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Maqoud F, Fabio G, Ciliero N, Antonacci M, Mastrangelo F, Sammarruco G, Cataldini R, Schirosi G, De Fazio S, Tricarico D. Multicenter Observational/Exploratory Study Addressed to the Evaluation of the Effectiveness and Safety of Pharmacological Therapy in Opioid-Dependent Patients in Maintenance Therapy in Southern Italy. Pharmaceutics 2022; 14:pharmaceutics14020461. [PMID: 35214192 PMCID: PMC8878258 DOI: 10.3390/pharmaceutics14020461] [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] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/28/2022] [Accepted: 02/14/2022] [Indexed: 02/04/2023] Open
Abstract
A multicenter-observational study was performed to assess the effectiveness of rac-methadone, levomethadone, and buprenorphine in opioid-dependent patients in polytherapy in Southern Italy. The primary endpoint was the reduction of urinary positivity to the substances and the maintaining doses. Patients (N = 266, age = 44.80 ± 5.65, male = 79.70%, female = 20.30%) have been recruited. At recruitment, 75% of them were on treatment with rac-methadone, levomethadone, and buprenorphine/naloxone. The patients were grouped into three clusters. The levomethadone patients of Cluster A (N patients = 211), after 180 days, showed stability in urinary methadone positivity, with a marked decrease in heroin −53 ± 4%, cannabinol’s −48 ± 2%, and cocaine −37 ± 6% positivity, with no differences between treatments. A lower QTcF value of 426 ± 8.4 ms was recorded in the levomethadone patients (delta = −19 ms) vs. rac-methadone, at significantly lower doses of levomethadone (−34%, −50.2% in males) (p < 0.05). The Cluster B data were collected from 37 patients, with a high prevalence of comorbidity infections (HIV/HCV/HPV), monitored for 21 months during COVID-19. High doses of levomethadone (58.33 ± 31.58 mg/day) were needed to stabilize those that were negative for opioids and cannabinoids, in contrast to the rac-methadone and buprenorphine/naloxone patients that showed positive toxicology. Eighteen patients of the Cluster C in double diagnosis (major depressive 38.90%, bipolar 27.78%, and schizophrenia 16.67%) were stabilized with high doses of racemate 97.5 ± 8 mg/day, 51.8 ± 5 mg/day of levomethadone (−46.8% vs. rac-methadone; −71% in men), and 2.5 ± 1 mg/day of buprenorphine/naloxone. Three patients in remission were treated with tapering doses of levomethadone. Significantly reduced QTcF values were recorded with levomethadone (delta −32 ms vs. rac-methadone) in the bipolar patients, as well as the schizophrenia patients in remission (delta −45.19 ms vs. rac-methadone). Our patients were safely stabilized. Levomethadone, compared to the racemate, contributes to reducing the illicit use, especially of opioids and cannabinoids at significantly lower doses with cardiovascular safety, which, in bipolar patients, is clinically significant.
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Affiliation(s)
- Fatima Maqoud
- Department of Pharmacy-Pharmaceutical Sciences, Pharmacology, University of Bari, Via Orabona 4, 70125 Bari, Italy; (F.M.); (N.C.); (M.A.)
| | - Giada Fabio
- Ser.D. Bari, ASL-BA, Via Amendola, 124/C, 70126 Bari, Italy;
| | - Nunzio Ciliero
- Department of Pharmacy-Pharmaceutical Sciences, Pharmacology, University of Bari, Via Orabona 4, 70125 Bari, Italy; (F.M.); (N.C.); (M.A.)
| | - Marina Antonacci
- Department of Pharmacy-Pharmaceutical Sciences, Pharmacology, University of Bari, Via Orabona 4, 70125 Bari, Italy; (F.M.); (N.C.); (M.A.)
| | - Francesca Mastrangelo
- Ser.D. Lanciano, ASL2 Lanciano-Vasto-Chieti, Via Martiri Lancianesi 17/19, 66100 Chieti, Italy;
| | - Giorgio Sammarruco
- Ser.D. Poggiardo, Piazza Partigiani, s.n.c., Poggiardo, 73037 Lecce, Italy;
| | - Roberto Cataldini
- U.O. Double Diagnosis Gallipoli, Via Marconi, 1, 73014 Gallipoli, Italy;
| | - Gabriella Schirosi
- Ser.D. Taranto, Contrada “Rondinella” c/o Ospedale “Testa” Strada Statale 106, 74100 Taranto, Italy;
| | | | - Domenico Tricarico
- Department of Pharmacy-Pharmaceutical Sciences, Pharmacology, University of Bari, Via Orabona 4, 70125 Bari, Italy; (F.M.); (N.C.); (M.A.)
- Correspondence:
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Weisshaar S, Brandt L, Litschauer B, Sheik-Rezaei S, Moser L, Nirnberger G, Kühberger E, Bauer U, Firbas C, Gouya G, Wolzt M, Fischer G. Dose-dependent naloxone-induced morphine withdrawal symptoms in opioid-dependent males-a double-blinded, randomized study. Br J Clin Pharmacol 2020; 86:1610-1619. [PMID: 32145041 PMCID: PMC7373709 DOI: 10.1111/bcp.14271] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 11/01/2019] [Accepted: 02/26/2020] [Indexed: 12/28/2022] Open
Abstract
Aims Oral opioid preparations combined with naloxone are intended to induce a transient acute withdrawal syndrome to avoid intravenous misuse. This trial aimed to establish an appropriate morphine–naloxone dose ratio for an abuse‐deterrent oral opioid formulation. Methods In a randomized, double‐blinded, 2 × 2 cross‐over trial, 43 patients with opioid use disorder were challenged with intravenous morphine HCl Ph.Eur. (75 mg; [morphine mono]) or morphine HCl Ph.Eur. and naloxone HCl Ph.Eur. at ratios of 100:1 (75 mg: 0.75 mg; [morphine–naloxone 100:1]) or 200:1 (75 mg: 0.375 mg; [morphine–naloxone 200:1]). Acute naloxone‐induced opioid withdrawal was evaluated using subjective (Short Opiate Withdrawal Scale–German [SOWS‐G]) and observer‐rated (Objective Opiate Withdrawal Scale [OOWS], Wang scale) questionnaires, and physiological parameters. For statistical analysis, the area under the curve between baseline and 20 minutes after drug administration of the outcome variables was calculated. Results Intravenous morphine–naloxone caused rapid withdrawal symptoms. Coadministration of naloxone dose‐dependently (morphine–naloxone 100:1 > morphine–naloxone 200:1) increased SOWS‐G, OOWS and Wang Scale area under the curve when compared to morphine mono, respectively (all P < .0001). A similar response was detectable for changes of pupil diameter. Blood pressure and respiratory rate changed heterogeneously, and heart rate was unaltered by morphine without or with naloxone. Conclusion Morphine–naloxone 100:1 effectively suppresses the pleasurable effects of intravenous morphine and results in an aversive withdrawal reaction. A lower naloxone concentration as used in morphine–naloxone 200:1 does not appear to be appropriate to prevent intravenous morphine misuse.
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Affiliation(s)
- Stefan Weisshaar
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Laura Brandt
- Department of Applied Psychology: Work, Education & Economy, Faculty of Psychology, University of Vienna, Vienna, Austria.,Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Brigitte Litschauer
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Safoura Sheik-Rezaei
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Laura Moser
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | | | | | - Christa Firbas
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Ghazaleh Gouya
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Michael Wolzt
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Gabriele Fischer
- Center for Public Health, Medical University of Vienna, Vienna, Austria
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Enhancement and Suppression of Ionization in Drug Analysis Using HPLC-MS/MS in Support of Therapeutic Drug Monitoring: A Review of Current Knowledge of Its Minimization and Assessment. Ther Drug Monit 2018; 40:1-8. [PMID: 29240615 DOI: 10.1097/ftd.0000000000000471] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
High-performance liquid chromatography coupled with tandem mass spectrometry is commonly used for quantitation of analytes in biological matrices, because of the selectivity, sensitivity, and high throughput offered by this technique. However, the presence of both suppression and enhancement of ionization (SEI) by matrix components is an increasingly recognized impediment to accurate results. The existence of SEI indicates that ionization efficiency is a result of the chemical environment seen by both the analyte and internal standard during ion formation. SEI is influenced by the type and the make of ion source used, mobile-phase composition, extent of sample preparation, and the ability to chromatographically separate other compounds that may influence ionization of the analyte and/or internal standard. A comprehensive review of the phenomenon of SEI in high-performance liquid chromatography coupled with tandem mass spectrometry was conducted, and a summary of salient papers relating to therapeutic agents in biological matrices is presented. Suggestions for approaches to minimize, normalize, or assess SEI and its deleterious effect on accuracy and sensitivity, and hence the validity of quantitative results, are provided. Consideration is also given to a strategy to test for SEI, including the number of samples from different sources that are required to adequately test for SEI.
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Volpe DA, Xu Y, Sahajwalla CG, Younis IR, Patel V. Methadone Metabolism and Drug-Drug Interactions: In Vitro and In Vivo Literature Review. J Pharm Sci 2018; 107:2983-2991. [PMID: 30205091 DOI: 10.1016/j.xphs.2018.08.025] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 08/20/2018] [Accepted: 08/24/2018] [Indexed: 11/19/2022]
Abstract
Methadone is utilized for the treatment of individuals with opiate dependence. Methadone undergoes N-demethylation by multiple cytochrome P450 (CYP) enzymes including CYP3A4, CYP2B6, CYP2C19, CYP2D6, CYP2C9, and CYP2C8. In vivo, polymorphism effects on methadone systemic exposure have been noted for CYP2B6, CYP3A4, and CYP2D6. Clinical drug interaction studies with antiviral drugs in methadone maintenance treatment patients yield varying results on methadone pharmacokinetics and pharmacodynamics. In general, CYP inhibitors altered methadone exposure with no adverse effects. CYP inducers generally decreased methadone exposure with some reports of withdrawal symptoms in the subjects. Interaction studies with antiviral drug combinations yielding differing results depend on the enzyme(s) affected. For certain antiviral medicines which are dual inhibitor(s) and inducer(s) for CYP enzymes, their effect on methadone pharmacokinetics can change with time since the effect of induction is usually delayed compared to the effect of inhibition.
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Affiliation(s)
- Donna A Volpe
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland 20993.
| | - Yun Xu
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland 20993
| | - Chandrahas G Sahajwalla
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland 20993
| | - Islam R Younis
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland 20993
| | - Vikram Patel
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland 20993
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Ahmad T, Valentovic MA, Rankin GO. Effects of cytochrome P450 single nucleotide polymorphisms on methadone metabolism and pharmacodynamics. Biochem Pharmacol 2018; 153:196-204. [PMID: 29458047 DOI: 10.1016/j.bcp.2018.02.020] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 02/14/2018] [Indexed: 01/11/2023]
Abstract
Methadone is a synthetic, long-acting opioid with a single chiral center forming two enantiomers, (R)-methadone and (S)-methadone, each having specific pharmacological actions. Concentrations of (R)- and (S)-methadone above therapeutic levels have the ability to cause serious, life-threatening, and fatal side effects. This toxicity can be due in part to the pharmacogenetics of an individual, which influences the pharmacokinetic and pharmacodynamic properties of the drug. Methadone is primarily metabolized in the liver by cytochrome P450 (CYP) enzymes, predominately by CYP2B6, followed by CYP3A4, 2C19, 2D6, and to a lesser extent, CYP2C18, 3A7, 2C8, 2C9, 3A5, and 1A2. Single nucleotide polymorphisms (SNPs) located within CYPs have the potential to play an important role in altering methadone metabolism and pharmacodynamics. Several SNPs in the CYP2B6, 3A4, 2C19, 2D6, and 3A5 genes result in increases in methadone plasma concentrations, decreased N-demethylation, and decreased methadone clearance. In particular, carriers of CYP2B6*6/*6 may have a greater risk for detrimental adverse effects, as methadone metabolism and clearance are diminished in these individuals. CYP2B6*4, on the other hand, has been observed to decrease plasma concentrations of methadone due to increased methadone clearance. The involvement, contribution, and understanding the role of SNPs in CYP2B6, and other CYP genes, in methadone metabolism can improve the therapeutic uses of methadone in patient outcome and the development of personalized medicine.
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Affiliation(s)
- Taha Ahmad
- Department of Biomedical Sciences, Toxicology Research Cluster, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV 25755-9310, USA
| | - Monica A Valentovic
- Department of Biomedical Sciences, Toxicology Research Cluster, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV 25755-9310, USA
| | - Gary O Rankin
- Department of Biomedical Sciences, Toxicology Research Cluster, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV 25755-9310, USA.
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Mannaioni G, Lanzi C, Lotti M, Galli V, Totti A, Pacileo I, Sili M, Pracucci C, Dilaghi A, Bertieri L, Quaranta M, Orsini F, Occupati B, Michahelles A, Ciuti R, Bianchini E, Fabbro G, Biggeri A, Masini E, Moroni F. Methadone Dose Adjustments, Plasma R-Methadone Levels and Therapeutic Outcome of Heroin Users: A Randomized Clinical Trial. Eur Addict Res 2018; 24:9-18. [PMID: 29393208 DOI: 10.1159/000485029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 11/07/2017] [Indexed: 11/19/2022]
Abstract
AIMS We aimed to improve the retention in treatment and therapeutic outcome of methadone maintenance treatment (MMT) patients by adjusting the oral methadone dose in order to reach a "target" plasma R-methadone level (80-250 ng/mL). METHODS A multicenter randomized controlled trial was organized. RESULTS The intention-to-treat statistical analysis showed that repeated dose adjustments performed in order to obtain therapeutic plasma R-methadone levels did not improve retention in treatment of heroin-dependent patients. However, patients having plasma methadone levels in the "target range" at the beginning of the study had a better retention in treatment than controls. Furthermore, patients succeeding in keeping plasma R-methadone target levels (per protocol analysis) remained in treatment and improved their social scores better than controls. -Conclusion: Although the primary endpoint of this study was not demonstrated, a post hoc and a per protocol analysis suggested that patients in MMT with plasma R-methadone concentrations in the target range have a better therapeutic outcome than controls.
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Affiliation(s)
- Guido Mannaioni
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Cecilia Lanzi
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Michela Lotti
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Valentina Galli
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Arianna Totti
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Ilaria Pacileo
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Maria Sili
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Chiara Pracucci
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Arianna Dilaghi
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Lara Bertieri
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Mariarita Quaranta
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Francesco Orsini
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | | | | | | | | | | | | | - Emanuela Masini
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Flavio Moroni
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
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Ahmad T, Sabet S, Primerano DA, Richards-Waugh LL, Rankin GO. Tell-Tale SNPs: The Role of CYP2B6 in Methadone Fatalities. J Anal Toxicol 2017; 41:325-333. [PMID: 28184434 DOI: 10.1093/jat/bkw135] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 12/14/2016] [Indexed: 11/14/2022] Open
Abstract
Cytochrome P450 (CYP) enzyme 2B6 plays a significant role in the stereo-selective metabolism of (S)-methadone to 2-ethyl-1,5-dimethyl-3,3-diphenylpyrrolidine, an inactive methadone metabolite. Elevated (S)-methadone can cause cardiotoxicity by prolonging the QT interval of the heart's electrical cycle. Large inter-individual variability of methadone pharmacokinetics causes discordance in the relationship between dose, plasma concentrations and side effects. The purpose of this study was to determine if one or more single nucleotide polymorphisms (SNPs) located within the CYP2B6 gene contributes to a poor metabolizer phenotype for methadone in these fatal cases. The genetic analysis was conducted on 125 Caucasian methadone-only fatalities obtained from the West Virginia and Kentucky Offices of the Chief Medical Examiner. The frequency of eight exonic and intronic SNPs (rs2279344, rs3211371, rs3745274, rs4803419, rs8192709, rs8192719, rs12721655 and rs35979566) was determined. The frequencies of SNPs rs3745274 (*9, c516G > T, Q172H), and rs8192719 (21563 C > T) were enhanced in the methadone-only group. Higher blood methadone concentrations were observed in individuals who were genotyped homozygous for SNP rs3211371 (*5, c1459C > T, R487C). These results indicate that these three CYP2B6 SNPs are associated with methadone fatalities.
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Affiliation(s)
- Taha Ahmad
- Department of Biomedical Sciences, Joan C. Edwards School of Medicine, Marshall University, 1700 Third Avenue, Huntington, WV 25755, USA
| | - Samie Sabet
- Department of Biomedical Sciences, Joan C. Edwards School of Medicine, Marshall University, 1700 Third Avenue, Huntington, WV 25755, USA
| | - Donald A Primerano
- Department of Biomedical Sciences, Joan C. Edwards School of Medicine, Marshall University, 1700 Third Avenue, Huntington, WV 25755, USA
| | - Lauren L Richards-Waugh
- Forensic Science Department, Marshall University, 1401 Forensic Science Drive, Huntington, WV 25701, USA
| | - Gary O Rankin
- Department of Biomedical Sciences, Joan C. Edwards School of Medicine, Marshall University, 1700 Third Avenue, Huntington, WV 25755, USA
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Dinis-Oliveira RJ. Metabolomics of methadone: clinical and forensic toxicological implications and variability of dose response. Drug Metab Rev 2016; 48:568-576. [DOI: 10.1080/03602532.2016.1192642] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Graziani M, Nisticò R. Gender differences in pharmacokinetics and pharmacodynamics of methadone substitution therapy. Front Pharmacol 2015; 6:122. [PMID: 26106330 PMCID: PMC4460328 DOI: 10.3389/fphar.2015.00122] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 05/25/2015] [Indexed: 12/17/2022] Open
Abstract
Gender-related differences in the pharmacological effects of drug are an emerging topic. This review examines gender differences in both pharmacokinetic and pharmacodynamic aspects of methadone, a long-acting opioid agonist that is prescribed as a treatment for opioid dependence and the management of chronic pain. Method: We performed a search in the Medline database from 1990 to 2014 in order to find published literature related to gender differences in pharmacokinetics (PK) and pharmacodynamics (PD) of methadone. Results: None of the studies were carried out with the primary or secondary aim to identify any gender differences in the pharmacokinetic profile of methadone. Importantly; high inter-subjects variability in PK parameters was found also intra female population. The reported differences in volume of distribution could be ascribed to the physiological differences between men and women in body weight and composition, taking into account that the dose of methadone was established irrespective of body weight of patients (Peles and Adelson, 2006). On the other hand, the few studies present in literature found no gender difference in some direct pharmacodynamic parameters. Some reports have suggested that female gender is associated with an increased risk for long-QT-related cardiac arrhythmias in methadone maintenance subjects. Conclusion: Even though it may be too simplistic to expect variability only in one parameter to explain inter-individual variation in methadone response, we believe that a better knowledge of gender-related differences might have significant implications for better outcomes in opioid dependence substitution therapy in women.
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Affiliation(s)
- Manuela Graziani
- Vittorio Erspamer School of Physiology and Pharmacology, Sapienza University of Rome Rome, Italy ; Drug Addiction and Clinical Pharmacology Unit, University Hospital Umberto I, Sapienza University of Rome Rome, Italy
| | - Robert Nisticò
- Department of Biology, University of Rome Tor Vergata Rome, Italy
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Richards-Waugh LL, Primerano DA, Dementieva Y, Kraner JC, Rankin GO. Fatal methadone toxicity: potential role of CYP3A4 genetic polymorphism. J Anal Toxicol 2015; 38:541-7. [PMID: 25217544 DOI: 10.1093/jat/bku091] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Methadone is difficult to administer as a therapeutic agent because of a wide range of interindividual pharmacokinetics, likely due to genetic variability of the CYP450 enzymes responsible for metabolism to its principal metabolite 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP). CYP3A4 is one of the primary CYP450 isoforms responsible for the metabolism of methadone to EDDP in humans. The purpose of this study was to evaluate the role of CYP3A4 genetic polymorphisms in accidental methadone fatalities. A study cohort consisting of 136 methadone-only and 92 combined methadone/benzodiazepine fatalities was selected from cases investigated at the West Virginia and Kentucky Offices of the Chief Medical Examiner. Seven single nucleotide polymorphisms (SNPs) were genotyped within the CYP3A4 gene. Observed allelic and genotypic frequencies were compared with expected frequencies obtained from The National Center for Biotechnology Information dbSNP database. SNPs rs2242480 and rs2740574 demonstrated an apparent enrichment within the methadone-only overdose fatalities compared with the control group and the general population. This enrichment was not apparent in the methadone/benzodiazepine cases for these two SNPs. Our findings indicate that there may be two or more SNPs on the CYP3A4 gene that cause or contribute to the methadone poor metabolizer phenotype.
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Affiliation(s)
| | - Donald A Primerano
- Department of Biochemistry and Microbiology, Marshall University, Huntington, WV, USA
| | | | - James C Kraner
- Office of the Chief Medical Examiner, Charleston, WV, USA
| | - Gary O Rankin
- Department of Pharmacology, Physiology and Toxicology, Marshall University, Huntington, WV, USA
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Meini M, Moncini M, Daini L, Giarratana T, Scaramelli D, Chericoni S, Stefanelli F, Rucci P. Relationship between plasma concentrations of the l-enantiomer of methadone and response to methadone maintenance treatment. Eur J Pharmacol 2015; 760:1-6. [PMID: 25891369 DOI: 10.1016/j.ejphar.2015.03.081] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 03/20/2015] [Accepted: 03/27/2015] [Indexed: 10/23/2022]
Abstract
This study evaluated the relationship between the plasma concentration of l-methadone and response to methadone in real-world patients, in order to identify a minimum plasma concentration above which methadone treatment is effective. Ninety-four patients with opioid dependence under maintenance methadone treatment were consecutively recruited. Response was defined as negative urine analyses in the three weeks prior to the blood sampling. The percentage of participants with a plasma l-methadone concentration between 100 and 250 ng/ml was 54.2% among those with a methadone dosage ≥60 mg/day. Plasma l-methadone concentrations were significantly higher in patients with negative urine analyses compared with those with positive urine analyses (median 93 vs. 77 ng/ml, Mann-Whitney test, P<0.05). Above plasma l-methadone concentrations of 200 ng/ml no heroin use was reported and urine analyses were negative. Moreover, above concentrations of 250 ng/ml craving was absent. Examination of demographic correlates of treatment outcome indicated that older age, a stable job and being married were protective against the use of heroin. Mean plasma l-methadone concentration was significantly lower in patients who used cannabis compared with those who did not use cannabis, after adjusting for methadone dosage. In conclusion our results identify specific cut-offs for plasma l-methadone concentrations about which therapeutic response is observed and provide new evidence that therapeutic response is associated with patient׳s demographic characteristics. This underscores the need to monitor plasma methadone concentrations as part of Drug Addiction Services routine practice, in order to provide an objective framework for changing the methadone dosage.
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Affiliation(s)
- Milo Meini
- Department of Drug Addiction Medicine, Local Health Authority of Pisa, Italy
| | - Marco Moncini
- Department of Drug Addiction Medicine, Local Health Authority of Pisa, Italy
| | - Laura Daini
- Department of Drug Addiction Medicine, Local Health Authority of Pisa, Italy
| | - Tania Giarratana
- Department of Drug Addiction Medicine, Local Health Authority of Pisa, Italy
| | - Daniela Scaramelli
- Department of Drug Addiction Medicine, Local Health Authority of Pisa, Italy
| | - Silvio Chericoni
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Section of Forensic Medicine, University of Pisa and University Hospital Trust, Pisa, Italy
| | - Fabio Stefanelli
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Section of Forensic Medicine, University of Pisa and University Hospital Trust, Pisa, Italy
| | - Paola Rucci
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna, Via San Giacomo 12, 40126 Bologna, Italy.
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Bouquié R, Hélène Hernando, Guillaume Deslandes, Mostefa Daho AB, Renaud C, Grall-Bronnec M, Dailly E, Jolliet P. Chiral on-line solid phase extraction coupled to liquid chromatography–tandem mass spectrometry assay for quantification of (R) and (S) enantiomers of methadone and its main metabolite in plasma. Talanta 2015; 134:373-378. [DOI: 10.1016/j.talanta.2014.11.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 11/17/2014] [Accepted: 11/22/2014] [Indexed: 11/28/2022]
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13
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Bell J. Pharmacological maintenance treatments of opiate addiction. Br J Clin Pharmacol 2014; 77:253-63. [PMID: 23210630 DOI: 10.1111/bcp.12051] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 11/21/2012] [Indexed: 12/18/2022] Open
Abstract
For people seeking treatment, the course of heroin addiction tends to be chronic and relapsing, and longer duration of treatment is associated with better outcomes. Heroin addiction is strongly associated with deviant behaviour and crime, and the objectives in treating heroin addiction have been a blend of humane support, rehabilitation, public health intervention and crime control. Reduction in street heroin use is the foundation on which all these outcomes are based. The pharmacological basis of maintenance treatment of dependent individuals is to minimize withdrawal symptoms and attenuate the reinforcing effects of street heroin, leading to reduction or cessation of street heroin use. Opioid maintenance treatment can be moderately effective in suppressing heroin use, although deviations from evidence-based approaches, particularly the use of suboptimal doses, have meant that treatment as delivered in practice may have resulted in poorer outcomes than predicted by research. Methadone treatment has been 'programmatic', with a one-size-fits-all approach that in part reflects the perceived need to impose discipline on deviant individuals. However, differences in pharmacokinetics and in side-effects mean that many patients do not respond optimally to methadone. Injectable diamorphine (heroin) provides a more reinforcing medication for some 'nonresponders' and can be a valuable option in the rehabilitation of demoralized, socially excluded individuals. Buprenorphine, a partial agonist, is a less reinforcing medication with different side-effects and less risk of overdose. Not only is it a different medication, but also it can be used in a different paradigm of treatment, office-based opioid treatment, with less structure and offering greater patient autonomy.
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Affiliation(s)
- James Bell
- Kings Health Partners, London, SE5 8RS, UK
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Chevillard L, Declèves X, Baud FJ, Risède P, Mégarbane B. Respiratory effects of diazepam/methadone combination in rats: a study based on concentration/effect relationships. Drug Alcohol Depend 2013; 131:298-307. [PMID: 23332448 DOI: 10.1016/j.drugalcdep.2012.12.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 12/12/2012] [Accepted: 12/18/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Methadone may cause respiratory depression and fatalities. Concomitant use of benzodiazepines in methadone-treated patients for chronic pain or as maintenance therapy for opiate abuse is common. However, the exact contribution of benzodiazepines to methadone-induced respiratory toxicity remains debatable. METHODS We investigated the respiratory effects of the combination diazepam (20mg/kg)/methadone (5mg/kg) in the rat, focusing on methadone concentration/effect relationships. Respiratory effects were studied using arterial blood gases and whole-body plethysmography. Plasma concentrations of both R- and S-methadone enantiomers were measured using high-performance liquid chiral chromatography coupled to mass spectrometry. To clarify mechanisms of diazepam/methadone interaction, methadone metabolism was investigated in vitro using rat liver microsomes. RESULTS Diazepam/methadone co-administration significantly increased methadone-related effects on inspiratory time (p<0.001) but did not significantly alter the other respiratory parameters when compared with methadone alone, despite significant increase in the area under the curve of plasma R-methadone concentrations measured during 240 min (p<0.05). Diazepam/methadone co-incubation with microsomes in vitro resulted in a significant inhibition of methadone metabolism (p<0.01), with 50%-inhibitory diazepam concentrations of 25.02 ± 0.18 μmol/L and 25.18 ± 0.23 μmol/L for R- and S-methadone, respectively. CONCLUSION We concluded that co-administration of high-doses of diazepam and methadone in rats is not responsible for additional respiratory depression in comparison to methadone alone, despite significant metabolic interaction between the drugs. In humans, although our experimental data may suggest the relative safety of benzodiazepine/methadone co-prescription, physicians should remain cautious as other underlying conditions may enhance this drug-drug interaction.
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Affiliation(s)
- Lucie Chevillard
- INSERM U705, CNRS UMR8206, Université Paris Descartes, Sorbonne Paris Cité, Faculté de Pharmacie, Neuropsychopharmacologie des addictions, Paris, France.
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15
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Jantos R, Skopp G. Postmortem blood and tissue concentrations of R- and S-enantiomers of methadone and its metabolite EDDP. Forensic Sci Int 2013; 226:254-60. [DOI: 10.1016/j.forsciint.2013.01.038] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 01/22/2013] [Accepted: 01/26/2013] [Indexed: 11/25/2022]
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16
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Abstract
AIMS Opioids have been implicated in emotion regulation. Opioid users report decreased negative emotional response, but there has been no formal study on the effect of opioid administration on emotional reactivity. The aim of this study was to investigate the effect of methadone on emotional reactivity in methadone-maintained patients. DESIGN Velten's mood induction procedures were used to induce elative and depressive emotional reactions in the subjects. Each group was administered both induction procedures at 0 hour and 3 hours (corresponding with trough and peak plasma methadone concentrations in methadone subjects). SETTING A drug treatment clinic with an out-patient methadone maintenance treatment programme. PARTICIPANTS Twenty-one subjects currently on methadone maintenance treatment and 21 controls with no history of opioid dependence. MEASUREMENTS Emotional reactivity was measured using mood visual analogue scales. FINDINGS At 0 hour, methadone and control subjects showed similar elation (methadone 13.2 ± 3.1 mean ± standard error of the mean [SEM], control 14.4 ± 3.7) and depression reactivity (methadone 23.6 ± 5.0, control 25.1 ± 5.0). However, at 3 hours repeated measures showed that methadone subjects had significantly decreased depression reactivity (methadone 18.5 ± 4.6, control 36.7 ± 5.7; P = 0.021) and elation reactivity (methadone 4.4 ± 1.9, control 19.0 ± 2.4) compared to controls. CONCLUSIONS Opioid addicts on methadone maintenance appear to be less reactive to mood induction at times of peak plasma methadone concentration than non-addict controls; this suggests that methadone blunts both elative and depressive emotional reactivity.
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Affiliation(s)
- Steven M Savvas
- Discipline of Pharmacology, University of Adelaide, South Australia, Australia.
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17
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18
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Fonseca F, de la Torre R, Díaz L, Pastor A, Cuyàs E, Pizarro N, Khymenets O, Farré M, Torrens M. Contribution of cytochrome P450 and ABCB1 genetic variability on methadone pharmacokinetics, dose requirements, and response. PLoS One 2011; 6:e19527. [PMID: 21589866 PMCID: PMC3093392 DOI: 10.1371/journal.pone.0019527] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2010] [Accepted: 04/06/2011] [Indexed: 12/22/2022] Open
Abstract
Although the efficacy of methadone maintenance treatment (MMT) in opioid dependence disorder has been well established, the influence of methadone pharmacokinetics in dose requirement and clinical outcome remains controversial. The aim of this study is to analyze methadone dosage in responder and nonresponder patients considering pharmacogenetic and pharmacokinetic factors that may contribute to dosage adequacy. Opioid dependence patients (meeting Diagnostic and Statistical Manual of Mental Disorders, [4(th) Edition] criteria) from a MMT community program were recruited. Patients were clinically assessed and blood samples were obtained to determine plasma concentrations of (R,S)-, (R) and (S)-methadone and to study allelic variants of genes encoding CYP3A5, CYP2D6, CYP2B6, CYP2C9, CYP2C19, and P-glycoprotein. Responders and nonresponders were defined by illicit opioid consumption detected in random urinalysis. The final sample consisted in 105 opioid dependent patients of Caucasian origin. Responder patients received higher doses of methadone and have been included into treatment for a longer period. No differences were found in terms of genotype frequencies between groups. Only CYP2D6 metabolizing phenotype differences were found in outcome status, methadone dose requirements, and plasma concentrations, being higher in the ultrarapid metabolizers. No other differences were found between phenotype and responder status, methadone dose requirements, neither in methadone plasma concentrations. Pharmacokinetic factors could explain some but not all differences in MMT outcome and methadone dose requirements.
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Affiliation(s)
- Francina Fonseca
- Institut de Neuropsiquiatria i Addiccions - Parc de Salut Mar, Barcelona, Spain
- Universitat Pompeu Fabra (CEXS-UPF), Barcelona, Spain
- Disorders by Use of Substances Research Group, Neuropsychopharmacology Research Program, Institut Municipal d'Investigació Mèdica (IMIM-Hospital del Mar Research Institute), Barcelona, Spain
| | - Rafael de la Torre
- Universitat Pompeu Fabra (CEXS-UPF), Barcelona, Spain
- Human Pharmacology and Clinical Neurosciences Research Group, Neuropsychopharmacology Research Program, Institut Municipal d'Investigació Mèdica (IMIM-Hospital del Mar Research Institute), Barcelona, Spain
- CIBER de Fisiopatología de la Obesidad y Nutrición (CB06/03), Hospital Clínico Universitario Santiago de Compostela, Santiago de Compostela, Spain
| | - Laura Díaz
- Institut de Neuropsiquiatria i Addiccions - Parc de Salut Mar, Barcelona, Spain
- Disorders by Use of Substances Research Group, Neuropsychopharmacology Research Program, Institut Municipal d'Investigació Mèdica (IMIM-Hospital del Mar Research Institute), Barcelona, Spain
| | - Antonio Pastor
- Human Pharmacology and Clinical Neurosciences Research Group, Neuropsychopharmacology Research Program, Institut Municipal d'Investigació Mèdica (IMIM-Hospital del Mar Research Institute), Barcelona, Spain
- Pharmacology Department, Autonomous University of Barcelona, Barcelona, Spain
| | - Elisabet Cuyàs
- Human Pharmacology and Clinical Neurosciences Research Group, Neuropsychopharmacology Research Program, Institut Municipal d'Investigació Mèdica (IMIM-Hospital del Mar Research Institute), Barcelona, Spain
- Pharmacology Department, Autonomous University of Barcelona, Barcelona, Spain
| | - Nieves Pizarro
- Human Pharmacology and Clinical Neurosciences Research Group, Neuropsychopharmacology Research Program, Institut Municipal d'Investigació Mèdica (IMIM-Hospital del Mar Research Institute), Barcelona, Spain
- Pharmacology Department, Autonomous University of Barcelona, Barcelona, Spain
| | - Olha Khymenets
- Human Pharmacology and Clinical Neurosciences Research Group, Neuropsychopharmacology Research Program, Institut Municipal d'Investigació Mèdica (IMIM-Hospital del Mar Research Institute), Barcelona, Spain
- CIBER de Fisiopatología de la Obesidad y Nutrición (CB06/03), Hospital Clínico Universitario Santiago de Compostela, Santiago de Compostela, Spain
| | - Magí Farré
- Human Pharmacology and Clinical Neurosciences Research Group, Neuropsychopharmacology Research Program, Institut Municipal d'Investigació Mèdica (IMIM-Hospital del Mar Research Institute), Barcelona, Spain
- Pharmacology Department, Autonomous University of Barcelona, Barcelona, Spain
| | - Marta Torrens
- Institut de Neuropsiquiatria i Addiccions - Parc de Salut Mar, Barcelona, Spain
- Disorders by Use of Substances Research Group, Neuropsychopharmacology Research Program, Institut Municipal d'Investigació Mèdica (IMIM-Hospital del Mar Research Institute), Barcelona, Spain
- Psychiatric Department, Autonomous University of Barcelona, Barcelona, Spain
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19
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Soyka M, Zingg C. Feasability and safety of transfer from racemic methadone to (R)-methadone in primary care: clinical results from an open study. World J Biol Psychiatry 2010; 10:217-24. [PMID: 19629858 DOI: 10.1080/15622970802416057] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Methadone is a proven first-line treatment in opioid dependence but few studies have addressed the efficacy of different isoforms of methadone or the transfer from one form to the other. This was a 4-week open study to examine the feasibility and safety of transfer from racemic methadone to (R)-methadone in primary care patients. A total of 1552 opioid-dependent patients formerly treated with racemic methadone were included and followed for 4 weeks after transfer to (R)-methadone. There were few drop-outs, and 1426 patients (91.9%) completed the 4-week transfer period. There were few adverse events or side effects and no deaths occurred during treatment. The number of drug-positive urine screens decreased from 61.2 to 39.8%. Withdrawal symptoms, craving and compliance improved significantly after transfer to (R)-methadone. We conclude that transfer from racemic to (R)-methadone is a safe and practical procedure.
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Affiliation(s)
- Michael Soyka
- Psychiatric Hospital, University of Munich, Munich, Germany.
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20
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Buchard A, Linnet K, Johansen SS, Munkholm J, Fregerslev M, Morling N. Postmortem blood concentrations of R- and S-enantiomers of methadone and EDDP in drug users: influence of co-medication and p-glycoprotein genotype. J Forensic Sci 2010; 55:457-63. [PMID: 20102450 DOI: 10.1111/j.1556-4029.2009.01278.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
We investigated toxicological and pharmacogenetic factors that could influence methadone toxicity using postmortem samples. R- and S-methadone were measured in femoral blood from 90 postmortem cases, mainly drug users. The R-enantiomer concentrations significantly exceeded that of the S-enantiomers (Wilcoxon's test, p < 0.001). The samples were divided into four groups according to other drugs detected (methadone only, methadone and strong analgesics, methadone and benzodiazepines, or methadone and other drugs). There was no significant difference in any of the R-methadone/total methadone ratios among the four groups. The median R/S ratio was 1.38, which tends to be higher than that reported for the plasma of living subjects. In addition, we investigated whether small nucleotide polymorphisms in the MDR1 gene that encode the drug transporter P-glycoprotein were associated with the concentrations of R- and S-methadone and its metabolite 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine. No significant association was detected.
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Affiliation(s)
- Anders Buchard
- Section of Forensic Genetics, Department of Forensic Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
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21
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Chevillard L, Mégarbane B, Baud FJ, Risède P, Declèves X, Mager D, Milan N, Ricordel I. Mechanisms of respiratory insufficiency induced by methadone overdose in rats. Addict Biol 2010; 15:62-80. [PMID: 20002023 DOI: 10.1111/j.1369-1600.2009.00184.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Methadone may cause respiratory depression. We aimed to understand methadone-related effects on ventilation as well as each opioid-receptor (OR) role. We studied the respiratory effects of intraperitoneal methadone at 1.5, 5, and 15 mg/kg (corresponding to 80% of the lethal dose-50%) in rats using arterial blood gases and plethysmography. OR antagonists, including intravenous 10 mg/kg-naloxonazine at 5 minutes (mu-OR antagonist), subcutaneous 30 mg/kg-naloxonazine at 24 hours (micro1-OR antagonist), 3 mg/kg-naltrindole at 45 minutes (delta-OR antagonist) and 5 mg/kg-Nor-binaltorphimine at 6 hours (kappa-OR antagonist) were pre-administered. Plasma concentrations of methadone enantiomers were measured using high-performance liquid chromatography coupled to mass-spectrometry. Methadone dose-dependent inspiratory time (T(I)) increase tended to be linear. Respiratory depression was observed only at 15 mg/kg and characterized by an increase in expiratory time (T(E)) resulting in hypoxemia and respiratory acidosis. Intravenous naloxonazine completely reversed all methadone-related effects on ventilation, while subcutaneous naloxonazine reduced its effects on pH (P < 0.05), PaCO(2) (P < 0.01) and T(E) (P < 0.001) but only partially on T(I) (P < 0.001). Naltrindole reduced methadone-related effects on T(E) (P < 0.001). Nor-binaltorphimine increased methadone-related effects on pH and PaO(2) (P < 0.05) Respiratory effects as a function of plasma R-methadone concentrations showed a decrease in PaO(2) (EC(50): 1.14 microg/ml) at lower concentrations than those necessary for PaCO(2) increase (EC(50): 3.35 microg/ml). Similarly, increased T(I) (EC(50): 0.501 microg/ml) was obtained at lower concentrations than those for T(E) (EC(50): 4.83 microg/ml). Methadone-induced hypoxemia is caused by mu-ORs and modulated by kappa-ORs. Additionally, methadone-induced increase in T(E) is caused by mu1- and delta-opioid receptors while increase in T(I) is caused by mu-ORs.
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MESH Headings
- Acidosis, Respiratory/chemically induced
- Acidosis, Respiratory/physiopathology
- Animals
- Dose-Response Relationship, Drug
- Drug Overdose/physiopathology
- Exhalation/drug effects
- Exhalation/physiology
- Hypoxia/chemically induced
- Hypoxia/physiopathology
- Injections, Intraperitoneal
- Injections, Intravenous
- Injections, Subcutaneous
- Male
- Methadone/pharmacokinetics
- Methadone/toxicity
- Narcotic Antagonists/pharmacology
- Narcotics/pharmacokinetics
- Narcotics/toxicity
- Oxygen/blood
- Rats
- Rats, Sprague-Dawley
- Receptors, Opioid/drug effects
- Receptors, Opioid/physiology
- Receptors, Opioid, delta/drug effects
- Receptors, Opioid, delta/physiology
- Receptors, Opioid, kappa/drug effects
- Receptors, Opioid, kappa/physiology
- Receptors, Opioid, mu/drug effects
- Receptors, Opioid, mu/physiology
- Respiratory Insufficiency/physiopathology
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Affiliation(s)
- Lucie Chevillard
- Université Paris-Descartes, Faculté de Pharmacie, Neuropsychopharmacologie des addictions, CNRS, UMR 7157, Paris, France
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22
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Cannabis and benzodiazepines as determinants of methadone trough plasma concentration variability in maintenance treatment: a transnational study. Eur J Clin Pharmacol 2009; 65:1113-20. [DOI: 10.1007/s00228-009-0706-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2008] [Accepted: 06/20/2009] [Indexed: 11/25/2022]
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23
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Major depressive disorder and patient satisfaction in relation to methadone pharmacokinetics and pharmacodynamics in stabilized methadone maintenance patients. J Clin Psychopharmacol 2009; 29:77-81. [PMID: 19142113 DOI: 10.1097/jcp.0b013e318192eb00] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Many patients enrolled in methadone maintenance treatment experience significant interdose opioid withdrawal. Mood states have been related to patient satisfaction with treatment and may influence how methadone patients experience opioid withdrawal. The objective of this study was to investigate the influence of major depressive disorder on response to methadone in patients on methadone maintenance treatment. Seventeen methadone patients (7 depressed and 10 not depressed) had pharmacokinetic and pharmacodynamic assessments (opioid withdrawal, drug effects, and mood) over one 24-hour dosing interval. Subjects were also divided based on their satisfaction with methadone treatment: 12 holders and 5 nonholders. Depressed subjects experienced more dysphoric opioid effects as measured by the Addiction Research Centre Inventory (area under the effect versus time curve, 14 +/- 32 vs -31 +/- 47, P < 0.04) and had higher scores on the Subjective Opioid Withdrawal Scale (area under the effect versus time curve, 33 +/- 97 vs -74 +/- 67, P < 0.02) over the dosage interval. Hamilton Depression scores significantly correlated with trough subjective opioid withdrawal scale scores (r = 0.7, P < 0.004). Nonholders had significantly higher exposure to unbound (S)-methadone compared with holders, specifically: trough concentration (6.1 +/- 2.7 ng/mL vs 2.7 +/- 1.7 ng/mL, P < 0.01), average steady-state concentration (7.6 +/- 4.0 ng/mL vs 4.1 +/- 2.5 ng/mL, P < 0.05), maximum concentration (14.6 +/- 7.1 ng/mL vs 7.5 +/- 4.2 ng/mL, P < 0.04), and area under the curve (183 +/- 95 h*ng/mL vs 99 +/- 61 h*ng/mL, P < 0.05). Study findings suggest that (S)-methadone may relate to patients' dissatisfaction with methadone treatment. Depressed methadone patients may be more sensitive to negative opioid effects and opioid withdrawal.
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Afshari R, Maxwell SRJ, Bateman DN. Hemodynamic effects of methadone and dihydrocodeine in overdose. Clin Toxicol (Phila) 2009; 45:763-72. [PMID: 17852162 DOI: 10.1080/15563650701502691] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Opioid overdose is an increasing health problem worldwide. The cardiovascular toxicity of opioids contributes to morbidity and mortality in overdose but the hemodynamic effects of opioids reported in animal and human studies are contradictory. METHODS We performed a prospective observational study of patients admitted to hospital following an overdose of methadone, dihydrocodeine, or low dose paracetamol (10 each). Basic cardiovascular indices including peripheral blood pressure, pulse rate, radial augmentation index and derived measures of aortic systolic, diastolic, pulse, and mean and end systolic pressures were measured every six hours for up to 18-23 hours after exposure or until hospital discharge. RESULTS Dihydrocodeine and methadone significantly reduced peripheral and aortic systolic, mean and end systolic pressures. Both opioids significantly decreased peripheral pulse pressure, but only methadone decreased aortic blood pressure. Dihydrocodeine reduced systemic and aortic diastolic blood pressure, an effect not induced by methadone. Methadone significantly reduced peripheral pulse pressure. Augmentation index and heart rate, however, did not change. Both opioids decreased arterial oxygen saturation. CONCLUSION These results suggest that dihydrocodeine and methadone in overdose both have a significant effect on central and peripheral hemodynamics. These effects might be expected to reduce cardiac afterload, providing a pharmacological explanation for the apparent benefit of opioids in cardiovascular diseases.
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Affiliation(s)
- R Afshari
- Medical Toxicology Centre, Imam Reza (P) Hospital, Mashhad, Iran.
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25
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Fonseca F, Marti-Almor J, Pastor A, Cladellas M, Farré M, de la Torre R, Torrens M. Prevalence of long QTc interval in methadone maintenance patients. Drug Alcohol Depend 2009; 99:327-32. [PMID: 18774239 DOI: 10.1016/j.drugalcdep.2008.06.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Revised: 06/27/2008] [Accepted: 06/27/2008] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is a concern about cardiac rhythm disorders related to QTc interval prolongation induced by methadone. A cross-sectional study was designed to evaluate the prevalence of long QTc (LQTc) interval in patients in methadone maintenance treatment (MMT) and risk factors for LQTc. METHODS The study population included 109 subjects (74 males, median age 43 years). Socio-demographic and toxicological variables were recorded, as well as concomitant use of drugs related with QT prolongation, history of heart diseases, and corrected QT interval by heart rate (QTc) in the ECG. Plasma concentrations of (R)-methadone and (S)-methadone enantiomers were determined in 69 subjects. RESULTS Ten patients (9.2%) presented a QTc above 440 ms but a QTc above 500 ms was observed in only 2 (1.8%). Patients with QTc above 440 ms compared with the remaining subjects were older (median [25th-75th percentile range]: 49 [39-56] years vs. 37 [33-43]; Wilcoxon's W=217.5, p=0.002) and took a higher daily dose of methadone (median [25th-75th percentile range]: 120 [66-228] mg/day vs. 60 [40-110] mg/day; W=298.5, p=0.037). Methadone dose correlated with QTc interval (Pearson's r(2)=0.291, p=0.002). Patients with and without long QTc showed no differences in plasma concentrations of (R)-methadone and (S)-methadone enantiomers. CONCLUSIONS The prevalence of LQTc was 9.2%. An association between LQTc and methadone doses was observed but the relationship with plasma concentrations of methadone enantiomers is unclear.
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Affiliation(s)
- Francina Fonseca
- Drug Addiction Unit, IAPS-Hospital del Mar, Passeig Marítim 25-29, 08003 Barcelona, Spain
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26
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Li Y, Kantelip JP, Gerritsen-van Schieveen P, Davani S. Interindividual variability of methadone response: impact of genetic polymorphism. Mol Diagn Ther 2008; 12:109-24. [PMID: 18422375 DOI: 10.1007/bf03256276] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Methadone, an opioid analgesic, is used clinically in pain therapy as well as for substitution therapy in opioid addiction. It has a large interindividual variability in response and a narrow therapeutic index. Genetic polymorphisms in genes coding for methadone-metabolizing enzymes, transporter proteins (p-glycoprotein; P-gp), and mu-opioid receptors may explain part of the observed interindividual variation in the pharmacokinetics and pharmacodynamics of methadone. Cytochrome P450 (CYP) 3A4 and 2B6 have been identified as the main CYP isoforms involved in methadone metabolism. Methadone is a P-gp substrate, and, although there are inconsistent reports, ABCB1 genetic polymorphisms also contribute slightly to the interindividual variability of methadone kinetics and influence dose requirements. Genetic polymorphism is the cause of high interindividual variability of methadone blood concentrations for a given dose; for example, in order to obtain methadone plasma concentrations of 250 ng/mL, doses of racemic methadone as low as 55 mg/day or as high as 921 mg/day can be required in a 70-kg patient without any co-medication. The clinician must be aware of the pharmacokinetic properties and pharmacological interactions of methadone in order to personalize methadone administration. In the future, pharmacogenetics, at a limited level, can also be expected to facilitate individualized methadone therapy.
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Affiliation(s)
- Yongfang Li
- Department of Clinical Pharmacology and Toxicology, University Hospital Besançon, Besançon, France
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27
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Linnet K, Johansen SS, Buchard A, Munkholm J, Morling N. Dominance of pre-analytical over analytical variation for measurement of methadone and its main metabolite in postmortem femoral blood. Forensic Sci Int 2008; 179:78-82. [DOI: 10.1016/j.forsciint.2008.04.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2008] [Revised: 04/21/2008] [Accepted: 04/23/2008] [Indexed: 10/22/2022]
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28
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Mégarbane B, Declèves X, Bloch V, Bardin C, Chast F, Baud FJ. Case report: quantification of methadone-induced respiratory depression using toxicokinetic/toxicodynamic relationships. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2007; 11:R5. [PMID: 17224045 PMCID: PMC2151854 DOI: 10.1186/cc5150] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2006] [Revised: 12/28/2006] [Accepted: 01/15/2007] [Indexed: 01/29/2023]
Abstract
Introduction Methadone, the most widely delivered maintenance therapy for heroin addicts, may be responsible for life-threatening poisonings with respiratory depression. The toxicokinetics and the toxicokinetic/toxicodynamic (TK/TD) relationships of methadone enantiomers have been poorly investigated in acute poisonings. The aim of this study was to describe the relationships between methadone-related respiratory effects and their corresponding concentrations. Methods We report a 44-year-old methadone-maintained patient who ingested a 240-mg dose of methadone. He was found comatose with pinpoint pupils and respiratory depression. He was successfully treated with intravenous naloxone infusion over the course of 31 hours at a rate adapted to maintain normal consciousness and respiratory rate. We performed a TK/TD analysis of the naloxone infusion rate needed to maintain his respiratory rate at more than 12 breaths per minute (as toxicodynamics parameter) versus plasma R,S- and R-methadone concentrations (as toxicokinetics parameter), determined using an enantioselective high-performance liquid chromatography assay. Results Initial plasma R,S-methadone concentration was 1,204 ng/ml. Decrease in plasma R- and S-methadone concentrations was linear and demonstrated a first-order pharmacokinetics (maximal observed concentrations 566 and 637 ng/ml, half-lives 16.1 and 13.2 hours, respectively). TK/TD correlation between naloxone infusion rate and R,S- and R-methadone concentrations fitted well a sigmoidal Emax model (concentration associated with a half-maximum effect [EC50] 334 and 173 ng/ml, Hill coefficient 10.0 and 7.8, respectively). In our chronically treated patient, EC50 values were in the range of previously reported values regarding methadone analgesic effects, suggesting that plasma methadone concentrations to prevent withdrawal are lower than those associated with methadone analgesic effects. Conclusion After the ingestion of a toxic dose of a racemic mixture, plasma R- and S-enantiomer concentrations decreased in parallel. Despite large inter-individual variability in methadone toxicokinetics and toxicodynamics, TK/TD relationships would be helpful for providing quantitative data regarding the respiratory response to methadone in poisonings. However, further confirmatory TK/TD data are needed.
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Affiliation(s)
- Bruno Mégarbane
- INSERM U705, CNRS, UMR 7157; Université Paris 7; Assistance Publique – Hôpitaux de Paris, Hôpital Lariboisière, Réanimation Médicale et Toxicologique, 2 Rue Ambroise Paré, 75010, Paris, France
- INSERM U705, CNRS, UMR 7157; Université Paris 7; Assistance Publique – Hôpitaux de Paris, Hôpital Fernand Widal, 200 Rue du Faubourg Saint Denis, 75018, Paris, France
| | - Xavier Declèves
- INSERM U705, CNRS, UMR 7157; Université Paris 7; Assistance Publique – Hôpitaux de Paris, Hôpital Fernand Widal, 200 Rue du Faubourg Saint Denis, 75018, Paris, France
| | - Vanessa Bloch
- INSERM U705, CNRS, UMR 7157; Université Paris 7; Assistance Publique – Hôpitaux de Paris, Hôpital Lariboisière, Réanimation Médicale et Toxicologique, 2 Rue Ambroise Paré, 75010, Paris, France
- INSERM U705, CNRS, UMR 7157; Université Paris 7; Assistance Publique – Hôpitaux de Paris, Hôpital Fernand Widal, 200 Rue du Faubourg Saint Denis, 75018, Paris, France
| | - Christophe Bardin
- Assistance Publique – Hôpitaux de Paris, Hôpital Hôtel-Dieu, Laboratoire de Toxicologie, 1 Place Notre-Dame 75004, Paris, France
| | - François Chast
- Assistance Publique – Hôpitaux de Paris, Hôpital Hôtel-Dieu, Laboratoire de Toxicologie, 1 Place Notre-Dame 75004, Paris, France
| | - Frédéric J Baud
- INSERM U705, CNRS, UMR 7157; Université Paris 7; Assistance Publique – Hôpitaux de Paris, Hôpital Lariboisière, Réanimation Médicale et Toxicologique, 2 Rue Ambroise Paré, 75010, Paris, France
- INSERM U705, CNRS, UMR 7157; Université Paris 7; Assistance Publique – Hôpitaux de Paris, Hôpital Fernand Widal, 200 Rue du Faubourg Saint Denis, 75018, Paris, France
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Hanna J, Foster DJR, Salter A, Somogyi AA, White JM, Bochner F. Within- and between- subject variability in methadone pharmacokinetics and pharmacodynamics in methadone maintenance subjects. Br J Clin Pharmacol 2006; 60:404-13. [PMID: 16187972 PMCID: PMC1884832 DOI: 10.1111/j.1365-2125.2005.02464.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
AIMS To investigate within- and between-subject variability of the pharmacodynamics and pharmacokinetics of (R)- and (S)-methadone in methadone maintenance subjects at steady-state. METHODS Six non-holder subjects were studied on three occasions at 7-16 day intervals; doses (20-170 mg/day) remained unchanged. Blood samples and pharmacodynamic data were collected 10-12 times over a 24-h inter-dosing interval. All pharmacodynamic data were expressed as the area under the end-point versus time curve. Using analyses of variance with mixed effects, best estimates were made of the ratio of between- to within-subject variation, with corresponding 95% confidence intervals (CI) for within-subject variation at the average value. RESULTS Subjects were relatively consistent between occasions, whereas there was much greater between-subject variability (P < 0.02) for all measures. Estimates of the ratio of between- to within-subject variation ranged from 2.2-12.8 for pharmacodynamic measures, and 1.3-7.9 for pharmacokinetic parameters. For pain, total mood disturbance, withdrawal, pupil size and respiration rate, 95% CI for within-subject measures ranged < or = 2-fold, while this was greater for subjective direct opioid effects (4.2-fold). For CL/F of the active (R)-methadone, the variance ratio was 4.9 (P < 0.0003), with 95% CI for within-subject measures ranging < or = 2-fold. (S)-methadone CL/F demonstrated greater within-subject variability (3.4-fold), possibly contributing to a smaller (2.7; P < 0.0003) ratio of between- to within-subject variance. CONCLUSIONS Non-holder methadone maintenance treatment participants appear to respond consistently with respect to pharmacokinetics and pharmacodynamics over a 1-2 month period. Such knowledge may help prescribers to determine whether alternative dosing regimens or treatments might be more appropriate in this population.
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Affiliation(s)
- Julia Hanna
- Department of Clinical and Experimental Pharmacology, University of AdelaideAdelaide, Australia
| | - David JR Foster
- Department of Clinical and Experimental Pharmacology, University of AdelaideAdelaide, Australia
| | - Amy Salter
- Department of Public Health, University of AdelaideAdelaide, Australia
| | - Andrew A Somogyi
- Department of Clinical and Experimental Pharmacology, University of AdelaideAdelaide, Australia
- Department of Clinical Pharmacology, Royal Adelaide HospitalAdelaide, Australia
| | - Jason M White
- Department of Clinical and Experimental Pharmacology, University of AdelaideAdelaide, Australia
| | - Felix Bochner
- Department of Clinical and Experimental Pharmacology, University of AdelaideAdelaide, Australia
- Department of Clinical Pharmacology, Royal Adelaide HospitalAdelaide, Australia
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Foster DJR, Morton EB, Heinkele G, Mürdter TE, Somogyi AA. Stereoselective Quantification of Methadone and a d6-labeled Isotopomer Using High Performance Liquid Chromatography-Atmospheric Pressure Chemical Ionization Mass-Spectrometry: Application to a Pharmacokinetic Study in a Methadone Maintained Subject. Ther Drug Monit 2006; 28:559-67. [PMID: 16885725 DOI: 10.1097/00007691-200608000-00012] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
There is evidence that the apparent oral clearance of rac-methadone is induced during the early phase of methadone maintenance treatment. However, it is not known if this is due to changes in bioavailability or if this phenomenon is stereoselective. This knowledge can be obtained by administering a dose of stable-labeled methadone at selected times during ongoing treatment. Therefore, the authors developed a stereoselective high performance liquid chromatography-atmospheric pressure chemical ionization mass-spectrometry assay for the quantification of the enantiomers of methadone and a d(6)-labeled isotopomer. The compounds were quantified in a single assay after liquid-liquid extraction and stereoselective high performance liquid chromatograph with atmospheric pressure chemical ionization-mass spectrometry detection. The following ions were monitored: m/z 310.15 for unlabeled methadone; m/z 316.15 for methadone-d(6); and m/z 313.15 for the methadone-d(3) (internal standard). Calibration curves ranged from 0.5 to 75 ng/mL for each compound. Extraction recovery was approximately 80% for all analytes, without evidence of differences between the unlabeled and stable-labeled compounds or concentration dependency. Minor ion promotion was observed (<15%) but this was identical for all analytes including the d(3)-labeled internal standard, with peak area ratios in extracted samples identical to control injections. The isotopomers did not alter each others' ionisation, even at 10:1 concentration ratios, and 10-fold diluted samples were within 10% of the nominal concentration. Assay performance was acceptable, with interassay and intra-assay bias and precision <10% for all compounds, including the upper and lower limits of quantitation. In conclusion, the assay was successfully applied to quantify the concentration of the methadone enantiomers of both orally administered unlabeled methadone and an intravenous 5 mg dose of methadone-d(6) in a patient receiving chronic oral methadone maintenance therapy.
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Affiliation(s)
- David J R Foster
- Department of Clinical and Experimental Pharmacology, University of Adelaide, Adelaide 5005, Australia.
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Mitchell TB, Dyer KR, Newcombe D, Somogyi AA, White JM. Fluctuations in (R,S)-methadone pharmacokinetics and response among long-term methadone maintenance patients. Addict Biol 2006; 11:170-4. [PMID: 16800831 DOI: 10.1111/j.1369-1600.2006.00014.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Knowledge of how methadone disposition may fluctuate during the course of maintenance treatment is presently limited. This study investigated long-term fluctuations in methadone pharmacokinetics in five methadone maintenance patients who participated in two 24-hour testing sessions separated by at least one year. Results indicated substantial fluctuations between sessions in dose-corrected average steady-state plasma (R)-methadone concentrations (Cav), ranging from a 51% decrease to a 466% increase. These fluctuations were not consistently associated with changes in methadone dose or self-reported withdrawal status. The plasma (S)-:(R)-methadone Cav ratio increased significantly (12%, P = 0.04) between the sessions, suggesting a different pattern of long-term change in the pharmacokinetics of each enantiomer over time. The pronounced and variable fluctuations in methadone disposition evident in these patients highlight the need for an individualized approach to patient dosing and monitoring.
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Affiliation(s)
- Timothy B Mitchell
- National Addiction Centre, Institute of Psychiatry, King's College London, UK.
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