidence from scientific and grey literature and community evidence that reflects 11 years of THN distribution in Canada. METHODS The Naloxone Guidance Development Group - a multidisciplinary team including people with lived and living experience and expertise of drug use - used the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument to inform development of this guidance. We considered published evidence identified through systematic reviews of all literature types, along with community evidence and expertise, to generate recommendations between December 2021 and September 2022. We solicited feedback on preliminary recommendations through an External Review Committee and a public input process. The project was funded by the Canadian Institutes of Health Research through the Canadian Research Initiative in Substance Misuse. We used the Guideline International Network principles for managing competing interests. RECOMMENDATIONS Existing evidence from the literature on THN was of low quality. We incorporated evidence from scientific and grey literature, and community expertise to develop our recommendations. These were in 3 areas: routes of naloxone administration, THN kit contents and overdose response. Take-home naloxone programs should offer the choice of both intramuscular and intranasal formulations of naloxone in THN kits. Recommended kit contents include naloxone, a naloxone delivery device, personal protective equipment, instructions and a carrying case. Trained community overdose responders should prioritize rescue breathing in the case of respiratory depression, and conventional cardiopulmonary resuscitation in the case of cardiac arrest, among other interventions. INTERPRETATION This guidance development project provides direction for THN programs in Canada in the context of limited published evidence, with recommendations developed in collaboration with diverse stakeholders.
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Affiliation(s)
- Max Ferguson
- BC Centre for Disease Control (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, BC; Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Public Health Ontario (PHO) (Leece); Dalla Lana School of Public Health (Leece, Elton-Marshall, Strike) and Department of Family and Community Medicine (Leece), University of Toronto; Institute for Mental Health Policy Research (Ali, Elton-Marshall), Centre for Addiction and Mental Health, Toronto, Ont.; School of Epidemiology and Public Health (Elton-Marshall), University of Ottawa, Ottawa, Ont.; Department of Medicine (Brothers), Dalhousie University, Halifax, NS; UCL Collaborative Centre for Inclusion Health (Brothers), University College London, London, UK; Center for Indigenous Health (Medley), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.; Overdose Emergency Response and Addictions Program (Medley), Vancouver Coastal Health, Vancouver, BC; Health Sciences Library (Lorenzetti), University of Calgary; Department of Community Health Sciences (Lorenzetti), Cumming School of Medicine, University of Calgary; O'Brien Institute for Public Health (Lorenzetti), University of Calgary, Calgary, Alta.; BC Centre on Substance Use (Gallant); School of Population and Public Health (Buxton), University of British Columbia, Vancouver, BC
| | - Katherine Rittenbach
- BC Centre for Disease Control (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, BC; Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Public Health Ontario (PHO) (Leece); Dalla Lana School of Public Health (Leece, Elton-Marshall, Strike) and Department of Family and Community Medicine (Leece), University of Toronto; Institute for Mental Health Policy Research (Ali, Elton-Marshall), Centre for Addiction and Mental Health, Toronto, Ont.; School of Epidemiology and Public Health (Elton-Marshall), University of Ottawa, Ottawa, Ont.; Department of Medicine (Brothers), Dalhousie University, Halifax, NS; UCL Collaborative Centre for Inclusion Health (Brothers), University College London, London, UK; Center for Indigenous Health (Medley), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.; Overdose Emergency Response and Addictions Program (Medley), Vancouver Coastal Health, Vancouver, BC; Health Sciences Library (Lorenzetti), University of Calgary; Department of Community Health Sciences (Lorenzetti), Cumming School of Medicine, University of Calgary; O'Brien Institute for Public Health (Lorenzetti), University of Calgary, Calgary, Alta.; BC Centre on Substance Use (Gallant); School of Population and Public Health (Buxton), University of British Columbia, Vancouver, BC
| | - Pamela Leece
- BC Centre for Disease Control (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, BC; Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Public Health Ontario (PHO) (Leece); Dalla Lana School of Public Health (Leece, Elton-Marshall, Strike) and Department of Family and Community Medicine (Leece), University of Toronto; Institute for Mental Health Policy Research (Ali, Elton-Marshall), Centre for Addiction and Mental Health, Toronto, Ont.; School of Epidemiology and Public Health (Elton-Marshall), University of Ottawa, Ottawa, Ont.; Department of Medicine (Brothers), Dalhousie University, Halifax, NS; UCL Collaborative Centre for Inclusion Health (Brothers), University College London, London, UK; Center for Indigenous Health (Medley), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.; Overdose Emergency Response and Addictions Program (Medley), Vancouver Coastal Health, Vancouver, BC; Health Sciences Library (Lorenzetti), University of Calgary; Department of Community Health Sciences (Lorenzetti), Cumming School of Medicine, University of Calgary; O'Brien Institute for Public Health (Lorenzetti), University of Calgary, Calgary, Alta.; BC Centre on Substance Use (Gallant); School of Population and Public Health (Buxton), University of British Columbia, Vancouver, BC
| | - Alison Adams
- BC Centre for Disease Control (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, BC; Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Public Health Ontario (PHO) (Leece); Dalla Lana School of Public Health (Leece, Elton-Marshall, Strike) and Department of Family and Community Medicine (Leece), University of Toronto; Institute for Mental Health Policy Research (Ali, Elton-Marshall), Centre for Addiction and Mental Health, Toronto, Ont.; School of Epidemiology and Public Health (Elton-Marshall), University of Ottawa, Ottawa, Ont.; Department of Medicine (Brothers), Dalhousie University, Halifax, NS; UCL Collaborative Centre for Inclusion Health (Brothers), University College London, London, UK; Center for Indigenous Health (Medley), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.; Overdose Emergency Response and Addictions Program (Medley), Vancouver Coastal Health, Vancouver, BC; Health Sciences Library (Lorenzetti), University of Calgary; Department of Community Health Sciences (Lorenzetti), Cumming School of Medicine, University of Calgary; O'Brien Institute for Public Health (Lorenzetti), University of Calgary, Calgary, Alta.; BC Centre on Substance Use (Gallant); School of Population and Public Health (Buxton), University of British Columbia, Vancouver, BC
| | - Farihah Ali
- BC Centre for Disease Control (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, BC; Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Public Health Ontario (PHO) (Leece); Dalla Lana School of Public Health (Leece, Elton-Marshall, Strike) and Department of Family and Community Medicine (Leece), University of Toronto; Institute for Mental Health Policy Research (Ali, Elton-Marshall), Centre for Addiction and Mental Health, Toronto, Ont.; School of Epidemiology and Public Health (Elton-Marshall), University of Ottawa, Ottawa, Ont.; Department of Medicine (Brothers), Dalhousie University, Halifax, NS; UCL Collaborative Centre for Inclusion Health (Brothers), University College London, London, UK; Center for Indigenous Health (Medley), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.; Overdose Emergency Response and Addictions Program (Medley), Vancouver Coastal Health, Vancouver, BC; Health Sciences Library (Lorenzetti), University of Calgary; Department of Community Health Sciences (Lorenzetti), Cumming School of Medicine, University of Calgary; O'Brien Institute for Public Health (Lorenzetti), University of Calgary, Calgary, Alta.; BC Centre on Substance Use (Gallant); School of Population and Public Health (Buxton), University of British Columbia, Vancouver, BC
| | - Tara Elton-Marshall
- BC Centre for Disease Control (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, BC; Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Public Health Ontario (PHO) (Leece); Dalla Lana School of Public Health (Leece, Elton-Marshall, Strike) and Department of Family and Community Medicine (Leece), University of Toronto; Institute for Mental Health Policy Research (Ali, Elton-Marshall), Centre for Addiction and Mental Health, Toronto, Ont.; School of Epidemiology and Public Health (Elton-Marshall), University of Ottawa, Ottawa, Ont.; Department of Medicine (Brothers), Dalhousie University, Halifax, NS; UCL Collaborative Centre for Inclusion Health (Brothers), University College London, London, UK; Center for Indigenous Health (Medley), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.; Overdose Emergency Response and Addictions Program (Medley), Vancouver Coastal Health, Vancouver, BC; Health Sciences Library (Lorenzetti), University of Calgary; Department of Community Health Sciences (Lorenzetti), Cumming School of Medicine, University of Calgary; O'Brien Institute for Public Health (Lorenzetti), University of Calgary, Calgary, Alta.; BC Centre on Substance Use (Gallant); School of Population and Public Health (Buxton), University of British Columbia, Vancouver, BC
| | - Charlene Burmeister
- BC Centre for Disease Control (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, BC; Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Public Health Ontario (PHO) (Leece); Dalla Lana School of Public Health (Leece, Elton-Marshall, Strike) and Department of Family and Community Medicine (Leece), University of Toronto; Institute for Mental Health Policy Research (Ali, Elton-Marshall), Centre for Addiction and Mental Health, Toronto, Ont.; School of Epidemiology and Public Health (Elton-Marshall), University of Ottawa, Ottawa, Ont.; Department of Medicine (Brothers), Dalhousie University, Halifax, NS; UCL Collaborative Centre for Inclusion Health (Brothers), University College London, London, UK; Center for Indigenous Health (Medley), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.; Overdose Emergency Response and Addictions Program (Medley), Vancouver Coastal Health, Vancouver, BC; Health Sciences Library (Lorenzetti), University of Calgary; Department of Community Health Sciences (Lorenzetti), Cumming School of Medicine, University of Calgary; O'Brien Institute for Public Health (Lorenzetti), University of Calgary, Calgary, Alta.; BC Centre on Substance Use (Gallant); School of Population and Public Health (Buxton), University of British Columbia, Vancouver, BC
| | - Thomas D Brothers
- BC Centre for Disease Control (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, BC; Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Public Health Ontario (PHO) (Leece); Dalla Lana School of Public Health (Leece, Elton-Marshall, Strike) and Department of Family and Community Medicine (Leece), University of Toronto; Institute for Mental Health Policy Research (Ali, Elton-Marshall), Centre for Addiction and Mental Health, Toronto, Ont.; School of Epidemiology and Public Health (Elton-Marshall), University of Ottawa, Ottawa, Ont.; Department of Medicine (Brothers), Dalhousie University, Halifax, NS; UCL Collaborative Centre for Inclusion Health (Brothers), University College London, London, UK; Center for Indigenous Health (Medley), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.; Overdose Emergency Response and Addictions Program (Medley), Vancouver Coastal Health, Vancouver, BC; Health Sciences Library (Lorenzetti), University of Calgary; Department of Community Health Sciences (Lorenzetti), Cumming School of Medicine, University of Calgary; O'Brien Institute for Public Health (Lorenzetti), University of Calgary, Calgary, Alta.; BC Centre on Substance Use (Gallant); School of Population and Public Health (Buxton), University of British Columbia, Vancouver, BC
| | - Andrea Medley
- BC Centre for Disease Control (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, BC; Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Public Health Ontario (PHO) (Leece); Dalla Lana School of Public Health (Leece, Elton-Marshall, Strike) and Department of Family and Community Medicine (Leece), University of Toronto; Institute for Mental Health Policy Research (Ali, Elton-Marshall), Centre for Addiction and Mental Health, Toronto, Ont.; School of Epidemiology and Public Health (Elton-Marshall), University of Ottawa, Ottawa, Ont.; Department of Medicine (Brothers), Dalhousie University, Halifax, NS; UCL Collaborative Centre for Inclusion Health (Brothers), University College London, London, UK; Center for Indigenous Health (Medley), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.; Overdose Emergency Response and Addictions Program (Medley), Vancouver Coastal Health, Vancouver, BC; Health Sciences Library (Lorenzetti), University of Calgary; Department of Community Health Sciences (Lorenzetti), Cumming School of Medicine, University of Calgary; O'Brien Institute for Public Health (Lorenzetti), University of Calgary, Calgary, Alta.; BC Centre on Substance Use (Gallant); School of Population and Public Health (Buxton), University of British Columbia, Vancouver, BC
| | - Paul Choisil
- BC Centre for Disease Control (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, BC; Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Public Health Ontario (PHO) (Leece); Dalla Lana School of Public Health (Leece, Elton-Marshall, Strike) and Department of Family and Community Medicine (Leece), University of Toronto; Institute for Mental Health Policy Research (Ali, Elton-Marshall), Centre for Addiction and Mental Health, Toronto, Ont.; School of Epidemiology and Public Health (Elton-Marshall), University of Ottawa, Ottawa, Ont.; Department of Medicine (Brothers), Dalhousie University, Halifax, NS; UCL Collaborative Centre for Inclusion Health (Brothers), University College London, London, UK; Center for Indigenous Health (Medley), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.; Overdose Emergency Response and Addictions Program (Medley), Vancouver Coastal Health, Vancouver, BC; Health Sciences Library (Lorenzetti), University of Calgary; Department of Community Health Sciences (Lorenzetti), Cumming School of Medicine, University of Calgary; O'Brien Institute for Public Health (Lorenzetti), University of Calgary, Calgary, Alta.; BC Centre on Substance Use (Gallant); School of Population and Public Health (Buxton), University of British Columbia, Vancouver, BC
| | - Carol Strike
- BC Centre for Disease Control (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, BC; Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Public Health Ontario (PHO) (Leece); Dalla Lana School of Public Health (Leece, Elton-Marshall, Strike) and Department of Family and Community Medicine (Leece), University of Toronto; Institute for Mental Health Policy Research (Ali, Elton-Marshall), Centre for Addiction and Mental Health, Toronto, Ont.; School of Epidemiology and Public Health (Elton-Marshall), University of Ottawa, Ottawa, Ont.; Department of Medicine (Brothers), Dalhousie University, Halifax, NS; UCL Collaborative Centre for Inclusion Health (Brothers), University College London, London, UK; Center for Indigenous Health (Medley), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.; Overdose Emergency Response and Addictions Program (Medley), Vancouver Coastal Health, Vancouver, BC; Health Sciences Library (Lorenzetti), University of Calgary; Department of Community Health Sciences (Lorenzetti), Cumming School of Medicine, University of Calgary; O'Brien Institute for Public Health (Lorenzetti), University of Calgary, Calgary, Alta.; BC Centre on Substance Use (Gallant); School of Population and Public Health (Buxton), University of British Columbia, Vancouver, BC
| | - Justin Ng
- BC Centre for Disease Control (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, BC; Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Public Health Ontario (PHO) (Leece); Dalla Lana School of Public Health (Leece, Elton-Marshall, Strike) and Department of Family and Community Medicine (Leece), University of Toronto; Institute for Mental Health Policy Research (Ali, Elton-Marshall), Centre for Addiction and Mental Health, Toronto, Ont.; School of Epidemiology and Public Health (Elton-Marshall), University of Ottawa, Ottawa, Ont.; Department of Medicine (Brothers), Dalhousie University, Halifax, NS; UCL Collaborative Centre for Inclusion Health (Brothers), University College London, London, UK; Center for Indigenous Health (Medley), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.; Overdose Emergency Response and Addictions Program (Medley), Vancouver Coastal Health, Vancouver, BC; Health Sciences Library (Lorenzetti), University of Calgary; Department of Community Health Sciences (Lorenzetti), Cumming School of Medicine, University of Calgary; O'Brien Institute for Public Health (Lorenzetti), University of Calgary, Calgary, Alta.; BC Centre on Substance Use (Gallant); School of Population and Public Health (Buxton), University of British Columbia, Vancouver, BC
| | - Diane L Lorenzetti
- BC Centre for Disease Control (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, BC; Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Public Health Ontario (PHO) (Leece); Dalla Lana School of Public Health (Leece, Elton-Marshall, Strike) and Department of Family and Community Medicine (Leece), University of Toronto; Institute for Mental Health Policy Research (Ali, Elton-Marshall), Centre for Addiction and Mental Health, Toronto, Ont.; School of Epidemiology and Public Health (Elton-Marshall), University of Ottawa, Ottawa, Ont.; Department of Medicine (Brothers), Dalhousie University, Halifax, NS; UCL Collaborative Centre for Inclusion Health (Brothers), University College London, London, UK; Center for Indigenous Health (Medley), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.; Overdose Emergency Response and Addictions Program (Medley), Vancouver Coastal Health, Vancouver, BC; Health Sciences Library (Lorenzetti), University of Calgary; Department of Community Health Sciences (Lorenzetti), Cumming School of Medicine, University of Calgary; O'Brien Institute for Public Health (Lorenzetti), University of Calgary, Calgary, Alta.; BC Centre on Substance Use (Gallant); School of Population and Public Health (Buxton), University of British Columbia, Vancouver, BC
| | - Kat Gallant
- BC Centre for Disease Control (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, BC; Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Public Health Ontario (PHO) (Leece); Dalla Lana School of Public Health (Leece, Elton-Marshall, Strike) and Department of Family and Community Medicine (Leece), University of Toronto; Institute for Mental Health Policy Research (Ali, Elton-Marshall), Centre for Addiction and Mental Health, Toronto, Ont.; School of Epidemiology and Public Health (Elton-Marshall), University of Ottawa, Ottawa, Ont.; Department of Medicine (Brothers), Dalhousie University, Halifax, NS; UCL Collaborative Centre for Inclusion Health (Brothers), University College London, London, UK; Center for Indigenous Health (Medley), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.; Overdose Emergency Response and Addictions Program (Medley), Vancouver Coastal Health, Vancouver, BC; Health Sciences Library (Lorenzetti), University of Calgary; Department of Community Health Sciences (Lorenzetti), Cumming School of Medicine, University of Calgary; O'Brien Institute for Public Health (Lorenzetti), University of Calgary, Calgary, Alta.; BC Centre on Substance Use (Gallant); School of Population and Public Health (Buxton), University of British Columbia, Vancouver, BC
| | - Jane A Buxton
- BC Centre for Disease Control (Ferguson, Adams, Burmeister, Choisil, Ng, Buxton), Vancouver, BC; Department of Psychiatry (Rittenbach), University of Calgary, Calgary, Alta.; Department of Psychiatry (Rittenbach), University of Alberta, Edmonton, Alta.; Public Health Ontario (PHO) (Leece); Dalla Lana School of Public Health (Leece, Elton-Marshall, Strike) and Department of Family and Community Medicine (Leece), University of Toronto; Institute for Mental Health Policy Research (Ali, Elton-Marshall), Centre for Addiction and Mental Health, Toronto, Ont.; School of Epidemiology and Public Health (Elton-Marshall), University of Ottawa, Ottawa, Ont.; Department of Medicine (Brothers), Dalhousie University, Halifax, NS; UCL Collaborative Centre for Inclusion Health (Brothers), University College London, London, UK; Center for Indigenous Health (Medley), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.; Overdose Emergency Response and Addictions Program (Medley), Vancouver Coastal Health, Vancouver, BC; Health Sciences Library (Lorenzetti), University of Calgary; Department of Community Health Sciences (Lorenzetti), Cumming School of Medicine, University of Calgary; O'Brien Institute for Public Health (Lorenzetti), University of Calgary, Calgary, Alta.; BC Centre on Substance Use (Gallant); School of Population and Public Health (Buxton), University of British Columbia, Vancouver, BC
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Metrebian N, Carter B, Eide D, McDonald R, Neale J, Parkin S, Dascal T, Mackie C, Day E, Guterstam J, Horsburgh K, Kåberg M, Kelleher M, Smith J, Thiesen H, Strang J. A study protocol for a European, mixed methods, prospective, cohort study of the effectiveness of naloxone administration by community members, in reversing opioid overdose: NalPORS. BMC Public Health 2023; 23:1608. [PMID: 37612698 PMCID: PMC10463843 DOI: 10.1186/s12889-023-16445-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 08/02/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Worldwide, opioid use causes more than 100,000 overdose deaths annually. Naloxone has proven efficacy in reversing opioid overdoses and is approved as an emergency antidote to opioid overdose. Take home naloxone (THN) programmes have been introduced to provide 'community members', who are likely to observe opioid overdoses, with naloxone kits and train them to recognise an overdose and administer naloxone. The acceptability and feasibility of THN programmes has been demonstrated, but the real-life effectiveness of naloxone administration by community members is not known. In recent years, the approval of several concentrated naloxone nasal-spray formulations (in addition to injectable formulations, eg.prenoxad) potentially increases acceptability and scope for wider provision. This study aims to determine the effectiveness of THN (all formulations) in real-world conditions. METHODS A European, multi-country, prospective cohort study, to assess the use of THN by community members to reverse opioid overdoses in a six-month, follow-up period. Participants provided with THN from participating harm reduction and drug treatment sites will be recruited to the study and followed-up for six months. We are particularly interested in the experiences of community members who have been provided with THN and have witnessed an opioid overdose. All participants who witness an opioid overdose during the six-month period (target approx. 600) will be asked to take part in a structured interview about this event. Of these, 60 will be invited to participate in a qualitative interview. A Post Authorisation Efficacy Study (PAES) for the concentrated nasal naloxone, Nyxoid, has been integrated into the study design. DISCUSSION There are many challenges involved in evaluating the real-life effectiveness of THN. It is not possible to use a randomised trial design, recruitment of community members provided with THN will depend upon recruitment sites distributing THN kits, and the type of THN received by participants will depend on regulations and on local clinical and policy decision-makers. Following up this population, some of whom may be itinerant, over the 6-month study period will be challenging, but we plan to maintain contact with participants through regular text message reminders and staff contact. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05072249. Date of Registration: 8.10.2021.
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Affiliation(s)
| | - Ben Carter
- Biostatistics and Health Informatics, King's College London, London, UK
| | - Desiree Eide
- National Addiction Centre, King's College London, London, UK
- Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway
| | - Rebecca McDonald
- National Addiction Centre, King's College London, London, UK
- Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway
| | - Joanne Neale
- National Addiction Centre, King's College London, London, UK
| | - Stephen Parkin
- National Addiction Centre, King's College London, London, UK
| | - Teodora Dascal
- National Addiction Centre, King's College London, London, UK
| | - Clare Mackie
- National Addiction Centre, King's College London, London, UK
| | - Ed Day
- Birmingham & Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Joar Guterstam
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, & Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | | | - Martin Kåberg
- Stockholm Centre for Dependency Disorders, Stockholm, Sweden
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Mike Kelleher
- South London and Maudsley NHS Foundation Trust, London, UK
| | | | | | - John Strang
- National Addiction Centre, King's College London, London, UK.
- South London and Maudsley NHS Foundation Trust, London, UK.
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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: 1] [Impact Index Per Article: 1.0] [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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Zarei MJ, Ramezani M, Sahraie Z, Shadnia S, Erfan Talab Evini P, Mostafazadeh B, Rahimi M. Comparing Two Naloxone Tapering Methods in Management of Methadone Intoxication; a Quasi-experimental Study. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2023; 11:e46. [PMID: 37609540 PMCID: PMC10440751 DOI: 10.22037/aaem.v11i1.2047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Introduction Even though naloxone is the main treatment for methadone poisoning treatment there are controversies about the proper method of its tapering. This study aimed to compare two methods in this regard. Method This study was a prospective, single-blind pilot quasi-experimental study on non-addicted adult patients poisoned with methadone. Patients were randomly divided into 2 groups. In one group, after stabilization of respiratory conditions and consciousness, naloxone was tapered using the half-life of methadone and in the other group, naloxone was tapered using the half-life of naloxone. Recurrence of symptoms and changes in venous blood gas parameters were compared between groups as outcome. Results 52 patients were included (51.92% female). 31 cases entered Group A (tapering based on methadone's half-life) and 21 cases entered Group B (tapering based on naloxone's half-life). The two groups were similar regarding mean age (p = 0.575), gender distribution (p = 0.535), the cause of methadone use (p = 0.599), previous medical history (p = 0.529), previous methadone use (p = 0.654), drug use history (p = 0.444), and vital signs on arrival to emergency department (p = 0.054). The cases of re-decreasing consciousness during tapering (52.38% vs. 25.81%; p = 0.049) and after discontinuation of naloxone (72.73% vs. 37.50%; p = 0.050) were higher in the tapering based on naloxone half-life group. The relative risk reduction (RRR) for naloxone half-life group was -1.03 and for methadone half-life group was 0.51. The absolute risk reduction (ARR) was 0.27 (95% confidence interval (CI) = 0.01-0.53) and the number needed to treat (NNT) was 3.7 (95% CI= 1.87- 150.53). There was not any statistically significant difference between groups regarding pH, HCO3, and PCO2 changes during tapering and after naloxone discontinuation (p > 0.05). However, repeated measures analysis of variance (ANOVA), showed that in the tapering based on methadone's half-life group, the number of changes and stability in the normal range were better (p < 0.001). Conclusion It seems that, by tapering naloxone based on methadone's half-life, not only blood acid-base disorders are treated, but they also remain stable after discontinuation and the possibility of symptom recurrence is reduced.
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Affiliation(s)
- Mohammad Javad Zarei
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maral Ramezani
- Department of Pharmacology, School of Medicine, Arak University of Medical Sciences, Arak, Iran
- Traditional and Complementary Medicine Research Center, Arak University of Medical Sciences, Arak, Iran
| | - Zahra Sahraie
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shahin Shadnia
- Toxicological Research Center, Excellence Center & Department of Clinical Toxicology
| | | | - Babak Mostafazadeh
- Toxicological Research Center, Excellence Center & Department of Clinical Toxicology
| | - Mitra Rahimi
- Toxicological Research Center, Excellence Center & Department of Clinical Toxicology
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Tsekouras AA, Macheras P. Re-examining Naloxone Pharmacokinetics After Intranasal and Intramuscular Administration Using the Finite Absorption Time Concept. Eur J Drug Metab Pharmacokinet 2023:10.1007/s13318-023-00831-x. [PMID: 37266859 DOI: 10.1007/s13318-023-00831-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Naloxone for opioid overdose treatment can be administered by intravenous injection, intramuscular injection, or intranasal administration. Published data indicate differences in naloxone pharmacokinetics depending on the route of administration. The aim of this study was to analyze pharmacokinetic data in the same way that we recently successfully applied the concept of the finite absorption time in orally administered drug formulations. METHODS Using the model equations already derived, we performed least squares analysis on 24 sets of naloxone concentration in the blood as a function of time. RESULTS We found that intramuscular and intranasal administration can be described more accurately when considering zero-order absorption kinetics for finite time compared with classical first order absorption kinetics for infinite time. CONCLUSIONS One-compartment models work well for most cases. Two-compartment models provide better details, but have higher parameter uncertainties. The absorption duration can be determined directly from the model parameters and thus allow an easy comparison between the ways of administration. Furthermore, the precise site of injection for intramuscular delivery appears to make a difference in terms of the duration of the drug absorption.
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Affiliation(s)
- Athanasios A Tsekouras
- Department of Chemistry, Laboratory of Physical Chemistry, National and Kapodistrian University of Athens, Athens, Greece
- PharmaInformatics Unit, Research Center ATHENA, Athens, Greece
| | - Panos Macheras
- PharmaInformatics Unit, Research Center ATHENA, Athens, Greece.
- Faculty of Pharmacy, Laboratory of Biopharmaceutics Pharmacokinetics, National and Kapodistrian University of Athens, Athens, Greece.
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Trøstheim M, Eikemo M, Haaker J, Frost JJ, Leknes S. Opioid antagonism in humans: a primer on optimal dose and timing for central mu-opioid receptor blockade. Neuropsychopharmacology 2023; 48:299-307. [PMID: 35978096 PMCID: PMC7613944 DOI: 10.1038/s41386-022-01416-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 07/06/2022] [Accepted: 07/28/2022] [Indexed: 12/26/2022]
Abstract
Non-human animal studies outline precise mechanisms of central mu-opioid regulation of pain, stress, affiliation and reward processing. In humans, pharmacological blockade with non-selective opioid antagonists such as naloxone and naltrexone is typically used to assess involvement of the mu-opioid system in such processing. However, robust estimates of the opioid receptor blockade achieved by opioid antagonists are missing. Dose and timing schedules are highly variable and often based on single studies. Here, we provide a detailed analysis of central opioid receptor blockade after opioid antagonism based on existing positron emission tomography data. We also create models for estimating opioid receptor blockade with intravenous naloxone and oral naltrexone. We find that common doses of intravenous naloxone (0.10-0.15 mg/kg) and oral naltrexone (50 mg) are more than sufficient to produce full blockade of central MOR (>90% receptor occupancy) for the duration of a typical experimental session (~60 min), presumably due to initial super saturation of receptors. Simulations indicate that these doses also produce high KOR blockade (78-100%) and some DOR blockade (10% with naltrexone and 48-74% with naloxone). Lower doses (e.g., 0.01 mg/kg intravenous naloxone) are estimated to produce less DOR and KOR blockade while still achieving a high level of MOR blockade for ~30 min. The models and simulations form the basis of two novel web applications for detailed planning and evaluation of experiments with opioid antagonists. These tools and recommendations enable selection of appropriate antagonists, doses and assessment time points, and determination of the achieved receptor blockade in previous studies.
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Affiliation(s)
- Martin Trøstheim
- Department of Diagnostic Physics, Oslo University Hospital, Oslo, Norway. .,Department of Psychology, University of Oslo, Oslo, Norway.
| | - Marie Eikemo
- grid.5510.10000 0004 1936 8921Department of Psychology, University of Oslo, Oslo, Norway
| | - Jan Haaker
- grid.13648.380000 0001 2180 3484Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Siri Leknes
- grid.55325.340000 0004 0389 8485Department of Diagnostic Physics, Oslo University Hospital, Oslo, Norway ,grid.5510.10000 0004 1936 8921Department of Psychology, University of Oslo, Oslo, Norway
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16
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Skulberg AK, Tylleskär I, Valberg M, Braarud A, Dale J, Heyerdahl F, Skålhegg T, Barstein J, Mellesmo S, Dale O. Comparison of intranasal and intramuscular naloxone in opioid overdoses managed by ambulance staff: a double-dummy, randomised, controlled trial. Addiction 2022; 117:1658-1667. [PMID: 35137493 PMCID: PMC9302677 DOI: 10.1111/add.15806] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 12/22/2021] [Indexed: 01/03/2023]
Abstract
AIMS To measure and evaluate clinical response to nasal naloxone in opioid overdoses in the pre-hospital environment. DESIGN Randomised, controlled, double-dummy, blinded, non-inferiority trial, and conducted at two centres. SETTING Participants were included by ambulance staff in Oslo and Trondheim, Norway, and treated at the place where the overdose occurred. PARTICIPANTS Men and women age above 18 years with miosis, rate of respiration ≤8/min, and Glasgow Coma Score <12/15 were included. Informed consent was obtained through a deferred-consent procedure. INTERVENTION AND COMPARATOR A commercially available 1.4 mg/0.1 mL intranasal naloxone was compared with 0.8 mg/2 mL naloxone administered intramuscularly. MEASUREMENTS The primary end-point was restoration of spontaneous respiration of ≥10 breaths/min within 10 minutes. Secondary outcomes included time to restoration of spontaneous respiration, recurrence of overdose within 12 hours and adverse events. FINDINGS In total, 201 participants were analysed in the per-protocol population. Heroin was suspected in 196 cases. With 82% of the participants being men, 105 (97.2%) in the intramuscular group and 74 (79.6%) in the intranasal group returned to adequate spontaneous respiration within 10 minutes after one dose. The estimated risk difference was 17.5% (95% CI, 8.9%-26.1%) in favour of the intramuscular group. The risk of receiving additional naloxone was 19.4% (95% CI, 9.0%-29.7%) higher in the intranasal group. Adverse reactions were evenly distributed, except for drug withdrawal reactions, where the estimated risk difference was 6.8% (95% CI, 0.2%-13%) in favour of the intranasal group in a post hoc analysis. CONCLUSION Intranasal naloxone (1.4 mg/0.1 mL) was less efficient than 0.8 mg intramuscular naloxone for return to spontaneous breathing within 10 minutes in overdose patients in the pre-hospital environment when compared head-to-head. Intranasal naloxone at 1.4 mg/0.1 mL restored breathing in 80% of participants after one dose and had few mild adverse reactions.
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Affiliation(s)
- Arne Kristian Skulberg
- Department of Circulation and Medical ImagingNorwegian University of Science and TechnologyTrondheimNorway,Division of Prehospital ServicesOslo University HospitalOsloNorway,Department of Research and DevelopmentThe Norwegian Air Ambulance FoundationOsloNorway
| | - Ida Tylleskär
- Department of Circulation and Medical ImagingNorwegian University of Science and TechnologyTrondheimNorway,Department of Emergency Medicine and Pre‐Hospital Services, St. Olav's HospitalTrondheim University HospitalTrondheimNorway
| | - Morten Valberg
- Oslo Centre for Biostatistics and EpidemiologyOslo University HospitalOsloNorway
| | | | - Jostein Dale
- Department of Research and DevelopmentThe Norwegian Air Ambulance FoundationOsloNorway,Department of Emergency Medicine and Pre‐Hospital Services, St. Olav's HospitalTrondheim University HospitalTrondheimNorway
| | - Fridtjof Heyerdahl
- Division of Prehospital ServicesOslo University HospitalOsloNorway,Department of Research and DevelopmentThe Norwegian Air Ambulance FoundationOsloNorway
| | - Tore Skålhegg
- Division of Prehospital ServicesOslo University HospitalOsloNorway
| | - Jan Barstein
- Department of Emergency Medicine and Pre‐Hospital Services, St. Olav's HospitalTrondheim University HospitalTrondheimNorway
| | - Sindre Mellesmo
- Division of Prehospital ServicesOslo University HospitalOsloNorway
| | - Ola Dale
- Department of Circulation and Medical ImagingNorwegian University of Science and TechnologyTrondheimNorway
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17
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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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18
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Effects of episodic future thinking on reinforcement pathology during smoking cessation treatment among individuals with substance use disorders. Psychopharmacology (Berl) 2022; 239:631-642. [PMID: 35020047 PMCID: PMC8799566 DOI: 10.1007/s00213-021-06057-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/28/2021] [Indexed: 02/04/2023]
Abstract
RATIONALE Reinforcer pathology (RP) is a theoretical model based on two processes: delay discounting (DD) and drug demand. Given that RP has been shown to have a predictive value on smoking behaviors, several studies have explored which interventions can reduce RP. Consistent with the RP framework, episodic future thinking (EFT) has shown effects on treatment outcomes and RP processes. The vast majority of studies that assess the effects of EFT on RP consist of experimental studies, and no previous research has tested these effects in a clinical sample of smokers. OBJECTIVES The primary aim of this study was to assess the effects of EFT on RP throughout the course of a smoking cessation intervention in smokers with substance use disorders (SUDs). METHODS Participants were randomized to cognitive behavior therapy (CBT) + EFT (n = 39) or CBT + EFT + contingency management (n = 33). Cotinine, frequency of EFT practices, cigarette purchase task (CPT), and DD were evaluated in treatment sessions. Mixed-effects model repeated measures analysis was used to explore DD and CPT in-treatment changes as a function of EFT practices and cotinine levels. RESULTS Greater practice of the EFT component significantly reduced cigarette demand (p < .020) as well as DD (p = .003). Additionally, a greater reduction in cotinine levels coupled with greater EFT practice led to a greater decrease in cigarette demand (p < .014). CONCLUSIONS EFT reduced the two facets of RP in treatment-seeking smokers with SUDs.
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19
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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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20
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Neale J, Farrugia A, Campbell AN, Dietze P, Dwyer R, Fomiatti R, Jones JD, Comer SD, Fraser S, Strang J. UNDERSTANDING PREFERENCES FOR TYPE OF TAKE-HOME NALOXONE DEVICE: INTERNATIONAL QUALITATIVE ANALYSIS OF THE VIEWS OF PEOPLE WHO USE OPIOIDS. DRUGS (ABINGDON, ENGLAND) 2022; 29:109-120. [PMID: 35813841 PMCID: PMC9268211 DOI: 10.1080/09687637.2021.1872499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background Take-home naloxone (THN) is provided to non-medically trained people to reverse potential opioid overdoses. There is an increasing range of effective intramuscular (IM) and intranasal (IN) naloxone devices and this paper explores the types preferred by people who use opioids, using consumer behaviour literature to interpret the findings. Methods Data derive from two unconnected qualitative studies involving audio-recorded semi-structured interviews. Study 1 was conducted in the United States (n=21 users of non-medical/illicit opioids). Study 2 was conducted in Australia (n=42 users of non-medical/illicit or prescribed opioids). Findings Most participants preferred IN naloxone. Preferences were based on the ease, speed, safety and comfort of each device and underpinned by accounts of overdose revivals as being very rushed and frightening situations. Preferences related to complex interactions between the naloxone device ('product'); the knowledge, skills, experience and attitudes of the lay responder ('consumer'), and when, where and how naloxone was to be used ('usage situation'). Conclusions THN programs should offer choice of device when possible and nasal naloxone if resources permit. Asking people which devices they prefer and why and treating them as valued consumers of naloxone products can generate insights that improve future naloxone technology and increase THN uptake and usage.
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Affiliation(s)
- Joanne Neale
- National Addiction Centre, King’s College London, London, UK.,Centre for Social Research in Health, University of New South Wales, Sydney, Australia
| | | | - Aimee N. Campbell
- Division on Substance Use Disorders, Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, USA
| | - Paul Dietze
- Program on Behaviours and Health Risks, Burnet Institute, Melbourne, Australia.,National Drug Research Institute, Curtin University, Melbourne, Australia
| | - Robyn Dwyer
- Centre for Alcohol Policy Research, School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Renae Fomiatti
- Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Australia
| | - Jermaine D. Jones
- Division on Substance Use Disorders, Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, USA
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21
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Cid A, Patten A, Grindrod K, Beazely MA. Frequently asked questions about naloxone: Part 2. Can Pharm J (Ott) 2021; 154:385-387. [PMID: 34777648 PMCID: PMC8581805 DOI: 10.1177/17151635211045966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 07/27/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Ashley Cid
- School of Pharmacy, University of Waterloo, Kitchener, Ontario
| | - Alec Patten
- School of Pharmacy, University of Waterloo, Kitchener, Ontario
| | - Kelly Grindrod
- School of Pharmacy, University of Waterloo, Kitchener, Ontario
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22
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Treatment of overdose in the synthetic opioid era. Pharmacol Ther 2021; 233:108019. [PMID: 34637841 DOI: 10.1016/j.pharmthera.2021.108019] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/04/2021] [Accepted: 10/04/2021] [Indexed: 12/16/2022]
Abstract
Overdose deaths are often viewed as the leading edge of the opioid epidemic which has gripped the United States over the past two decades (Skolnick, 2018a). This emphasis is perhaps unsurprising because opioid overdose is both the number-one cause of death for individuals between 25 and 64 years old (Dezfulian et al., 2021) and a significant contributor to the decline in average lifespan (Dowell et al., 2017). Exacerbated by the COVID 19 pandemic, it was estimated there were 93,400 drug overdose deaths in the United States during the 12 months ending December 2020, with more than 69,000 (that is, >74%) of these fatalities attributed to opioid overdose (Ahmad et al., 2021). However, the focus on mortality statistics (Ahmad et al., 2021; Shover et al., 2020) tends to obscure the broader medical impact of nonfatal opioid overdose. Analyses of multiple databases indicate that for each opioid-induced fatality, there are between 6.4 and 8.4 non-fatal overdoses, exacting a significant burden on both the individual and society. Over the past 7-8 years, there has been an alarming increase in the misuse of synthetic opioids ("synthetics"), primarily fentanyl and related piperidine-based analogs. Within the past 2-3 years, a structurally unrelated class of high potency synthetics, benzimidazoles exemplified by etonitazene and isotonitazene ("iso"), have also appeared in illicit drug markets (Thompson, 2020; Ujvary et al. 2021). In 2020, it was estimated that over 80% of fatal opioid overdoses in the United States now involve synthetics (Ahmad et al., 2021). The unique physicochemical and pharmacological properties of synthetics described in this review are responsible for both the morbidity and mortality associated with their misuse as well as their widespread availability. This dramatic increase in the misuse of synthetics is often referred to as the "3rd wave" (Pardo et al., 2019; Volkow and Blanco, 2020) of the opioid epidemic. Among the consequences resulting from misuse of these potent opioids is the need for higher doses of the competitive antagonist, naloxone, to reverse an overdose. The development of more effective reversal agents such as those described in this review is an essential component of a tripartite strategy (Volkow and Collins, 2017) to reduce the biopsychosocial impact of opioid misuse in the "synthetic era".
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23
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Kassick A, Wu M, Luengas D, Ebqa’ai M, Tharika Nirmani LP, Tomycz N, Nelson TL, Pravetoni M, Raleigh MD, Averick S. Covalently Loaded Naloxone Nanoparticles as a Long-Acting Medical Countermeasure to Opioid Poisoning. ACS Pharmacol Transl Sci 2021; 4:1654-1664. [PMID: 34661081 PMCID: PMC8506606 DOI: 10.1021/acsptsci.1c00168] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Indexed: 01/27/2023]
Abstract
The mu opioid receptor antagonist naloxone has been a vital, long-standing countermeasure in the ongoing battle against opioid use disorders (OUD) and toxicity. However, due to its distinctive short elimination half-life, naloxone has shown diminished efficacy in cases of synthetic opioid poisoning as larger or repeated doses of the antidote have been required to achieve adequate reversal of severe respiratory depression and prevent episodes of renarcotization. This report describes the synthesis, characterization, and in vivo evaluation of a novel, nanoparticle-based naloxone formulation that provides extended protection against the toxic effects of the powerful synthetic opioid fentanyl. The strategy was predicated on a modified two-step protocol involving the synthesis and subsequent nanoprecipitation of a poly(lactic-co-glycolic acid) polymer scaffold bearing a covalently linked naloxone chain end (drug loading ∼7% w/w). Pharmacokinetic evaluation of the resulting covalently loaded naloxone nanoparticles (cNLX-NP) revealed an elimination half-life that was 34 times longer than high dose free naloxone (10 mg/kg) in male Sprague-Dawley rats. This enhancement was further demonstrated by cNLX-NP in subsequent in vivo studies affording protection against fentanyl-induced respiratory depression and antinociception for up to 48 h following a single intramuscular injection. These discoveries support further investigation of cNLX-NP as a potential therapeutic to reverse overdose and prevent renarcotization from fentanyl and its potent analogs.
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Affiliation(s)
- Andrew
J. Kassick
- Neuroscience
Disruptive Research Lab, Allegheny Health
Network Research Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, United States
- Neuroscience
Institute, Allegheny Health Network, Allegheny
General Hospital, Pittsburgh, Pennsylvania 15212, United States
| | - Mariah Wu
- Department
of Pharmacology, University of Minnesota
Medical School Twin Cities, Minneapolis, Minnesota 55455, United States
| | - Diego Luengas
- Department
of Pharmacology, University of Minnesota
Medical School Twin Cities, Minneapolis, Minnesota 55455, United States
| | - Mohammad Ebqa’ai
- Department
of Chemistry, Oklahoma State University, Stillwater, Oklahoma 74078, United States
| | - L. P. Tharika Nirmani
- Department
of Chemistry, Oklahoma State University, Stillwater, Oklahoma 74078, United States
| | - Nestor Tomycz
- Neuroscience
Institute, Allegheny Health Network, Allegheny
General Hospital, Pittsburgh, Pennsylvania 15212, United States
| | - Toby L. Nelson
- Department
of Chemistry, Oklahoma State University, Stillwater, Oklahoma 74078, United States
| | - Marco Pravetoni
- Department
of Pharmacology, University of Minnesota
Medical School Twin Cities, Minneapolis, Minnesota 55455, United States
| | - Michael D. Raleigh
- Department
of Pharmacology, University of Minnesota
Medical School Twin Cities, Minneapolis, Minnesota 55455, United States
| | - Saadyah Averick
- Neuroscience
Disruptive Research Lab, Allegheny Health
Network Research Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, United States
- Neuroscience
Institute, Allegheny Health Network, Allegheny
General Hospital, Pittsburgh, Pennsylvania 15212, United States
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24
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Tylleskar I, Skarra S, Skulberg AK, Dale O. The pharmacokinetic interaction between nasally administered naloxone and the opioid remifentanil in human volunteers. Eur J Clin Pharmacol 2021; 77:1901-1908. [PMID: 34327552 PMCID: PMC8585821 DOI: 10.1007/s00228-021-03190-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 07/10/2021] [Indexed: 01/16/2023]
Abstract
Purpose Remifentanil has been shown to increase the bioavailability of nasally administered naloxone. The aim of this study was to explore the nature of this observation. Methods We analysed samples from three pharmacokinetic studies to determine the serum concentrations of naloxone-3-glucuronide (N3G), the main metabolite of naloxone, with or without exposure to remifentanil. To enable direct comparison of the three studies, the data are presented as metabolic ratios (ratio of metabolite to mother substance, N3G/naloxone) and dose-corrected values of the area under the curve and maximum concentration (Cmax). Results Under remifentanil exposure, the time to maximum concentration (Tmax) for N3G was significantly higher for intranasal administration of 71 min compared to intramuscular administration of 40 min. The dose-corrected Cmax of N3G after intranasal administration of naloxone under remifentanil exposure was significantly lower (4.5 ng/mL) than in subjects not exposed to remifentanil (7.8–8.4 ng/mL). The metabolic ratios after intranasal administration rose quickly after 30–90 min and were 2–3 times higher at 360 min compared to intravenous and intramuscular administration. Remifentanil exposure resulted in a much slower increase of the N3G/naloxone ratio after intranasal administration compared to intranasal administration with the absence of remifentanil. After remifentanil infusion was discontinued, this effect gradually diminished. From 240 min there was no significant difference between the ratios observed after intranasal naloxone administration. Conclusion Remifentanil increases the bioavailability of naloxone after nasal administration by reducing the pre-systemic metabolism of the swallowed part of the nasal dose. Supplementary Information The online version contains supplementary material available at 10.1007/s00228-021-03190-1.
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Affiliation(s)
- Ida Tylleskar
- Department of Circulation and Medical Imaging, NTNU - Norwegian University of Science and Technology, Trondheim, Norway. .,Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Sissel Skarra
- Department of Circulation and Medical Imaging, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - Arne Kristian Skulberg
- Department of Circulation and Medical Imaging, NTNU - Norwegian University of Science and Technology, Trondheim, Norway.,Division of Prehospital Services, Oslo University Hospital, Oslo, Norway.,The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Ola Dale
- Department of Circulation and Medical Imaging, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
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25
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Thompson J, Salter J, Bui P, Herbert L, Mills D, Wagner D, Brent C. Safety, Efficacy, and Cost of 0.4-mg Versus 2-mg Intranasal Naloxone for Treatment of Prehospital Opioid Overdose. Ann Pharmacother 2021; 56:285-289. [PMID: 34229467 DOI: 10.1177/10600280211030918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Intranasal naloxone is commonly used to treat prehospital opioid overdose. However, the optimal dose is unclear, and currently, no study exists comparing the clinical effect of intranasal naloxone at different doses. OBJECTIVE The goal of this investigation was to compare the safety, efficacy, and cost of 0.4- versus 2-mg intranasal naloxone for treatment of prehospital opioid overdose. METHODS A retrospective, cross-sectional study was performed of 218 consecutive adult patients receiving intranasal naloxone in 2 neighboring counties in Southeast Michigan: one that used a 0.4-mg protocol and one that used a 2-mg protocol. Primary outcomes were response to initial dose, requirement of additional dosing, and incidence of adverse effects. Unpooled, 2-tailed, 2-sample t-tests and χ2 tests for homogeneity were performed with statistical significance defined as P <0.05. RESULTS There was no statistically significant difference between the 2 populations in age, mass, gender, proportion of exposures suspected as heroin, response to initial dose, required redosing, or total number of doses by any route. The overall rate of adverse effects was 2.1% under the lower-dose protocol and 29% under the higher-dose protocol (P < 0.001). The lower-dose protocol was 79% less costly. CONCLUSION AND RELEVANCE Treatment of prehospital opioid overdose using intranasal naloxone at an initial dose of 0.4 mg was equally effective during the prehospital period as treatment at an initial dose of 2 mg, was associated with a lower rate of adverse effects, and represented a 79% reduction in cost.
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Affiliation(s)
| | | | - Peter Bui
- University of Michigan, Ann Arbor, MI, USA
| | | | - David Mills
- Oakland County Medical Control Authority, Oakland County, MI, USA
| | - Deborah Wagner
- University of Michigan, Ann Arbor, MI, USA.,Washtenaw County Medical Control Authority, Washtenaw County, MI, USA
| | - Christine Brent
- University of Michigan, Ann Arbor, MI, USA.,Washtenaw County Medical Control Authority, Washtenaw County, MI, USA
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26
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Skulberg AK, Tylleskar I, Dale O. Intranasal Naloxone Administration. N Engl J Med 2021; 384:e96. [PMID: 34133872 DOI: 10.1056/nejmc2106983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | | | - Ola Dale
- Norwegian University of Science and Technology, Trondheim, Norway
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27
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Malmros Olsson E, Lönnqvist PA, Stiller CO, Eksborg S, Lundeberg S. Rapid systemic uptake of naloxone after intranasal administration in children. Paediatr Anaesth 2021; 31:631-636. [PMID: 33687794 DOI: 10.1111/pan.14175] [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: 11/23/2020] [Revised: 02/22/2021] [Accepted: 02/28/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Naloxone has a high affinity for the µ-opioid receptor and acts as a competitive antagonist, thus reversing the effects of opioids. Naloxone is often administrated intravenously, but there is a growing interest in the intranasal route in treating patients with opioid overdose, and in reversing effects after therapeutic use of opioids. As administration is painless and no intravenous access is needed, the intranasal route is especially useful in children. AIM The aim of this study was to investigate the uptake of naloxone 0.4 mg/ml during the first 20 min after administration as a nasal spray in a pediatric population, with special focus on the time to achieve maximum plasma concentration. METHODS Twenty children, 6 months-10 years, were included in the study. The naloxone dose administered was 20 µg/kg, maximum 0.4 mg, divided into repeated doses of 0.1 ml in each nostril. Venous blood samples were collected at 5, 10, and 20 min after the end of administration. RESULTS All patients had quantifiable concentrations of naloxone in venous blood at 5 min, and within 20 min, peak concentration had been reached in more than half of the children. At 20 min after intranasal administration, the plasma naloxone concentrations were within the range of 2-6 nanogram/ml. CONCLUSION This study confirms the clinical experience that the rapid effect of naloxone after intranasal administration in children was reflected in rapid systemic uptake to achieve higher peak plasma concentrations than previously reported in adults.
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Affiliation(s)
- Eva Malmros Olsson
- Pediatric Pain Treatment Service, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Per-Arne Lönnqvist
- Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Carl-Olav Stiller
- Clinical Pharmacology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Staffan Eksborg
- Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Stefan Lundeberg
- Pediatric Pain Treatment Service, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Maloney LM, Alptunaer T, Coleman G, Ismael S, McKenna PJ, Marshall RT, Hernandez C, Williams DW. Prehospital Naloxone and Emergency Department Adverse Events: A Dose-Dependent Relationship. J Emerg Med 2020; 59:872-883. [PMID: 32972788 DOI: 10.1016/j.jemermed.2020.07.009] [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: 02/05/2020] [Revised: 06/05/2020] [Accepted: 07/01/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate prehospital and emergency department (ED) interventions and outcomes of patients who received prehospital naloxone for a suspected opioid overdose. OBJECTIVES The primary objective was to evaluate if the individual dose, individual route, total dose, number of prehospital naloxone administrations, or occurrence of a prehospital adverse event (AE) were associated with the occurrence of AEs in the ED. Secondary objectives included a subset analysis of patients who received additional naloxone while in the ED, or were admitted to an intensive care or step-down unit (ICU). METHODS This was a retrospective, observational chart review of adult patients who received prehospital naloxone and were transported by ambulance to a suburban academic tertiary care center between 2014 and 2017. Descriptive, univariate, and multivariate statistics were used, with p < 0.05 indicating significance. RESULTS There were 513 patients included in the analysis, with a median age of 29 years, and median total prehospital naloxone dose of 2 mg. An increasing number of prehospital naloxone doses, an occurrence of a prehospital AE, and a route of administration other than intranasally for the first dose of prehospital naloxone were significantly associated with an increased likelihood of an ED AE. Patients who received < 2 mg of prehospital naloxone had the least likelihood of being admitted to an ICU, whereas patients who received at least 6 mg had a dramatically increased likelihood of ICU admission. CONCLUSIONS Our results suggest that an increasing number of prehospital naloxone doses was significantly associated with an increased likelihood of an ED adverse event.
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Affiliation(s)
- Lauren M Maloney
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York
| | - Timur Alptunaer
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York
| | - Gia Coleman
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York
| | - Suleiman Ismael
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York
| | - Peter J McKenna
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York
| | - R Trevor Marshall
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York
| | - Cristina Hernandez
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York
| | - Daryl W Williams
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York
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29
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Skulberg AK, Tylleskär I, Braarud AC, Dale J, Heyerdahl F, Mellesmo S, Valberg M, Dale O. NTNU intranasal naloxone trial (NINA-1) study protocol for a double-blind, double-dummy, non-inferiority randomised controlled trial comparing intranasal 1.4 mg to intramuscular 0.8 mg naloxone for prehospital use. BMJ Open 2020; 10:e041556. [PMID: 33184084 PMCID: PMC7662429 DOI: 10.1136/bmjopen-2020-041556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Intranasal (IN) naloxone is widely used to treat opioid overdoses. The advantage of nasal administration compared with injection lies in its suitability for administration by lay people as it is needless. Approved formulations of nasal naloxone with bioavailability of approximately 50% have only undergone trials in healthy volunteers, while off-label nasal sprays with low bioavailability have been studied in patients. Randomised clinical trials are needed to investigate efficacy and safety of approved IN naloxone in patients suffering overdose. This study investigates whether the administration of 1.4 mg naloxone in 0.1 mL per dose is non-inferior to 0.8 mg intramuscular injection in patients treated for opioid overdose. METHODS AND ANALYSIS Sponsor is the Norwegian University of Science and Technology. The study has been developed in collaboration with user representatives. The primary endpoint is the restoration of spontaneous respiration≥10 breaths/min based on a sample of 200 opioid overdose cases. Double-dummy design ensures blinding, which will be maintained until the database is locked. ETHICS AND DISSEMINATION The study was approved by the Norwegian Medicines Agency and Regional Ethics Committees (REC: 2016/2000). It adheres to the Good Clinical Practice guidelines as set out by the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use.Informed consent will be sought through a differentiated model. This allows for deferred consent after inclusion for patients who have regained the ability to consent. Patients who are unable to consent prior to discharge by emergency services are given written information and can withdraw at a later date in line with user recommendations. Metadata will be published in the Norwegian University of Science and Technology Open repository. Deidentified individual participant data will be made available to recipients conditional of data processor agreement being entered. TRIAL REGISTRATION NUMBERS EudraCT Registry (2016-004072-22) and Clinicaltrials.gov Registry (NCT03518021).
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Affiliation(s)
- Arne Kristian Skulberg
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Division of Prehospital Services, Oslo University Hospital, Oslo, Norway
| | - Ida Tylleskär
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Clinic of Emergency Medicine and Prehospital Care, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | | | - Jostein Dale
- Clinic of Emergency Medicine and Prehospital Care, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Fridtjof Heyerdahl
- Division of Prehospital Services, Oslo University Hospital, Oslo, Norway
- Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Sindre Mellesmo
- Division of Prehospital Services, Oslo University Hospital, Oslo, Norway
| | - Morten Valberg
- Oslo Centre for Biostatistics and Epidemiology, University of Oslo, Oslo, Norway
| | - Ola Dale
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Research and Development, St Olavs University Hospital, Oslo, Norway
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Wolfes J, Ellermann C, Burde S, Leitz P, Bögeholz N, Willy K, Fehr M, Reinke F, Eckardt L, Frommeyer G. Divergent Electrophysiological Effects of Loperamide and Naloxone in a Sensitive Whole-Heart Model. Cardiovasc Toxicol 2020; 21:248-254. [PMID: 33125619 DOI: 10.1007/s12012-020-09616-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 10/16/2020] [Indexed: 11/24/2022]
Abstract
Several case reports suggest QT prolongation leading to ventricular arrhythmias with fatal outcome after intoxication with the μ-opioid receptor agonist and anti-diarrheal agent loperamide. The number of cases of loperamide misuse are growing due to its potential stimulating effects. Loperamide intoxications can be treated by naloxone. However, previous reports described a further QT prolongation associated with naloxone administration. Therefore, the aim of this study was to investigate the effects of loperamide and naloxone on the cardiac electrophysiology in a sensitive whole-heart model. Twenty-six hearts of New Zealand White rabbits were retrogradely perfused in a modified Langendorff apparatus. Monophasic action potentials were recorded by endo- and epicardially positioned catheters. Hearts were stimulated at different cycle lengths, thereby obtaining action potential duration at 90% of repolarization (APD90) and QT intervals. Programmed ventricular stimulation was used to assess ventricular vulnerability. Fourteen hearts were perfused with ascending concentrations of loperamide (0.2 μM, 0.35 μM, and 0.5 μM) after obtaining baseline data. Another 12 hearts were treated with naloxone (0.1 μM, 0.5 μM, 2 μM). Loperamide led to a significant increase in QT interval, APD90, and ventricular tachycardia (VT) episodes. In contrast, naloxone led to a decrease in QT interval and APD90. Accordingly, the number of VT episodes was unaltered. To the best of our knowledge, this is the first experimental study that investigated the effects of loperamide and naloxone in a whole-heart model. Loperamide led to a significant increase in action potential duration and QT interval. Simultaneously, the number of ventricular tachycardias was significantly increased. In contrast, naloxone led to a shortening of the action potential duration without altering arrhythmia susceptibility.
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Affiliation(s)
- Julian Wolfes
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Munster, Germany.
| | - Christian Ellermann
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Munster, Germany
| | - Sophie Burde
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Munster, Germany
| | - Patrick Leitz
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Munster, Germany
| | - Nils Bögeholz
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Munster, Germany
| | - Kevin Willy
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Munster, Germany
| | - Michael Fehr
- University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559, Hannover, Germany
| | - Florian Reinke
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Munster, Germany
| | - Lars Eckardt
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Munster, Germany
| | - Gerrit Frommeyer
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Munster, Germany
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Bonomo Y, Pastor A, Leung L, Blandthorn J, Dietze P. Managing opioid overdose in pregnancy with nasal naloxone. Aust N Z J Obstet Gynaecol 2020; 60:E11-E12. [PMID: 33043439 DOI: 10.1111/ajo.13216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/20/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Yvonne Bonomo
- Department of Addiction Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia.,Women's Alcohol and Drug Service, Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Adam Pastor
- Department of Addiction Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | - Laura Leung
- Pharmacy Department, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Julie Blandthorn
- Women's Alcohol and Drug Service, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Paul Dietze
- Alcohol and Drugs Research Group, Centre for Population Health, Behaviours and Health Risks Program, Burnet Institute, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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32
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Severe prolonged agitation due to intranasal naloxone overexposure. Am J Emerg Med 2020; 42:261.e1-261.e2. [PMID: 32919810 DOI: 10.1016/j.ajem.2020.08.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 11/23/2022] Open
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33
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Intranasal versus intramuscular naloxone for opioid overdose. Drug Ther Bull 2020; 58:134. [PMID: 32690489 DOI: 10.1136/dtb.2020.000046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Review of: Dietze P, Jauncey M, Salmon A. Effect of intranasal vs intramuscular naloxone on opioid overdose: a randomised clinical trial. JAMA Network Open 2019;2:e1914977.
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34
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Dretchen KL, Mesa Z, Robben M, Slade D, Hill S, Forsee K, Croutch C, Mesa M. Effects of Intranasal Epinephrine on Cerebrospinal Fluid Epinephrine Pharmacokinetics, Nasal Mucosa, Plasma Epinephrine Pharmacokinetics, and Cardiovascular Changes. Pharm Res 2020; 37:103. [PMID: 32448925 DOI: 10.1007/s11095-020-02829-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 04/21/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE We aimed to assess intranasal (IN) epinephrine effects on cerebrospinal fluid (CSF) absorption, nasal mucosa quality, plasma epinephrine pharmacokinetics (PK), and cardiovascular changes in dogs. METHODS CSF epinephrine concentration was measured and nasal mucosa quality was evaluated after IN epinephrine 4 mg and one or two 4 mg doses (21 min apart), respectively. Maximum plasma concentration [Cmax], time to Cmax [Tmax], area under the curve from 0 to 120 min [AUC0-120], and cardiovascular effects were evaluated after epinephrine IN (4 and 5 mg) and intramuscular (IM; 0.3 mg). Clinical observations were assessed. RESULTS After epinephrine IN, there were no changes in CSF epinephrine or nasal mucosa. Cmax, Tmax, and AUC1-120 were similar following epinephrine IN and IM. Epinephrine IN versus IM increased plasma epinephrine at 1 min (mean ± SEM, 1.15 ± 0.48 for 4 mg IN and 1.7 ± 0.72 for 5 mg IN versus 0.47 ± 0.11 ng/mL for 0.3 mg IM). Epinephrine IN and IM produced similar heart rate and ECG results. Clinical observations included salivation and vomiting. CONCLUSIONS Epinephrine IN did not alter CSF epinephrine or nasal tissue and had similar cardiovascular effects as epinephrine IM. Epinephrine IN rapidly increased plasma epinephrine concentration versus epinephrine IM.
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Affiliation(s)
- Kenneth L Dretchen
- Mesa Science Associates, Inc., 4539 Metropolitan Ct, Frederick, MD, 21701, USA.
| | - Zack Mesa
- Mesa Science Associates, Inc., 4539 Metropolitan Ct, Frederick, MD, 21701, USA
| | | | | | | | | | | | - Michael Mesa
- Mesa Science Associates, Inc., 4539 Metropolitan Ct, Frederick, MD, 21701, USA
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Dretchen KL, Mesa Z, Robben M, Slade D, Hill S, Croutch C, Kappeler K, Mesa M. Intranasal epinephrine in dogs: Pharmacokinetic and heart rate effects. Pharmacol Res Perspect 2020; 8:e00587. [PMID: 32302068 PMCID: PMC7164403 DOI: 10.1002/prp2.587] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 03/09/2020] [Accepted: 03/11/2020] [Indexed: 12/30/2022] Open
Abstract
Epinephrine is the standard of care for the treatment of severe allergy and anaphylaxis. Epinephrine is most often administered through the intramuscular (IM) route via autoinjector. The current study aimed to evaluate an alternative method of epinephrine treatment through intranasal (IN) delivery in dogs. The pharmacokinetic (PK) parameters of maximum plasma concentration (Cmax ), time to reach maximum plasma concentration (Tmax ), and area under the plasma concentration-time curve from 0 to 90 minutes (AUC0-90 ) were observed after IN epinephrine (2, 3, 4, 5, 10, and 20 mg) and IM epinephrine via autoinjector (0.15 and 0.3 mg) for 90 minutes. Heart rate effects were measured after IN (2 and 5 mg) and IM (0.15 and 0.3 mg) epinephrine administration. IN epinephrine (5 mg) demonstrated significantly greater plasma epinephrine concentration at 1 minute as compared with IM epinephrine (0.3 mg) (1.68 ± 0.65 ng/mL vs 0.21 ± 0.08 ng/mL, P = .03). There were no significant differences in Cmax , Tmax , and AUC0-90 between 2-mg IN and 0.15-mg IM epinephrine or between 5-mg IN and 0.3-mg IM epinephrine. IN epinephrine reduced heart rate increases, as compared to IM epinephrine. IN and IM epinephrine were both well-tolerated. Overall, IN epinephrine demonstrated advantages over IM epinephrine, including the rapid increase in plasma epinephrine and lack of increased heart rate over time.
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Affiliation(s)
| | - Zack Mesa
- Mesa Science Associates, Inc.FrederickMDUSA
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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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Troberg K, Isendahl P, Blomé MA, Dahlman D, Håkansson A. Protocol for a multi-site study of the effects of overdose prevention education with naloxone distribution program in Skåne County, Sweden. BMC Psychiatry 2020; 20:49. [PMID: 32028921 PMCID: PMC7006080 DOI: 10.1186/s12888-020-2470-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 01/30/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Continuously high rates of overdose deaths in Sweden led to the decision by the Skåne County to initiate the first regional take-home naloxone program in Sweden. The project aims to study the effect of overdose prevention education and naloxone distribution on overdose mortality in Skåne County. Secondary outcome measures include non-fatal overdoses and overdose-related harm in the general population, as well as cohort-specific effects in study participants regarding overdoses, mortality and retention in naloxone program. METHODS Implementation of a multi-site train-the-trainer cascade model was launched in June 2018. Twenty four facilities, including opioid substitution treatment units, needle exchange programs and in-patient addiction units were included for the first line of start-up, aspiring to reach a majority of individuals at-risk within the first 6 months. Serving as self-sufficient naloxone hubs, these units provide training, naloxone distribution and study recruitment. During 3 years, questionnaires are obtained from initial training, follow up, every sixth month, and upon refill. Estimated sample size is 2000 subjects. Naloxone distribution rates are reported, by each unit, every 6 months. Medical diagnoses, toxicological raw data and data on mortality and cause of death will be collected from national and regional registers, both for included naloxone recipients and for the general population. Data on vital status and treatment needs will be collected from registers of emergency and prehospital care. DISCUSSION Despite a growing body of literature on naloxone distribution, studies on population effect on mortality are scarce. Most previous studies and reports have been uncontrolled, thus not being able to link naloxone distribution to survival, in relation to a comparison period. As Swedish registers present the opportunity to monitor individuals and entire populations over time, conditions for conducting systematic follow-ups in the Swedish population are good, serving the opportunity to study the impact of large scale overdose prevention education and naloxone distribution and thus fill the knowledge gap. TRIAL REGISTRATION Naloxone Treatment in Skåne County - Effect on Drug-related Mortality and Overdose-related Complications, NCT03570099, registered on 26 June 2018.
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Affiliation(s)
- Katja Troberg
- Department of Clinical Sciences, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden. .,Division of Psychiatry, Addiction Center Malmö, Region Skåne, Malmö, Sweden. .,Malmö Addiction Centre, Clinical Research Unit, Södra Förstadsg. 35, Plan 4, S-205 02, Malmö, Sweden.
| | - Pernilla Isendahl
- grid.411843.b0000 0004 0623 9987Department of Infectious Disease, University Hospital Skåne, Malmö, Sweden
| | - Marianne Alanko Blomé
- grid.411843.b0000 0004 0623 9987Department of Infectious Disease, University Hospital Skåne, Malmö, Sweden ,Regional Office for Communicable Disease Control, Malmö, Sweden
| | - Disa Dahlman
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden ,grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
| | - Anders Håkansson
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden ,grid.426217.40000 0004 0624 3273Division of Psychiatry, Addiction Center Malmö, Region Skåne, Malmö, Sweden
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Take-Home Naloxone for the Emergency Interim Management of Opioid Overdose: The Public Health Application of an Emergency Medicine. Drugs 2020; 79:1395-1418. [PMID: 31352603 PMCID: PMC6728289 DOI: 10.1007/s40265-019-01154-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Naloxone is a well-established essential medicine for the treatment of life-threatening heroin/opioid overdose in emergency medicine. Over two decades, the concept of 'take-home naloxone' has evolved, comprising pre-provision of an emergency supply to laypersons likely to witness an opioid overdose (e.g. peers and family members of people who use opioids as well as non-medical personnel), with the recommendation to administer the naloxone to the overdose victim as interim care while awaiting an ambulance. There is an urgent need for more widespread naloxone access considering the growing problem of opioid overdose deaths, accounting for more than 100,000 deaths worldwide annually. Rises in mortality are particularly sharp in North America, where the ongoing prescription opioid problem is now overlaid with a rapid growth in overdose deaths from heroin and illicit fentanyl. Using opioids alone is dangerous, and the mortality risk is clustered at certain times and contexts, including on prison release and discharge from hospital and residential care. The provision of take-home naloxone has required the introduction of new legislation and new naloxone products. These include pre-filled syringes and auto-injectors and, crucially, new concentrated nasal sprays (four formulations recently approved in different countries) with speed of onset comparable to intramuscular naloxone and relative bioavailability of approximately 40-50%. Choosing the right naloxone dose in the fentanyl era is a matter of ongoing debate, but the safety margin of the approved nasal sprays is superior to improvised nasal kits. New legislation in different countries permits over-the-counter sales or other prescription-free methods of provision. However, access remains uneven with take-home naloxone still not provided in many countries and communities, and with ongoing barriers contributing to implementation inertia. Take-home naloxone is an important component of the response to the global overdose problem, but greater commitment to implementation will be essential, alongside improved affordable products, if a greater impact is to be achieved.
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Carpenter J, Murray BP, Atti S, Moran TP, Yancey A, Morgan B. Naloxone Dosing After Opioid Overdose in the Era of Illicitly Manufactured Fentanyl. J Med Toxicol 2020; 16:41-48. [PMID: 31471760 PMCID: PMC6942078 DOI: 10.1007/s13181-019-00735-w] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 08/01/2019] [Accepted: 08/21/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Illicitly manufactured fentanyl (IMF) is responsible for a growing number of deaths. Some case series have suggested that IMF overdoses require significantly higher naloxone doses than heroin overdoses. Our objective was to determine if the naloxone dose required to treat an opioid overdose is associated with the finding of fentanyl, opiates, or both on urine drug screen (UDS). METHODS A retrospective chart review was conducted at a single emergency department and its affiliated emergency medical services (EMS) agency. The charts of all patients who received naloxone through this EMS from 1/1/2017 to 6/15/2018 were reviewed. The study included patients diagnosed with a non-suicidal opioid overdose whose UDS was positive for opiates, fentanyl, or both. Data collected included demographics, vital signs, initial GCS, EMS and ED naloxone administrations, response to treatment, laboratory findings, and ED disposition. The fentanyl-only and fentanyl + opiate groups were compared to the opiate-only group using the stratified (by ED provider) variant of the Mann-Whitney U test. RESULTS Eight hundred and thirty-seven charts were reviewed, and 121 subjects were included in the final analysis. The median age of included subjects was 38 years and 75% were male. In the naloxone dose analysis, neither the fentanyl-only (median 0.8 mg, IQR 0.4-1.6; p = 0.68) nor the fentanyl + opiate (median 0.8 mg, IQR 0.4-1.2; p = 0.56) groups differed from the opiate-only group (median 0.58 mg, IQR 0.4-1.6). CONCLUSION Our findings refute the notion that high potency synthetic opioids like illicitly manufactured fentanyl require increased doses of naloxone to successfully treat an overdose. There were no significant differences in the dose of naloxone required to treat opioid overdose patients with UDS evidence of exposure to fentanyl, opiates, or both. Further evaluation of naloxone stocking and dosing protocols is needed.
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Affiliation(s)
- Joseph Carpenter
- Georgia Poison Center, 50 Hurt Plaza SE, Suite 600, Atlanta, GA, 30303, USA.
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | | | - Sukhshant Atti
- Georgia Poison Center, 50 Hurt Plaza SE, Suite 600, Atlanta, GA, 30303, USA
| | - Tim P Moran
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Arthur Yancey
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Brent Morgan
- Georgia Poison Center, 50 Hurt Plaza SE, Suite 600, Atlanta, GA, 30303, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Bell J, Strang J. Medication Treatment of Opioid Use Disorder. Biol Psychiatry 2020; 87:82-88. [PMID: 31420089 DOI: 10.1016/j.biopsych.2019.06.020] [Citation(s) in RCA: 147] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 06/25/2019] [Accepted: 06/25/2019] [Indexed: 12/19/2022]
Abstract
Opioid use disorder (OUD) is a chronic, relapsing condition, often associated with legal, interpersonal, and employment problems. Medications demonstrated to be effective for OUD are methadone (a full opioid agonist), buprenorphine (a partial agonist), and naltrexone (an opioid antagonist). Methadone and buprenorphine act by suppressing opioid withdrawal symptoms and attenuating the effects of other opioids. Naltrexone blocks the effects of opioid agonists. Oral methadone has the strongest evidence for effectiveness. Longer duration of treatment allows restoration of social connections and is associated with better outcomes. Treatments for OUD may be limited by poor adherence to treatment recommendations and by high rates of relapse and increased risk of overdose after leaving treatment. Treatment with methadone and buprenorphine has the additional risk of diversion and misuse of medication. New depot and implant formulations of buprenorphine and naltrexone have been developed to address issues of safety and problems of poor treatment adherence. For people with OUD who do not respond to these treatments, there is accumulating evidence for supervised injectable opioid treatment (prescribing pharmaceutical heroin). Another medication mode of minimizing risk of overdose is take-home naloxone. Naloxone is an opioid antagonist used to reverse opioid overdose, and take-home naloxone programs aim to prevent fatal overdose. All medication-assisted treatment is limited by lack of access and by stigma. In seeking to stem the rising toll from OUD, expanding access to approved treatment such as methadone, for which there remains the best evidence of efficacy, may be the most useful approach.
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Affiliation(s)
- James Bell
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
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Dietze P, Jauncey M, Salmon A, Mohebbi M, Latimer J, van Beek I, McGrath C, Kerr D. Effect of Intranasal vs Intramuscular Naloxone on Opioid Overdose: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e1914977. [PMID: 31722024 PMCID: PMC6902775 DOI: 10.1001/jamanetworkopen.2019.14977] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Previous unblinded clinical trials suggested that the intranasal route of naloxone hydrochloride was inferior to the widely used intramuscular route for the reversal of opioid overdose. OBJECTIVE To test whether a dose of naloxone administered intranasally is as effective as the same dose of intramuscularly administered naloxone in reversing opioid overdose. DESIGN, SETTING, AND PARTICIPANTS A double-blind, double-dummy randomized clinical trial was conducted at the Uniting Medically Supervised Injecting Centre in Sydney, Australia. Clients of the center were recruited to participate from February 1, 2012, to January 3, 2017. Eligible clients were aged 18 years or older with a history of injecting drug use (n = 197). Intention-to-treat analysis was performed for all participants who received both intranasal and intramuscular modes of treatment (active or placebo). INTERVENTIONS Clients were randomized to receive 1 of 2 treatments: (1) intranasal administration of naloxone hydrochloride 800 μg per 1 mL and intramuscular administration of placebo 1 mL or (2) intramuscular administration of naloxone hydrochloride 800 μg per 1 mL and intranasal administration of placebo 1 mL. MAIN OUTCOMES AND MEASURES The primary outcome measure was the need for a rescue dose of intramuscular naloxone hydrochloride (800 μg) 10 minutes after the initial treatment. Secondary outcome measures included time to adequate respiratory rate greater than or equal to 10 breaths per minute and time to Glasgow Coma Scale score greater than or equal to 13. RESULTS A total of 197 clients (173 [87.8%] male; mean [SD] age, 34.0 [7.82] years) completed the trial, of whom 93 (47.2%) were randomized to intramuscular naloxone dose and 104 (52.8%) to intranasal naloxone dose. Clients randomized to intramuscular naloxone administration were less likely to require a rescue dose of naloxone compared with clients randomized to intranasal naloxone administration (8 [8.6%] vs 24 [23.1%]; odds ratio, 0.35; 95% CI, 0.15-0.66; P = .002). A 65% increase in hazard (hazard ratio, 1.65; 95% CI, 1.21-2.25; P = .002) for time to respiratory rate of at least 10 and an 81% increase in hazard (hazard ratio, 1.81; 95% CI, 1.28-2.56; P = .001) for time to Glasgow Coma Scale score of at least 13 were observed for the group receiving intranasal naloxone compared with the group receiving intramuscular naloxone. No major adverse events were reported for either group. CONCLUSIONS AND RELEVANCE This trial showed that intranasally administered naloxone in a supervised injecting facility can reverse opioid overdose but not as efficiently as intramuscularly administered naloxone can, findings that largely replicate those of previous unblinded clinical trials. These results suggest that determining the optimal dose and concentration of intranasal naloxone to respond to opioid overdose in real-world conditions is an international priority. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12611000852954.
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Affiliation(s)
- Paul Dietze
- Behaviours and Health Risks Program, Burnet Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Marianne Jauncey
- Uniting Medically Supervised Injecting Centre, Kings Cross, New South Wales, Australia
| | - Allison Salmon
- Uniting Medically Supervised Injecting Centre, Kings Cross, New South Wales, Australia
| | - Mohammadreza Mohebbi
- Biostatistics Unit, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | - Julie Latimer
- Uniting Medically Supervised Injecting Centre, Kings Cross, New South Wales, Australia
| | - Ingrid van Beek
- South Eastern Sydney Local Health District, New South Wales, Australia
- Kirby Institute, University of New South Wales, Sydney, Sydney, New South Wales, Australia
| | - Colette McGrath
- Justice Health Forensic Mental Health Network, New South Wales Health, Randwick, New South Wales, Australia
| | - Debra Kerr
- Centre for Quality and Patient Safety, School of Nursing and Midwifery, Deakin University, Geelong, Australia
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Koons A, Cannon R, Beauchamp G, Katz K, Cook M, Surmaitis R. HOUR Prediction Rule. Acad Emerg Med 2019; 26:1201-1202. [PMID: 31002439 DOI: 10.1111/acem.13769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Andrew Koons
- Emergency Medicine and Medical Toxicology, Lehigh Valley Health Network, Bethlehem, PA
| | - Robert Cannon
- Emergency Medicine and Medical Toxicology, Lehigh Valley Health Network, Bethlehem, PA
| | - Gillian Beauchamp
- Emergency Medicine and Medical Toxicology, Lehigh Valley Health Network, Bethlehem, PA
| | - Kenneth Katz
- Emergency Medicine and Medical Toxicology, Lehigh Valley Health Network, Bethlehem, PA
| | - Matthew Cook
- Emergency Medicine and Medical Toxicology, Lehigh Valley Health Network, Bethlehem, PA
| | - Ryan Surmaitis
- Emergency Medicine and Medical Toxicology, Lehigh Valley Health Network, Bethlehem, PA
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Clemency BM, Eggleston W, Lindstrom HA. Pharmacokinetics and Pharmacodynamics of Naloxone. Acad Emerg Med 2019; 26:1203-1204. [PMID: 31002450 DOI: 10.1111/acem.13768] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Brian M. Clemency
- Department of Emergency Medicine University at Buffalo Jacobs School of Medicine and Biomedical Sciences Buffalo NY
| | | | - Heather A. Lindstrom
- Department of Emergency Medicine University at Buffalo Jacobs School of Medicine and Biomedical Sciences Buffalo NY
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Wahler BM, Lerche P, Ricco Pereira CH, Bednarski RM, KuKanich B, Lakritz J, Aarnes TK. Pharmacokinetics and pharmacodynamics of intranasal and intravenous naloxone hydrochloride administration in healthy dogs. Am J Vet Res 2019; 80:696-701. [PMID: 31246123 DOI: 10.2460/ajvr.80.7.696] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the pharmacokinetics and pharmacodynamics of naloxone hydrochloride in dogs following intranasal (IN) and IV administration. ANIMALS 6 healthy adult mixed-breed dogs. PROCEDURES In a blinded crossover design involving 2 experimental periods separated by a washout period (minimum of 7 days), dogs were randomly assigned to receive naloxone IN (4 mg via a commercially available fixed-dose naloxone atomizer; mean ± SD dose, 0.17 ± 0.02 mg/kg) or IV (0.04 mg/kg) in the first period and then the opposite treatment in the second period. Plasma naloxone concentrations, dog behavior, heart rate, and respiratory rate were evaluated for 24 hours/period. RESULTS Naloxone administered IN was well absorbed after a short lag time (mean ± SD, 2.3 ± 1.4 minutes). Mean maximum plasma concentration following IN and IV administration was 9.3 ± 2.5 ng/mL and 18.8 ± 3.9 ng/mL, respectively. Mean time to maximum concentration following IN administration was 22.5 ± 8.2 minutes. Mean terminal half-life after IN and IV administration was 47.4 ± 6.7 minutes and 37.0 ± 6.7 minutes, respectively. Mean bioavailability of naloxone administered IN was 32 ± 13%. There were no notable changes in dog behavior, heart rate, or respiratory rate following naloxone administration by either route. CONCLUSIONS AND CLINICAL RELEVANCE Use of a naloxone atomizer for IN naloxone administration in dogs may represent an effective alternative to IV administration in emergency situations involving opioid exposure. Future studies are needed to evaluate the efficacy of IN naloxone administration in dogs with opioid intoxication, including a determination of effective doses.
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Computational framework for predictive PBPK-PD-Tox simulations of opioids and antidotes. J Pharmacokinet Pharmacodyn 2019; 46:513-529. [PMID: 31396799 DOI: 10.1007/s10928-019-09648-1] [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: 02/13/2019] [Accepted: 07/29/2019] [Indexed: 10/26/2022]
Abstract
The primary goal of this work was to develop a computational tool to enable personalized prediction of pharmacological disposition and associated responses for opioids and antidotes. Here we present a computational framework for physiologically-based pharmacokinetic (PBPK) modeling of an opioid (morphine) and an antidote (naloxone). At present, the model is solely personalized according to an individual's mass. These PK models are integrated with a minimal pharmacodynamic model of respiratory depression induction (associated with opioid administration) and reversal (associated with antidote administration). The model was developed and validated on human data for IV administration of morphine and naloxone. The model can be further extended to consider different routes of administration, as well as to study different combinations of opioid receptor agonists and antagonists. This work provides the framework for a tool that could be used in model-based management of pain, pharmacological treatment of opioid addiction, appropriate use of antidotes for opioid overdose and evaluation of abuse deterrent formulations.
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Lai Joyce Chun K, Olsen A, Taing MW, Clavarino A, Hollingworth S, Dwyer R, Middleton M, Nielsen S. How prepared are pharmacists to provide over-the-counter naloxone? The role of previous education and new training opportunities. Res Social Adm Pharm 2019; 15:1014-1020. [DOI: 10.1016/j.sapharm.2019.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 03/04/2019] [Accepted: 03/06/2019] [Indexed: 02/05/2023]
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Hsu HJ, Yang Y, Pavuluri V, Abraham C, Naraharisetti SB, Ashraf M, Al-Ghabeish M. Effect of Formulation Variables on the Nasal Permeability and Stability of Naloxone Intranasal Formulations. AAPS PharmSciTech 2019; 20:232. [PMID: 31236738 DOI: 10.1208/s12249-019-1452-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 06/11/2019] [Indexed: 02/02/2023] Open
Abstract
Naloxone is an opioid antagonist with high affinity for μ-opioid receptor, and for this reason it is used for the emergency treatment of opioid overdose. Originally, it was available only as an injectable product. However, for the ease of administration, intranasal (IN) formulations have also become available. These IN formulations contain preservatives and stabilizers such as benzalkonium chloride (BKC), benzyl alcohol (BA), and ethylenediaminetetraacetic acid (EDTA). Some of these ingredients are known to affect permeability of drugs. This study focuses on investigating the effect of formulation variables including choice of preservatives, stabilizer, and pH on the permeability and stability of naloxone IN formulations. The in vitro permeability of naloxone was evaluated employing EpiAirway™ tissue-mounted Ussing chambers. BKC was found to enhance the apparent permeability (Papp) of naloxone significantly (p < 0.05) at very low concentration, while BA caused similar enhancement at a much higher concentration. EDTA was found to decrease Papp of naloxone by lowering the pH, and the Papp of naloxone was found to decrease approximately 51-fold with the decrease in formulation pH from 6.0 to 4.0. The product stability was, however, found optimal only below pH 5.0. Thus, selection of formulation ingredients, buffering agent, and pH of IN formulation is a balancing act for achieving desired permeability and optimal stability to achieve reasonable shelf life of naloxone IN formulation.
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La crise des overdoses américaines : une menace pour la France ? Rev Med Interne 2019; 40:389-394. [DOI: 10.1016/j.revmed.2018.10.389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 10/16/2018] [Accepted: 10/27/2018] [Indexed: 02/08/2023]
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