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Braun HM, Taylor JL, Axelrath S. Buprenorphine/naloxone - one formulation that doesn't fit all: a case report. Harm Reduct J 2024; 21:143. [PMID: 39080714 PMCID: PMC11287853 DOI: 10.1186/s12954-024-01054-2] [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: 04/29/2024] [Accepted: 07/03/2024] [Indexed: 08/03/2024] Open
Abstract
BACKGROUND Sublingual buprenorphine, approved for treatment of opioid use disorder since 2002, is most commonly available in co-formulation with naloxone. Naloxone is an opioid antagonist minimally absorbed when sublingual (SL) buprenorphine/naloxone is taken as prescribed; it is thought to reduce potential for misuse via intravenous administration. However, growing data and clinical experience demonstrate that previously accepted assumptions about the pharmacokinetics of these medications may not apply to all patients. CASE PRESENTATION We present a patient whose adverse post-administration side effects on SL buprenorphine/naloxone resolved with transition to SL buprenorphine monoproduct. DISCUSSION Naloxone can be detected in nearly all patients taking SL buprenorphine/naloxone, though with apparent variability in clinical effect. In a minority of patients, naloxone can contribute to adverse and potentially treatment-limiting side effects. Furthermore, the naloxone component is commonly misunderstood by patients and providers and can foster mistrust in the therapeutic relationship if providers are perceived to be withholding a more tolerable formulation. Prescribers should have a low threshold to offer buprenorphine alone when clinically appropriate.
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Affiliation(s)
- Hannan M Braun
- Division of General Internal Medicine, Denver Health and Hospital Authority, 301 W 6th Ave, Denver, 80204, CO, USA.
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Jessica L Taylor
- General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, USA
- Grayken Center for Addiction, Boston Medical Center, Boston, USA
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2
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Bozinoff N, Tardelli VS, Rubin-Kahana DS, Le Foll B. Patterns of use and adverse events reported among persons who regularly inject buprenorphine: a systematic review. Harm Reduct J 2022; 19:113. [PMID: 36229831 PMCID: PMC9559254 DOI: 10.1186/s12954-022-00695-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/30/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND AIMS Given the ongoing opioid crisis, novel interventions to treat severe opioid use disorder (OUD) are urgently needed. Injectable opioid agonist therapy (iOAT) with diacetylmorphine or hydromorphone is effective for the treatment of severe, treatment-refractory OUD, however barriers to implementation persist. Intravenous buprenorphine for the treatment of OUD (BUP iOAT) has several possible advantages over traditional iOAT, including a safety profile that might enable take-home dosing. We aimed to characterize injecting practices among real-world populations of persons who regularly inject buprenorphine, as well as associated adverse events reported in order to inform a possible future BUP iOAT intervention. METHODS We conducted a systematic review. We searched MEDLINE, EMBASE, and PsycINFO from inception through July 2020 and used backwards citation screening to search for publications reporting on dose, frequency among persons who regularly inject the drug, or adverse events associated with intravenous use of buprenorphine. The review was limited to English language publications and there was no limitation on study type. Study quality and risk of bias was assessed using the Mixed Methods Appraisal Tool. Narrative synthesis was used in reporting the results. RESULTS Eighty-eight studies were included in our review. Regular injection of buprenorphine was identified across diverse settings world-wide. Daily dose of oral buprenorphine injected was < 1-12 mg. Frequency of injection was 0-10 times daily. Adverse events could be characterized as known side effects of opioids/buprenorphine or injection-related complications. Most studies were deemed to be of low quality. CONCLUSIONS Extramedical, intravenous use of buprenorphine, continues to be documented. BUP iOAT may be feasible and results may inform the development of a study to test the efficacy and safety of such an intervention. Future work should also examine acceptability among people with severe OUD in North America. Our review was limited by the quality of included studies.
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Affiliation(s)
- Nikki Bozinoff
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, ON, Toronto, Canada.
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
- Addictions Division, Centre for Addiction and Mental Health, Toronto, ON, Canada.
| | - Vitor Soares Tardelli
- Departamento de Psiquiatria, Universidade Federal de Sao Paulo, São Paulo, Brazil
- Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Dafna Sara Rubin-Kahana
- Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Child, Youth, and Family Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Bernard Le Foll
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Addictions Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Division of Neurosciences and Clinical Translation, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
- Waypoint Research Institute, Waypoint Centre for Mental Health Care, Penetanguishene, ON, Canada
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3
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Ansari M, Rostam-Abadi Y, Baheshmat S, Hamzehzadeh M, Gholami J, Mojtabai R, Rahimi-Movaghar A. Buprenorphine abuse and health risks in Iran: A systematic review. Drug Alcohol Depend 2021; 226:108871. [PMID: 34214882 DOI: 10.1016/j.drugalcdep.2021.108871] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/14/2021] [Accepted: 06/16/2021] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Buprenorphine maintenance treatment (BMT) is widely used in Iran, and its use is growing continuously. We reviewed studies on buprenorphine use, non-prescribed use, use disorder and treatment-seeking for it, buprenorphine-associated poisoning, and mortality in Iran in the current systematic review. METHODS An Iranian database (Scientific Information Database; SID) and three International electronic databases (PubMed, Scopus, and Web of Science) were searched for publications up to August 2020 for the relevant data. Opportunistic methods (Contact with experts and backward citation tracking) were also used for this purpose. Identified records were screened for eligibility criteria, and data of included studies were extracted. For context, the trend of BMT in the country was also examined. RESULTS Ten studies were found on the prevalence of non-prescribed buprenorphine use, seven were on the regular use and use disorder, and two studies on buprenorphine poisoning. The last 12-month prevalence of non-prescribed use was lower than 0.5 % in the general population, university, and high school students. The indicator was 2.5 % among persons who use drugs in a 2018 national study. The proportion of buprenorphine poisoning was 4.9 % among all illicit substance poisoning cases admitted to a hospital. The proportion of buprenorphine poisoning cases among all acute pediatric drug poisoning cases increased from 1.2 % to 2.5 % in a 3-year study. CONCLUSION Despite the expansion of BMT in Iran in the last decade, the adverse health consequences associated with buprenorphine are infrequent, when compared to other opioids used in Iran, suggesting the safety of BMT for future expansion.
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Affiliation(s)
- Mina Ansari
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran.
| | - Yasna Rostam-Abadi
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran.
| | - Shahab Baheshmat
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran; Department of Neuroscience and Addiction Studies, School of Advanced Technologies in Medicine (SATiM), Tehran University of Medical Sciences, Tehran, Iran.
| | - Marziyeh Hamzehzadeh
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran; Department of Neuroscience and Addiction Studies, School of Advanced Technologies in Medicine (SATiM), Tehran University of Medical Sciences, Tehran, Iran.
| | - Jaleh Gholami
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran.
| | - Ramin Mojtabai
- Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins University Bloomberg School of Public Health, Baltimore, USA.
| | - Afarin Rahimi-Movaghar
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran.
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4
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Abstract
Opioid use disorder (OUD) represents a major public health problem that affects millions of people in the USA and worldwide. The relapsing and recurring aspect of OUD, driven by lasting neurobiological adaptations at different reward centres in the brain, represents a major obstacle towards successful long-term remission from opioid use. Currently, three drugs that modulate the function of the opioidergic receptors, methadone, buprenorphine and naltrexone have been approved by the US Food and Drug Administration (FDA) to treat OUD. In this review, we discuss the limitations and challenges associated with the current maintenance and medication-assisted withdrawal strategies commonly used to treat OUD. We further explore the involvement of glutamatergic, endocannabinoid and orexin signaling systems in the development, maintenance and expression of addiction-like behaviours in animal models of opioid addiction, and as potential and novel targets to expand therapeutic options to treat OUD. Despite a growing preclinical literature highlighting the role of these potential targets in animal models of opioid addiction, clinical and translational studies for novel treatments of OUD remain limited and inconclusive. Further preclinical and clinical investigations are needed to expand the arsenal of primary treatment options and adjuncts to maximise efficacy and prevent relapse.
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Abstract
: Buprenorphine is an effective treatment for opioid use disorder. As a high-affinity, partial agonist for the mu-opioid receptor, buprenorphine suppresses opioid withdrawal and craving, reduces illicit opioid use, and blocks exogenous opioid effects including respiratory depression. Other pharmacologic benefits of buprenorphine are its superior safety profile compared with full opioid agonists and its long half-life that allows daily or less-than-daily dosing. New and innovative buprenorphine formulations, with pharmacokinetic profiles that differ from the original tablet formulation, continue to be developed. These include higher bioavailability transmucosal tablets and films and also 6-month implantable and monthly injectable products. This growing array of available formulations allows more choices for patients and increased opportunity for clinicians to individualize treatment; thus, it is important for buprenorphine prescribers to understand these differences.
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Abstract
BACKGROUND Depression and post-traumatic stress disorder (PTSD) are leading causes of disability and loss of life by suicide. Currently, there are less than satisfactory medical solutions to treat these mental disorders. Here, we explore recent preclinical and clinical studies demonstrating the potential of using buprenorphine to treat major depressive disorder, treatment-resistant depression, and PTSD. METHOD Bibliographic databases were searched to include preclinical and clinical studies demonstrating the therapeutic potential of buprenorphine and the involvement of the kappa opioid receptor (KOR) in mediating these effects. RESULTS Original clinical studies examining the effectiveness of buprenorphine to treat depression were mixed. The majority of participants in the PTSD studies were males and suffer from chronic pain and/or substance use disorders. Nonetheless, these recent studies and analyses established proof of concept warranting farther investigations. Additionally, KOR likely mediates the antidepressant and some of the anxiolytic effects of buprenorphine. Still, it appears that the full spectrum of buprenorphine's beneficial effects might be due to activity at other opioid receptors as well. CONCLUSIONS Pharmaceuticals' abilities to treat medical conditions directly relates to their ability to act upon the endogenous biological systems related to the conditions. Thus, these recent findings are likely a reflection of the central role that the endogenous opioid system has in these mental illnesses. Further studies are necessary to study the involvement of endogenous opioid systems, and specifically KOR, in mediating buprenorphine's beneficial effects and the ability to treat these medical conditions while minimizing risks for misuse and diversion.
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Affiliation(s)
- Caitlin A Madison
- Behavioral and Cellular Neuroscience, Department of Psychological and Brain Sciences, Texas A&M University, 4235 TAMU, College Station, TX77843, USA
| | - Shoshana Eitan
- Behavioral and Cellular Neuroscience, Department of Psychological and Brain Sciences, Texas A&M University, 4235 TAMU, College Station, TX77843, USA
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7
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Dhagudu NK, Ambekar A, Agrawal A, Rao R, Mishra AK, Jain R, Singh S. Is there enough naloxone to deter the diversion? Effect of concurrent administration of intravenous naloxone on opioid agonist effects of intravenous buprenorphine: A randomised, double‐blind, within‐subject, crossover study among opioid‐dependent subjects. Drug Alcohol Rev 2020; 39:595-603. [DOI: 10.1111/dar.13057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 02/17/2020] [Accepted: 02/19/2020] [Indexed: 11/30/2022]
Affiliation(s)
| | - Atul Ambekar
- Department of Psychiatry and National Drug Dependence Treatment Center, National Drug Dependence Treatment CenterAll India Institute of Medical Sciences New Delhi India
| | - Alok Agrawal
- Department of Psychiatry and National Drug Dependence Treatment Center, National Drug Dependence Treatment CenterAll India Institute of Medical Sciences New Delhi India
| | - Ravindra Rao
- Department of Psychiatry and National Drug Dependence Treatment Center, National Drug Dependence Treatment CenterAll India Institute of Medical Sciences New Delhi India
| | - Ashwani K. Mishra
- Department of Psychiatry and National Drug Dependence Treatment Center, National Drug Dependence Treatment CenterAll India Institute of Medical Sciences New Delhi India
| | - Raka Jain
- Department of Psychiatry and National Drug Dependence Treatment Center, National Drug Dependence Treatment CenterAll India Institute of Medical Sciences New Delhi India
| | - Shalini Singh
- Department of Psychiatry and National Drug Dependence Treatment Center, National Drug Dependence Treatment CenterAll India Institute of Medical Sciences New Delhi India
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8
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Smith KE, Tillson MD, Staton M, Winston EM. Characterization of diverted buprenorphine use among adults entering corrections-based drug treatment in Kentucky. Drug Alcohol Depend 2020; 208:107837. [PMID: 31951906 PMCID: PMC7418075 DOI: 10.1016/j.drugalcdep.2020.107837] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 12/17/2019] [Accepted: 12/26/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND Illicit, medically unsupervised use of buprenorphine (i.e., "diverted use") among vulnerable and underserved populations, such as corrections-involved adults, remains underexplored. METHODS Survey data (2016-2017) collected as part of a clinical assessment of incarcerated adults entering corrections-based substance use treatment in Kentucky were analyzed. For years examined, 12,915 completed the survey. Removing cases for participants who did not reside in Kentucky for >6 months during the one-year pre-incarceration period (n = 908) resulted in a final sample size of 12,007. RESULTS Over a quarter of the sample reported past-year diverted buprenorphine use prior to incarceration and 21.8 % reported use during the 30-days prior to incarceration, using 6.5 months and 14.3 days on average, respectively. A greater proportion of participants who reported diverted buprenorphine use had previously been engaged with some substance use treatment (77.0 %) and reported greater perceived need for treatment (79.4 %) compared to those who did not report use. Use was more likely among participants who were younger, white, male, and who reported rural or Appalachian residence. Diverted buprenorphine users also evidenced extensive polydrug use and presented with greater substance use disorder severity. Non-medical prescription opioid, heroin, and diverted methadone use were associated with increased odds of diverted buprenorphine use while kratom was not. Diverted methadone use was associated with a 252.9 % increased likelihood of diverted buprenorphine use. CONCLUSIONS Diverted buprenorphine use among participants in this sample was associated with concerning high-risk behaviors and may indicate barriers to accessing opioid agonist therapies for corrections-involved Kentucky residents, particularly those in rural Appalachia.
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Affiliation(s)
- Kirsten E Smith
- Center on Drug and Alcohol and Research, University of Kentucky, Lexington, Kentucky 40508, United States; Kent School of Social Work, University of Louisville, Louisville, Kentucky, 40292, United States.
| | - Martha D Tillson
- Center on Drug and Alcohol and Research, University of Kentucky, Lexington, Kentucky 40508, United States; Department of Sociology, University of Kentucky, Lexington, Kentucky, 40508, United States
| | - Michele Staton
- Center on Drug and Alcohol and Research, University of Kentucky, Lexington, Kentucky 40508, United States; Department of Behavioral Science, University of Kentucky, Lexington, Kentucky, 40508, United States
| | - Erin M Winston
- Center on Drug and Alcohol and Research, University of Kentucky, Lexington, Kentucky 40508, United States
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9
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Blazes CK, Morrow JD. Reconsidering the Usefulness of Adding Naloxone to Buprenorphine. Front Psychiatry 2020; 11:549272. [PMID: 33061915 PMCID: PMC7517938 DOI: 10.3389/fpsyt.2020.549272] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 08/25/2020] [Indexed: 01/21/2023] Open
Affiliation(s)
| | - Jonathan D Morrow
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States.,Neuroscience Program, University of Michigan, Ann Arbor, MI, United States
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10
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Jordan CJ, Cao J, Newman AH, Xi ZX. Progress in agonist therapy for substance use disorders: Lessons learned from methadone and buprenorphine. Neuropharmacology 2019; 158:107609. [PMID: 31009632 PMCID: PMC6745247 DOI: 10.1016/j.neuropharm.2019.04.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/25/2019] [Accepted: 04/12/2019] [Indexed: 12/12/2022]
Abstract
Substance use disorders (SUD) are serious public health problems worldwide. Although significant progress has been made in understanding the neurobiology of drug reward and the transition to addiction, effective pharmacotherapies for SUD remain limited and a majority of drug users relapse even after a period of treatment. The United States Food and Drug Administration (FDA) has approved several medications for opioid, nicotine, and alcohol use disorders, whereas none are approved for the treatment of cocaine or other psychostimulant use disorders. The medications approved by the FDA for the treatment of SUD can be divided into two major classes - agonist replacement therapies, such as methadone and buprenorphine for opioid use disorders (OUD), nicotine replacement therapy (NRT) and varenicline for nicotine use disorders (NUD), and antagonist therapies, such as naloxone for opioid overdose and naltrexone for promoting abstinence. In the present review, we primarily focus on the pharmacological rationale of agonist replacement strategies in treatment of opioid dependence, and the potential translation of this rationale to new therapies for cocaine use disorders. We begin by describing the neural mechanisms underlying opioid reward, followed by preclinical and clinical findings supporting the utility of agonist therapies in the treatment of OUD. We then discuss recent progress of agonist therapies for cocaine use disorders based on lessons learned from methadone and buprenorphine. We contend that future studies should identify agonist pharmacotherapies that can facilitate abstinence in patients who are motivated to quit their illicit drug use. Focusing on those that are able to achieve abstinence from cocaine will provide a platform to broaden the effectiveness of medication and psychosocial treatment strategies for this underserved population. This article is part of the Special Issue entitled 'New Vistas in Opioid Pharmacology'.
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Affiliation(s)
- Chloe J Jordan
- Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, 21224, USA
| | - Jianjing Cao
- Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, 21224, USA
| | - Amy Hauck Newman
- Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, 21224, USA
| | - Zheng-Xiong Xi
- Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, 21224, USA.
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11
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Pravetoni M, Comer SD. Development of vaccines to treat opioid use disorders and reduce incidence of overdose. Neuropharmacology 2019; 158:107662. [PMID: 31173759 DOI: 10.1016/j.neuropharm.2019.06.001] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 05/01/2019] [Accepted: 06/02/2019] [Indexed: 02/06/2023]
Abstract
Vaccines offer a promising therapeutic strategy to treat substance use disorders (SUD). Vaccines have shown extensive preclinical proof of selectivity, safety, and efficacy against opioids, nicotine, cocaine, methamphetamine, and designer drugs. Despite clinical evaluation of vaccines targeting nicotine and cocaine showing proof of concept for this approach, no vaccine for SUD has yet reached the market. This review first discusses how vaccines for treatment of opioid use disorders (OUD) and reduction of opioid-induced fatal overdoses fit within the current medication assisted treatment (MAT) portfolio, and then summarizes ongoing efforts toward translation of vaccines targeting heroin, oxycodone, fentanyl, and other opioids. This article is part of the Special Issue entitled 'New Vistas in Opioid Pharmacology'.
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Affiliation(s)
- Marco Pravetoni
- University of Minnesota Medical School, Departments of Pharmacology and Medicine, Minneapolis, MN, USA; Hennepin Healthcare Research Institute, Minneapolis, MN, USA.
| | - Sandra D Comer
- Columbia University Irving Medical Center, Department of Psychiatry, The New York State Psychiatric Institute, New York, NY, USA
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12
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Simpson KJ, Moran MT, Foster ML, Shah DT, Chung DY, Nichols SD, McCall KL, Piper BJ. Descriptive, observational study of pharmaceutical and non-pharmaceutical arrests, use, and overdoses in Maine. BMJ Open 2019; 9:e027117. [PMID: 31036710 PMCID: PMC6501962 DOI: 10.1136/bmjopen-2018-027117] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES The Maine Diversion Alert Program grants healthcare providers access to law enforcement data on drug charges. The objectives of this report were to analyse variations in drug charges by demographics and examine recent trends in arrests, prescriptions of controlled substances and overdoses. DESIGN Observational. SETTING Arrests, controlled prescription medication distribution and overdoses in Maine. PARTICIPANTS Drug arrestees (n=1272) and decedents (n=2432). PRIMARY OUTCOME MEASURES Arrestees were analysed by sex and age. Substances involved in arrests were reported by schedule (I-V or non-controlled prescription) and into opioids, stimulants or other classes. Controlled substances reported to the Drug Enforcement Administration (2007-2017) were evaluated. Drug-induced deaths (2007-2017) reported to the medical examiner were examined by the substance(s) identified. RESULTS Males were more commonly arrested for stimulants and schedule II substances. More than two-thirds of arrests involved individuals under the age of 40. Individuals age >60 were elevated for oxycodone arrests. Over three-fifths (63.38%) of arrests involved schedule II-IV substances. Opioids accounted for almost half (44.6%) of arrests followed by stimulants (32.5%) and sedatives (9.1%). Arrests involving buprenorphine exceeded those for oxycodone, hydrocodone, methadone, tramadol and morphine, combined. Prescriptions for hydrocodone (-56.0%) and oxycodone (-46.9%) declined while buprenorphine increased (+58.1%) between 2012 and 2017. Deaths from 2007 to 2017 tripled. Acetylfentanyl and furanylfentanyl were the most common fentanyl analogues identified. CONCLUSIONS Although the overall profile of those arrested for drug crimes in 2017 involve males, age <40 and heroin, exceptions (oxycodone for older adults) were observed. Most prescription opioids are decreasing while deaths involving opioids continue to increase in Maine.
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Affiliation(s)
- Kevin J Simpson
- Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Matthew T Moran
- Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | | | - Dipam T Shah
- Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Daniel Y Chung
- Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | | | - Kenneth L McCall
- Pharmacy Practice, University of New England College of Pharmacy, Portland, Maine, USA
| | - Brian J Piper
- Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
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Doernberg M, Krawczyk N, Agus D, Fingerhood M. Demystifying buprenorphine misuse: Has fear of diversion gotten in the way of addressing the opioid crisis? Subst Abus 2019; 40:148-153. [PMID: 31008694 DOI: 10.1080/08897077.2019.1572052] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Buprenorphine is considered one of the most effective treatments for opioid use disorder and significantly reduces risk of overdose death. However, concerns about its diversion and misuse have often taken center stage in public discourse and in the design of practices and policies regarding its use. This has been to the detriment of many vulnerable patient populations, especially those involved in the criminal justice system. Policies that restrict access to buprenorphine in criminal justice and other settings due to concerns of diversion do not accurately reflect the relative risks and safety profile associated with it, creating unnecessary barriers that drive an illicit market of this much-needed medication. Although proper regulation of all controlled medications should be a priority, in most instances the benefits of buprenorphine highly outweigh its risks. In the midst of a national crisis, efforts should be focused on expanding, and not restricting, access to this lifesaving treatment.
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Affiliation(s)
- Molly Doernberg
- Yale University School of Public Health , New Haven , Connecticut , USA
| | - Noa Krawczyk
- Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA.,Behavioral Health Leadership Institute , Baltimore , Maryland , USA
| | - Deborah Agus
- Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA.,Behavioral Health Leadership Institute , Baltimore , Maryland , USA
| | - Michael Fingerhood
- Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA.,Johns Hopkins School of Medicine , Baltimore , Maryland , USA
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14
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Ho RCM, Chen KY, Broekman B, Mak A. Buprenorphine prescription, misuse and service provision: a global perspective. ACTA ACUST UNITED AC 2018. [DOI: 10.1192/apt.bp.108.005975] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SummaryBuprenorphine, a partial μ-opioid agonist and κ-opioid antagonist, is recommended as safe and effective maintenance treatment for opioid dependence. It offers the possibility of management in primary care settings. However, its prescription has led to diversion for illicit recreational use and resulted in medical complications and, rarely, fatal overdose in combination with other sedatives. The outcome of buprenorphine maintenance programmes varies from country to country and it is determined by the local therapeutic traditions, regulatory restrictions and existing service provision for opioid misusers. This article addresses the pharmacology of buprenorphine, the benefits and drawbacks of its prescription, service provision for opioid misuse around the world, policy recommendations, and prescribing training requirements.
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15
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Koffarnus MN, Kaplan BA. Clinical models of decision making in addiction. Pharmacol Biochem Behav 2018; 164:71-83. [PMID: 28851586 PMCID: PMC5747979 DOI: 10.1016/j.pbb.2017.08.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 08/08/2017] [Accepted: 08/21/2017] [Indexed: 01/25/2023]
Abstract
As research on decision making in addiction accumulates, it is increasingly clear that decision-making processes are dysfunctional in addiction and that this dysfunction may be fundamental to the initiation and maintenance of addictive behavior. How drug-dependent individuals value and choose among drug and nondrug rewards is consistently different from non-dependent individuals. The present review focuses on the assessment of decision-making in addiction. We cover the common behavioral tasks that have shown to be fruitful in decision-making research and highlight analytical and graphical considerations, when available, to facilitate comparisons within and among studies. Delay discounting tasks, drug demand tasks, drug choice tasks, the Iowa Gambling Task, and the Balloon Analogue Risk Task are included.
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Affiliation(s)
- Mikhail N Koffarnus
- Virginia Tech Carilion Research Institute, 2 Riverside Circle, Roanoke, VA 24016, United States.
| | - Brent A Kaplan
- Virginia Tech Carilion Research Institute, 2 Riverside Circle, Roanoke, VA 24016, United States
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Efficacy and tolerability of buccal buprenorphine in opioid-experienced patients with moderate to severe chronic low back pain: results of a phase 3, enriched enrollment, randomized withdrawal study. Pain 2017; 157:2517-2526. [PMID: 27434505 PMCID: PMC5065057 DOI: 10.1097/j.pain.0000000000000670] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Supplemental Digital Content is Available in the Text. In opioid-experienced patients (30-160 mg MSE/d), buccal buprenorphine was superior to placebo in 30%-50% pain reductions and PGIC, with similar constipation incidence. A buccal film of buprenorphine (BBUP) was evaluated for safety and efficacy in a multicenter, double-blind, placebo-controlled, enriched-enrollment, randomized-withdrawal study in opioid-experienced patients (30 to ≤160 mg/d morphine sulfate equivalent) with moderate to severe chronic low back pain taking around-the-clock opioid analgesics. Patients' opioid doses were tapered to ≤30 mg morphine sulfate equivalent before open-label titration with BBUP (range, 150-900 μg every 12 hours). Patients who responded (received adequate analgesia that was generally well tolerated for 14 days) were randomized to receive buprenorphine (n = 254) or placebo (n = 257) buccal film. The primary efficacy variable was the change from baseline to week 12 of double-blind treatment in mean average daily pain-intensity scores using a rating scale of 0 (no pain) to 10 (worst pain imaginable). In the intent-to-treat population, mean pain scores were 6.7 after opioid taper and declined to 2.8 after the BBUP titration period. After randomization, mean pain scores were lower in the BBUP group than in the placebo group; the difference between groups in the mean change from baseline to week 12 was −0.98 (95% CI, −1.32 to −0.64; P < 0.001). A significantly larger percentage of patients receiving BBUP than placebo had pain reductions ≥30% and ≥50% (P < 0.001 for both). In the double-blind portion of the study, the only adverse event reported more frequently with BBUP than placebo and in ≥5% of patients was vomiting (5.5% vs 2.3%). These findings demonstrate the efficacy and tolerability of BBUP in opioid-experienced patients taking around-the-clock opioid treatment for chronic low back pain.
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Jones JD, Manubay JM, Mogali S, Metz VE, Madera G, Martinez S, Mumtaz M, Comer SD. Abuse liability of intravenous buprenorphine vs. buprenorphine/naloxone: Importance of absolute naloxone amount. Drug Alcohol Depend 2017; 179:362-369. [PMID: 28844013 PMCID: PMC10071507 DOI: 10.1016/j.drugalcdep.2017.06.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 06/15/2017] [Accepted: 06/24/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND This study sought to determine the relative importance of a range of Bup/Nx doses compared to Bup alone in producing subjective and reinforcing effects. METHODS Heroin-using volunteers (n=13) were transitioned onto daily oral hydromorphone (40mg). Laboratory sessions assessed the reinforcing and subjective effects of intravenous (IV) doses of Bup (1.51, 2.16, 6.15, and 8.64mg) and Bup/Nx (1.51/0.44, 2.16/0.61, 6.15/1.71, and 8.64/2.44mg). Placebo (Pbo), heroin (25mg) and Nx (0.3mg) were tested as neutral, positive, and negative controls, respectively. RESULTS IV Bup alone was self-administered substantially less than IV heroin, though the two largest doses of Bup produced positive subjective effects, drug "Liking" (0-100mm), which were comparable to heroin (mean difference: Heroin vs Bup 6.15mg: -3.4mm, Heroin vs Bup 8.64mg: -11.3mm). All indicators of abuse potential seen with IV Bup alone were substantially decreased with the addition of Nx. All Bup/Nx combinations produced ratings of aversive effects, "Bad", which were comparable to, or greater than IV, Nx. On three of the four measures of aversive effects, the largest difference is seen with the 8.64 vs 8.64/2.44 condition. CONCLUSIONS This study further demonstrates the ability of the Bup/Nx combination to deter IV use. Although none of the Bup/Nx combinations showed indications of abuse potential, formulations with larger absolute Nx, may be less abusable as they precipitate a greater degree of withdrawal.
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Affiliation(s)
- Jermaine D Jones
- Division on Substance Use Disorders, New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA.
| | - Jeanne M Manubay
- Division on Substance Use Disorders, New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| | - Shanthi Mogali
- Division on Substance Use Disorders, New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| | - Verena E Metz
- Division on Substance Use Disorders, New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| | - Gabriela Madera
- Division on Substance Use Disorders, New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| | - Suky Martinez
- Division on Substance Use Disorders, New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA; Translational Research Training Program in Addiction, City College of New York, 160 Convent Avenue, New York, NY 10031, USA
| | - Mudassir Mumtaz
- Division on Substance Use Disorders, New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA; Translational Research Training Program in Addiction, City College of New York, 160 Convent Avenue, New York, NY 10031, USA
| | - Sandra D Comer
- Division on Substance Use Disorders, New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
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18
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Walsh SL, Comer SD, Lofwall MR, Vince B, Levy-Cooperman N, Kelsh D, Coe MA, Jones JD, Nuzzo PA, Tiberg F, Sheldon B, Kim S. Effect of Buprenorphine Weekly Depot (CAM2038) and Hydromorphone Blockade in Individuals With Opioid Use Disorder: A Randomized Clinical Trial. JAMA Psychiatry 2017; 74:894-902. [PMID: 28655025 PMCID: PMC5710238 DOI: 10.1001/jamapsychiatry.2017.1874] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Buprenorphine is an efficacious, widely used treatment for opioid use disorder (OUD). Daily oral transmucosal formulations can be associated with misuse, diversion, and nonadherence; these limitations may be obviated by a sustained release formulation. OBJECTIVE To evaluate the ability of a novel, weekly, subcutaneous buprenorphine depot formulation, CAM2038, to block euphorigenic opioid effects and suppress opioid withdrawal in non-treatment-seeking individuals with OUD. DESIGN, SETTING, AND PARTICIPANTS This multisite, double-blind, randomized within-patient study was conducted at 3 controlled inpatient research facilities. It involved 47 adults with DSM-V moderate-to-severe OUD. The study was conducted from October 12, 2015 (first patient enrolled), to April 21, 2016 (last patient visit). INTERVENTIONS A total of five 3-day test sessions evaluated the response to hydromorphone (0, 6, and 18 mg intramuscular in random order; 1 dose/session/day). After the first 3-day session (ie, qualification phase), participants were randomized to either CAM2038 weekly at 24 mg (n = 22) or 32 mg (n = 25); the assigned CAM2038 dose was given twice, 1 week apart (day 0 and 7). Four sets of sessions were conducted after randomization (days 1-3, 4-6, 8-10, and 11-13). MAIN OUTCOMES AND MEASURES The primary end point was maximum rating on the visual analog scale for drug liking. Secondary end points included other visual analog scale (eg, high and desire to use), opioid withdrawal scales, and physiological and pharmacokinetic outcomes. RESULTS A total of 46 of 47 randomized participants (mean [SD] age, 35.5 [9] years; 76% male [n = 35]) completed the study. Both weekly CAM2038 doses produced immediate and sustained blockade of hydromorphone effects (liking maximum effect, CAM2038, 24 mg: effect size, 0.813; P < .001, and CAM2038, 32 mg: effect size, 0.753; P < .001) and suppression of withdrawal (Clinical Opiate Withdrawal Scale, CAM2038, 24 mg: effect size, 0.617; P < .001, and CAM2038, 32 mg: effect size, 0.751; P < .001). CAM2038 produces a rapid initial rise of buprenorphine in plasma with maximum concentration around 24 hours, with an apparent half-life of 4 to 5 days and approximately 50% accumulation of trough concentration from first to second dose (trough concentration = 0.822 and 1.23 ng/mL for weeks 1 and 2, respectively, with 24 mg; trough concentration = 0.993 and 1.47 ng/mL for weeks 1 and 2, respectively, with 32 mg). CONCLUSIONS AND RELEVANCE CAM2038 weekly, 24 and 32 mg, was safely tolerated and produced immediate and sustained opioid blockade and withdrawal suppression. The results support the use of this depot formulation for treatment initiation and stabilization of patients with OUD, with the further benefit of obviating the risk for misuse and diversion of daily buprenorphine while retaining its therapeutic benefits. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT02611752.
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Affiliation(s)
- Sharon L. Walsh
- Center on Drug and Alcohol Research, University of Kentucky, Lexington
| | - Sandra D. Comer
- Department of Psychiatry, Columbia University, New York, New York
| | | | - Bradley Vince
- Vince and Associates Clinical Research, Overland Park, Kansas
| | | | - Debra Kelsh
- Vince and Associates Clinical Research, Overland Park, Kansas
| | - Marion A. Coe
- Center on Drug and Alcohol Research, University of Kentucky, Lexington
| | | | - Paul A. Nuzzo
- Center on Drug and Alcohol Research, University of Kentucky, Lexington
| | | | | | - Sonnie Kim
- Braeburn Pharmaceuticals, Princeton, New Jersey
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Jones JD, Sullivan MA, Vosburg SK, Manubay JM, Mogali S, Metz V, Comer SD. Abuse potential of intranasal buprenorphine versus buprenorphine/naloxone in buprenorphine-maintained heroin users. Addict Biol 2015; 20:784-98. [PMID: 25060839 DOI: 10.1111/adb.12163] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In spite of the clinical utility of buprenorphine, parenteral abuse of this medication has been reported in several laboratory investigations and in the real world. Studies have demonstrated lower abuse liability of the buprenorphine/naloxone combination relative to buprenorphine alone. However, clinical research has not yet examined the utility of the combined formulation to deter intranasal use in a buprenorphine-maintained population. Heroin-using volunteers (n = 12) lived in the hospital for 8-9 weeks and were maintained on each of three sublingual buprenorphine doses (2, 8, 24 mg). Under each maintenance dose, participants completed laboratory sessions during which the reinforcing and subjective effects of intranasal doses of buprenorphine (8, 16 mg), buprenorphine/naloxone (8/2, 8/8, 8/16, 16/4 mg) and controls (placebo, heroin 100 mg, naloxone 4 mg) were assessed. Intranasal buprenorphine alone typically produced increases in positive subjective effects and the 8 mg dose was self-administered above the level of placebo. The addition of naloxone dose dependently reduced positive subjective effects and increased aversive effects. No buprenorphine/naloxone combination dose was self-administered significantly more than placebo. These data suggest that within a buprenorphine-dependent population, intranasal buprenorphine/naloxone has reduced abuse potential in comparison to buprenorphine alone. These data strongly argue in favor of buprenorphine/naloxone rather than buprenorphine alone as the more reasonable option for managing the risk of buprenorphine misuse.
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Affiliation(s)
- Jermaine D. Jones
- Division of Substance Abuse; New York Psychiatric Institute and Department of Psychiatry; College of Physicians and Surgeons of Columbia University; New York NY USA
| | - Maria A. Sullivan
- Division of Substance Abuse; New York Psychiatric Institute and Department of Psychiatry; College of Physicians and Surgeons of Columbia University; New York NY USA
| | - Suzanne K. Vosburg
- Division of Substance Abuse; New York Psychiatric Institute and Department of Psychiatry; College of Physicians and Surgeons of Columbia University; New York NY USA
| | - Jeanne M. Manubay
- Division of Substance Abuse; New York Psychiatric Institute and Department of Psychiatry; College of Physicians and Surgeons of Columbia University; New York NY USA
| | - Shanthi Mogali
- Division of Substance Abuse; New York Psychiatric Institute and Department of Psychiatry; College of Physicians and Surgeons of Columbia University; New York NY USA
| | - Verena Metz
- Division of Substance Abuse; New York Psychiatric Institute and Department of Psychiatry; College of Physicians and Surgeons of Columbia University; New York NY USA
| | - Sandra D. Comer
- Division of Substance Abuse; New York Psychiatric Institute and Department of Psychiatry; College of Physicians and Surgeons of Columbia University; New York NY USA
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20
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The US FDA Draft Guidance for Developing Abuse-Deterrent Opioid Analgesics: 2014 and Beyond. Pharmaceut Med 2014. [DOI: 10.1007/s40290-014-0067-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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21
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Respiratory effects of buprenorphine/naloxone alone and in combination with diazepam in naive and tolerant rats. Toxicol Lett 2014; 228:75-84. [DOI: 10.1016/j.toxlet.2014.04.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 04/09/2014] [Accepted: 04/10/2014] [Indexed: 11/18/2022]
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22
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Jones JD, Madera G, Comer SD. The reinforcing and subjective effects of intravenous and intranasal buprenorphine in heroin users. Pharmacol Biochem Behav 2014; 122:299-306. [PMID: 24793093 DOI: 10.1016/j.pbb.2014.04.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 04/21/2014] [Accepted: 04/24/2014] [Indexed: 11/24/2022]
Abstract
Abuse of buprenorphine (BUP) by the intravenous (IV) route has been documented in several studies, and reports of intranasal (IN) abuse are increasing. However, no studies have directly compared the effects of BUP when it is administered intranasally and intravenously. The present secondary analysis used data from two separate studies to compare the reinforcing and subjective effects of IV and IN buprenorphine. One study evaluated IV buprenorphine (N=13) and the other evaluated IN buprenorphine (N=12). Participants were maintained on 2 mg sublingual (SL) BUP and tested with each intranasal or intravenous buprenorphine test dose (0 mg, 2 mg, 4 mg, 8 mg, and 16 mg). During morning laboratory sessions, participants received money (US $20) and sample doses of IN or IV BUP, and then completed subjective effects questionnaires. Later that day, they completed a self-administration task to receive 10% portions of the drug and/or money they previously sampled. In general, positive subjective ratings for both IV and IN BUP were significantly greater than placebo, with IV BUP having a greater effect than IN BUP. All active BUP doses (IV and IN) maintained significantly higher progressive ratio breakpoint values than placebo, but breakpoint values for IV BUP were greater than for IN BUP. Buprenorphine is an effective maintenance treatment for opioid dependence, valued for its ability to reduce the positive subjective effects of other opioids. Nevertheless, the present data demonstrate that in participants maintained on a low dose of SL BUP, the medication itself has abuse liability when used intravenously or intranasally.
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Affiliation(s)
- Jermaine D Jones
- Division on Substance Abuse, New York Psychiatric Institute and Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA.
| | - Gabriela Madera
- Division on Substance Abuse, New York Psychiatric Institute and Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| | - Sandra D Comer
- Division on Substance Abuse, New York Psychiatric Institute and Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
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23
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Lavonas EJ, Severtson SG, Martinez EM, Bucher-Bartelson B, Le Lait MC, Green JL, Murrelle LE, Cicero TJ, Kurtz SP, Rosenblum A, Surratt HL, Dart RC. Abuse and diversion of buprenorphine sublingual tablets and film. J Subst Abuse Treat 2014; 47:27-34. [PMID: 24680219 DOI: 10.1016/j.jsat.2014.02.003] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 02/12/2014] [Accepted: 02/17/2014] [Indexed: 10/25/2022]
Abstract
Buprenorphine abuse is common worldwide. Rates of abuse and diversion of three sublingual buprenorphine formulations (single ingredient tablets; naloxone combination tablets and film) were compared. Data were obtained from the Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS) System Poison Center, Drug Diversion, Opioid Treatment (OTP), Survey of Key Informants' Patients (SKIP), and College Survey Programs through December 2012. To control for drug availability, event ratios (rates) were calculated quarterly, based on the number of patients filling prescriptions for each formulation ("unique recipients of a dispensed drug," URDD) and averaged and compared using negative binomial regression. Abuse rates in the OTP, SKIP, and College Survey Programs were greatest for single ingredient tablets, and abuse rates in the Poison Center Program and illicit diversion rates were greatest for the combination tablets. Combination film rates were significantly less than rates for either tablet formulation in all programs. No geographic pattern could be discerned.
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Affiliation(s)
- Eric J Lavonas
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, 777 Bannock Street, MC 0180, Denver, CO, 80204, USA.
| | - S Geoffrey Severtson
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, 777 Bannock Street, MC 0180, Denver, CO, 80204, USA.
| | - Erin M Martinez
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, 777 Bannock Street, MC 0180, Denver, CO, 80204, USA.
| | - Becki Bucher-Bartelson
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, 777 Bannock Street, MC 0180, Denver, CO, 80204, USA.
| | - Marie-Claire Le Lait
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, 777 Bannock Street, MC 0180, Denver, CO, 80204, USA.
| | - Jody L Green
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, 777 Bannock Street, MC 0180, Denver, CO, 80204, USA.
| | - Lenn E Murrelle
- Venebio Group, LLC, 7400 Beaufont Springs Drive, Suite 300, Richmond, VA 23225, USA.
| | - Theodore J Cicero
- Department of Psychiatry, Washington University in St. Louis, One Brookings Drive, Campus Box 8134, St. Louis, MO 63130 USA.
| | - Steven P Kurtz
- Center for Applied Research on Substance Use and Health Disparities, Nova Southeastern University, 2 NE 40th Street, Suite 404, Miami, FL 33137 USA.
| | - Andrew Rosenblum
- Institute for Treatment and Services Research, National Development and Research Institutes, 71 West 23rd Street, 4th floor, New York, NY 10010 USA.
| | - Hilary L Surratt
- Center for Applied Research on Substance Use and Health Disparities, Nova Southeastern University, 2 NE 40th Street, Suite 404, Miami, FL 33137 USA.
| | - Richard C Dart
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, 777 Bannock Street, MC 0180, Denver, CO, 80204, USA.
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Otiashvili D, Piralishvili G, Sikharulidze Z, Kamkamidze G, Poole S, Woody GE. Methadone and buprenorphine-naloxone are effective in reducing illicit buprenorphine and other opioid use, and reducing HIV risk behavior--outcomes of a randomized trial. Drug Alcohol Depend 2013; 133:376-82. [PMID: 23916321 PMCID: PMC3818507 DOI: 10.1016/j.drugalcdep.2013.06.024] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 06/10/2013] [Accepted: 06/23/2013] [Indexed: 11/28/2022]
Abstract
AIMS Determine the extent to which buprenorphine injectors continue treatment with buprenorphine-naloxone or methadone, and the impact of these treatments on substance use and HIV risk in the Republic of Georgia. METHODS Randomized controlled 12-week trial of daily-observed methadone or buprenorphine-naloxone followed by a dose taper, referral to ongoing treatment, and follow-up at week 20 at the Uranti Clinic in Tbilisi, Republic of Georgia. Eighty consenting treatment-seeking individuals (40/group) aged 25 and above who met ICD-10 criteria for opioid dependence with physiologic features and reported injecting buprenorphine 10 or more times in the past 30 days. Opioid use according to urine tests and self-reports, treatment retention, and HIV risk behavior as determined by the Risk Assessment Battery. RESULTS Mean age of participants was 33.7 (SD5.7), 4 were female, mean history of opioid injection use was 5.8 years (SD4.6), none were HIV+ at intake or at the 12-week assessment and 73.4% were HCV+. Sixty-eight participants (85%) completed the 12-week medication phase (33 from methadone and 35 from buprenorphine/naloxone group); 37 (46%) were in treatment at the 20-week follow-up (21 from methadone and 16 from the buprenorphine/naloxone group). In both study arms, treatment resulted in a marked reduction in unprescribed buprenorphine, other opioid use, and HIV injecting risk behavior with no clinically significant differences between the two treatment arms. CONCLUSIONS Daily observed methadone or buprenorphine-naloxone are effective treatments for non-medical buprenorphine and other opioid use in the Republic of Georgia and likely to be useful for preventing HIV infection.
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Affiliation(s)
- David Otiashvili
- Addiction Research Centre, Alternative Georgia, Tbilisi 0177, Georgia; Department of Psychiatry, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 121 08 Prague, Czech Republic.
| | - Gvantsa Piralishvili
- Centre for Mental Health and Prevention of Addiction, Tbilisi 0186, Georgia (Republic of)
| | - Zura Sikharulidze
- Centre for Medical, Socio-economic and Cultural Issues, Uranti, Tbilisi 0177, Georgia (Republic of)
| | | | - Sabrina Poole
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania and Treatment Research Institute, Philadelphia, PA 19106
| | - George E. Woody
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania and Treatment Research Institute, Philadelphia, PA 19106
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25
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Comparison of a drug versus money and drug versus drug self-administration choice procedure with oxycodone and morphine in opioid addicts. Behav Pharmacol 2013; 24:504-16. [PMID: 23839029 DOI: 10.1097/fbp.0b013e328363d1c4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This double-blind, placebo-controlled study investigated the effects of oral morphine (0, 45, 135 mg/70 kg) and oral oxycodone (0, 15, 45 mg/70 kg) on buprenorphine-maintained opioid addicts. As a 3: 1 morphine : oxycodone oral dose ratio yielded equivalent subjective and physiological effects in nondependent individuals, this ratio was used in the present study. Two self-administration laboratory procedures - that is, a drug versus money and a drug versus drug procedure - were assessed. Study participants (N=12) lived in the hospital and were maintained on 4 mg/day sublingual buprenorphine. When participants chose between drug and money, money was preferred over all drug doses; only high-dose oxycodone was self-administered more than placebo. When participants chose between drug and drug, both drugs were chosen more than placebo, high doses of each drug were chosen over low doses, and high-dose oxycodone was preferred over high-dose morphine. The subjective, performance-impairing, and miotic effects of high-dose oxycodone were generally greater than those of high-dose morphine. The study demonstrated that a 3: 1 oral dose ratio of morphine : oxycodone was not equipotent in buprenorphine-dependent individuals. Both self-administration procedures were effective for assessing the relative reinforcing effects of drugs; preference for one procedure should be driven by the specific research question of interest.
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Abstract
Drug self-administration procedures in laboratory settings allow us to closely model drug-taking behavior in real-world settings. This review provides an overview of many of the common self-administration methods used in human laboratory research. Typically, self-administration studies provide a quantifiable measure of the reinforcing effect of a drug, which is believed to be predictive of its potential for abuse. Several adaptations of the self-administration paradigm exist, the simplest of which allows participants free access to the drug under investigation. Free-access procedures allow investigators to observe patterns of drug self-administration and drug effects in a controlled setting. Allowing participants to choose between two simultaneously available reinforcers (choice procedures) is another well-established method of assessing the reinforcing effects of a drug. Offering a choice between two reinforcers (e.g. two different doses of the same drug, two different drugs, or drug and nondrug reinforcers) provides researchers with a point of comparison (e.g. between a drug of known abuse potential and a novel drug). When combined with other endpoints, such as subjective effects ratings, physiological responses, and cognitive performance, human self-administration paradigms have contributed significantly to our understanding of the factors that contribute to, maintain, and alter drug-taking behavior including: craving, positive subjective effects, toxicity, drug interactions and abstinence. This area of research has also begun to incorporate other techniques such as imaging and genetics to further understand the multifaceted nature of substance abuse. The present paper summarizes the different self-administration techniques that are commonly used today and the application of other procedures that may complement interpretation of the drug self-administration findings.
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Affiliation(s)
- Jermaine D Jones
- Department of Psychiatry, Division on Substance Abuse, New York Psychiatric Institute, College of Physicians and Surgeons of Columbia University, New York, NY 10032, USA.
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27
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Lofwall MR, Havens JR. Inability to access buprenorphine treatment as a risk factor for using diverted buprenorphine. Drug Alcohol Depend 2012; 126:379-83. [PMID: 22704124 PMCID: PMC3449053 DOI: 10.1016/j.drugalcdep.2012.05.025] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 05/17/2012] [Accepted: 05/19/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND As buprenorphine prescribing has increased in the United States so have reports of its diversion. The study purpose was to examine frequency and source of and risk factors for diverted buprenorphine use over a 6-month period in an Appalachian community sample of prescription opioid abusers. METHODS There were 503 participants at baseline; 471 completed the 6-month follow-up assessment. Psychiatric disorders and demographic, drug use, and social network characteristics were ascertained at baseline and follow-up. Multivariable logistic regression was used to determine the predictors of diverted buprenorphine use over the 6-month period. RESULTS Lifetime buprenorphine use "to get high" was 70.1%. Nearly half (46.5%) used diverted buprenorphine over the 6-month follow-up period; among these persons, 9.6% and 50.6% were daily and sporadic (1-2 uses over the 6-months) users, respectively. The most common sources were dealers (58.7%) and friends (31.6%). Predictors of increased risk of use of diverted buprenorphine during the 6-month follow-up included inability to access buprenorphine treatment (AOR: 7.31, 95% CI: 2.07, 25.8), meeting criteria for generalized anxiety disorder, and past 30 day use of OxyContin, methamphetamine and/or alcohol. CONCLUSIONS These results suggest that improving, rather than limiting, access to good quality affordable buprenorphine treatment may be an effective public health strategy to mitigate buprenorphine abuse. Future work should evaluate why more persons did not attempt to access treatment, determine how motivations change over time, and how different motivations affect diversion of the different buprenorphine formulations.
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Affiliation(s)
- Michelle R. Lofwall
- Department of Psychiatry, University of Kentucky College of Medicine, Lexington, Kentucky,Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Jennifer R. Havens
- Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, Kentucky,Department of Epidemiology, University of Kentucky College of Public Health, Lexington, Kentucky
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Earley PH. Opioid substitution therapy for dependent health care practitioners: approach with caution. Mayo Clin Proc 2012; 87:803-4; author reply 806-8. [PMID: 22862867 PMCID: PMC3498089 DOI: 10.1016/j.mayocp.2012.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2012] [Accepted: 06/11/2012] [Indexed: 11/22/2022]
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Abstract
Buprenorphine/naloxone has recently been introduced in Australia and is available for unsupervised dosing within Queensland. A retrospective observational study of data collected during 2000-2007 for clients obtaining injecting equipment from the Brisbane Harm Reduction Centre in Queensland is presented. The numbers of service occasions and needles and syringes were used as surrogate drug use measures. Buprenorphine and naloxone were misused at lower rates when compared with buprenorphine and methadone. Furthermore, the misuse of opioid replacement therapies represented less than 5% of all illicit opioid injections. Implications and study limitations are discussed.
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Affiliation(s)
- Andrew Smirnov
- School of Population Health, University of Queensland, Brisbane, Australia.
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Larance B, Degenhardt L, Lintzeris N, Bell J, Winstock A, Dietze P, Mattick R, Ali R, Horyniak D. Post-marketing surveillance of buprenorphine-naloxone in Australia: diversion, injection and adherence with supervised dosing. Drug Alcohol Depend 2011; 118:265-73. [PMID: 21565452 DOI: 10.1016/j.drugalcdep.2011.04.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Revised: 04/04/2011] [Accepted: 04/04/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND These studies compared the diversion and injection of buprenorphine-naloxone (BNX), buprenorphine (BPN) and methadone (MET) in Australia. METHODS Surveys were conducted with regular injecting drug users (IDUs) (2004-2009, N=881-943), opioid substitution treatment (OST) clients (2008, N=440) and authorised OST prescribers (2007, N=291). Key outcome measures include the unsanctioned removal of supervised doses, diversion, injection, motivations, drug liking and street price. Levels of injection among IDUs were adjusted for background availability of medications. Doses not taken as directed by OST clients were adjusted by total number of daily doses dispensed. RESULTS Among regular IDUs, levels of injection were lower for BNX relative to BPN, but comparable to those for MET, adjusting for background availability. Among OST clients, fewer BNX clients (13%) reported recently injecting their medication, than BPN (28%) and MET clients (23%). Fewer MET clients (10%) reported removal of supervised doses, than BPN (35%) and BNX clients (22%). There were no differences in prevalence of recent diversion (28% of all OST clients). Adjusting for the total doses dispensed, more BPN was injected (10%), removed (12%) and diverted (5%), than MET (5%, <1% and 2% respectively) and BNX (5%, 9% and <1% respectively). In 2009, the median street price of BNX was equivalent to that for BPN. CONCLUSIONS BNX was less commonly and less frequently injected than BPN, but both sublingual medications were diverted more than liquid MET.
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Affiliation(s)
- Briony Larance
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052, Australia.
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31
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Middleton L, Nuzzo P, Lofwall M, Moody D, Walsh S. The pharmacodynamic and pharmacokinetic profile of intranasal crushed buprenorphine and buprenorphine/naloxone tablets in opioid abusers. Addiction 2011; 106:1460-73. [PMID: 21395892 PMCID: PMC3776483 DOI: 10.1111/j.1360-0443.2011.03424.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS Sublingual buprenorphine and buprenorphine/naloxone are efficacious opioid dependence pharmacotherapies, but there are reports of their diversion and misuse by the intranasal route. The study objectives were to characterize and compare their intranasal pharmacodynamic and pharmacokinetic profiles. DESIGN A randomized, double-blind, placebo-controlled, cross-over study. SETTING An in-patient research unit at the University of Kentucky. PARTICIPANTS Healthy adults (n = 10) abusing, but not physically dependent on, intranasal opioids. MEASUREMENTS Six sessions (72 hours apart) tested five intranasal doses [0/0, crushed buprenorphine (2, 8 mg), crushed buprenorphine/naloxone (2/0.5, 8/2 mg)] and one intravenous dose (0.8 mg buprenorphine/0.2 mg naloxone for bioavailability assessment). Plasma samples, physiological, subject- and observer-rated measures were collected before and for up to 72 hours after drug administration. FINDINGS Both formulations produced time- and dose-dependent increases on subjective and physiological mu-opioid agonist effects (e.g. 'liking', miosis). Subjects reported higher subjective ratings and street values for 8 mg compared to 8/2 mg, but these differences were not statistically significant. No significant formulation differences in peak plasma buprenorphine concentration or time-course were observed. Buprenorphine bioavailability was 38-44% and T(max) was 35-40 minutes after all intranasal doses. Naloxone bioavailability was 24% and 30% following 2/0.5 and 8/2 mg, respectively. CONCLUSIONS It is difficult to determine if observed differences in abuse potential between intranasal buprenorphine and buprenorphine/naloxone are clinically relevant at the doses tested. Greater bioavailability and faster onset of pharmacodynamic effects compared to sublingual administration suggests a motivation for intranasal misuse in non-dependent opioid abusers. However, significant naloxone absorption from intranasal buprenorphine/naloxone administration may deter the likelihood of intranasal misuse of buprenorphine/naloxone, but not buprenorphine, in opioid-dependent individuals.
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Affiliation(s)
- L.S. Middleton
- Department of Behavioral Science, University of Kentucky, Lexington, KY, USA,Center on Drug and Alcohol Research, University of Kentucky, Lexington, KY, USA
| | - P.A. Nuzzo
- Department of Behavioral Science, University of Kentucky, Lexington, KY, USA,Center on Drug and Alcohol Research, University of Kentucky, Lexington, KY, USA
| | - M.R. Lofwall
- Department of Behavioral Science, University of Kentucky, Lexington, KY, USA,Department of Psychiatry, University of Kentucky, Lexington, KY, USA,Center on Drug and Alcohol Research, University of Kentucky, Lexington, KY, USA
| | - D.E. Moody
- University of Utah, Center for Human Toxicology, Salt Lake City, UT, USA
| | - S.L. Walsh
- Department of Behavioral Science, University of Kentucky, Lexington, KY, USA,Department of Psychiatry, University of Kentucky, Lexington, KY, USA,Center on Drug and Alcohol Research, University of Kentucky, Lexington, KY, USA
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Yokell MA, Zaller ND, Green TC, Rich JD. Buprenorphine and buprenorphine/naloxone diversion, misuse, and illicit use: an international review. CURRENT DRUG ABUSE REVIEWS 2011; 4:28-41. [PMID: 21466501 PMCID: PMC3154701 DOI: 10.2174/1874473711104010028] [Citation(s) in RCA: 176] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Accepted: 03/24/2011] [Indexed: 11/22/2022]
Abstract
The diversion, misuse, and non-medically supervised use of buprenorphine and buprenorphine/naloxone by opioid users are reviewed. Buprenorphine and buprenorphine/naloxone are used globally as opioid analgesics and in the treatment of opioid dependency. Diversion of buprenorphine and buprenorphine/naloxone represents a complex medical and social issue, and has been widely documented in various geographical regions throughout the world. We first discuss the clinical properties of buprenorphine and its abuse potential. Second, we discuss its diversion and illicit use on an international level, as well as motivations for those activities. Third, we examine the medical risks and benefits of buprenorphine's non-medically supervised use and misuse. These risks and benefits include the effect of buprenorphine's use on HIV risk and the risk of its concomitant use with other medications and drugs of abuse. Finally, we discuss the implications of diversion, misuse, and non-medically supervised use (including potential measures to address issues of diversion); and potential areas for further research.
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Affiliation(s)
- Michael A. Yokell
- Division of Infectious Diseases, The Miriam Hospital, Providence, RI 02906, USA
- Center for AIDS Research, The Miriam Hospital, Providence, RI 02906, USA
| | - Nickolas D. Zaller
- Division of Infectious Diseases, The Miriam Hospital, Providence, RI 02906, USA
- Center for AIDS Research, The Miriam Hospital, Providence, RI 02906, USA
- Warren Alpert Medical School of Brown University, Providence, RI 02912, USA
| | - Traci C. Green
- Center for AIDS Research, The Miriam Hospital, Providence, RI 02906, USA
- Warren Alpert Medical School of Brown University, Providence, RI 02912, USA
- Rhode Island Hospital, Providence, RI 02903, USA
| | - Josiah D. Rich
- Division of Infectious Diseases, The Miriam Hospital, Providence, RI 02906, USA
- Center for AIDS Research, The Miriam Hospital, Providence, RI 02906, USA
- Warren Alpert Medical School of Brown University, Providence, RI 02912, USA
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Baker J, Rainey PM, Moody DE, Morse GD, Ma Q, McCance-Katz EF. Interactions between buprenorphine and antiretrovirals: nucleos(t)ide reverse transcriptase inhibitors (NRTI) didanosine, lamivudine, and tenofovir. Am J Addict 2010; 19:17-29. [PMID: 20132118 DOI: 10.1111/j.1521-0391.2009.00004.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
To improve outcomes among injection drug users with HIV and/or chronic hepatitis B, it is important to identify drug interactions between antiretroviral and opiate therapies. We report the results of a study designed to examine the interaction between buprenorphine and the nucleos(t)ide reverse transcriptase inhibitors (NRTI) didanosine (ddI), lamivudine (3TC), and tenofovir (TDF). Opioid-dependent, buprenorphine/naloxone-maintained, HIV-negative volunteers (n = 27) participated in two 24-hour sessions to determine (1) pharmacokinetics of buprenorphine alone and (2) pharmacokinetics of both buprenorphine and either ddI, 3TC, or TDF. Among buprenorphine/naloxone-maintained study participants, no significant changes in buprenorphine pharmacokinetics were observed following ddI, 3TC, or TDF administration. Buprenorphine had no significant effect on NRTI concentrations. Concomitant use of buprenorphine with ddI, 3TC, or TDF results in neither a significant pharmacokinetic nor pharmacodynamic interaction.
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Affiliation(s)
- Jennifer Baker
- Department of Psychiatry, Virginia Commonwealth University, Richmond, Virginia, USA
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Duke AN, Correia CJ, Walsh SL, Bigelow GE, Strain EC. Acute effects of intramuscular and sublingual buprenorphine and buprenorphine/naloxone in non-dependent opioid abusers. Psychopharmacology (Berl) 2010; 211:303-12. [PMID: 20577717 PMCID: PMC2941639 DOI: 10.1007/s00213-010-1898-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Accepted: 05/26/2010] [Indexed: 10/19/2022]
Abstract
RATIONALE Buprenorphine is a partial mu opioid receptor agonist with clinical efficacy as a pharmacotherapy for opioid dependence. A sublingual combination formulation was developed containing buprenorphine and naloxone with the intent of decreasing abuse liability in opioid-dependent individuals. However, the addition of naloxone may not limit abuse potential of this medication when taken by individuals without opioid physical dependence. OBJECTIVES The present study investigated the effects of buprenorphine alone and in combination with naloxone administered intramuscularly and sublingually to non-dependent opioid abusers. METHODS In a within-subject crossover design, non-dependent opioid-experienced volunteers (N = 8) were administered acute doses of buprenorphine (4, 8, and 16 mg) and buprenorphine/naloxone (4/1, 8/2, and 16/4 mg) via both intramuscular and sublingual routes, intramuscular hydromorphone (2 and 4 mg as an opioid agonist control), and placebo, for a total of 15 drug conditions. Laboratory sessions were conducted twice per week using a double-blind, double-dummy design. RESULTS Buprenorphine and buprenorphine/naloxone engendered effects similar to hydromorphone. Intramuscular administration produced a greater magnitude of effects compared to the sublingual route at the intermediate dose of buprenorphine and at both the low and high doses of the buprenorphine/naloxone combination. The addition of naloxone did not significantly alter the effects of buprenorphine. CONCLUSIONS These results suggest that buprenorphine and buprenorphine/naloxone have similar abuse potential in non-dependent opioid abusers, and that the addition of naloxone at these doses and in this dose ratio confers no evident advantage for decreasing the abuse potential of intramuscular or sublingual buprenorphine in this population.
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Affiliation(s)
- AN Duke
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - CJ Correia
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - SL Walsh
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - GE Bigelow
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - EC Strain
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
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35
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Vlahov D, Robertson AM, Strathdee SA. Prevention of HIV infection among injection drug users in resource-limited settings. Clin Infect Dis 2010; 50 Suppl 3:S114-21. [PMID: 20397939 PMCID: PMC3114556 DOI: 10.1086/651482] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Injection drug use contributes to considerable global morbidity and mortality associated with human immunodeficiency virus (HIV) infection and AIDS and other infections due to blood-borne pathogens through the direct sharing of needles, syringes, and other injection equipment. Of approximately 16 million injection drug users (IDUs) worldwide, an estimated 3 million are HIV infected. The prevalence of HIV infection among IDUs is high in many countries in Asia and eastern Europe and could exacerbate the HIV epidemic in sub-Saharan Africa. This review summarizes important components of a comprehensive program for prevention of HIV infection in IDUs, including unrestricted legal access to sterile syringes through needle exchange programs and enhanced pharmacy services, treatment for opioid dependence (ie, methadone and buprenorphine treatment), behavioral interventions, and identification and treatment of noninjection drug and alcohol use, which accounts for increased sexual transmission of HIV. Evidence supports the effectiveness of harm-reduction programs over punitive drug-control policies.
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Affiliation(s)
- David Vlahov
- Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, New York 10029, USA.
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Mitchell SG, Kelly SM, Brown BS, Reisinger HS, Peterson JA, Ruhf A, Agar MH, O'Grady KE, Schwartz RP. Uses of Diverted Methadone and Buprenorphine by Opioid-Addicted Individuals in Baltimore, Maryland. Am J Addict 2010. [DOI: 10.1080/10550490903077820] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Gwin Mitchell S, Kelly SM, Brown BS, Schacht Reisinger H, Peterson JA, Ruhf A, Agar MH, O'Grady KE, Schwartz RP. Uses of diverted methadone and buprenorphine by opioid-addicted individuals in Baltimore, Maryland. Am J Addict 2010; 18:346-55. [PMID: 19874152 DOI: 10.3109/10550490903077820] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This study examined the uses of diverted methadone and buprenorphine among opiate-addicted individuals recruited from new admissions to methadone programs and from out-of-treatment individuals recruited from the streets. Self-report data regarding diversion were obtained from surveys and semi-structured qualitative interviews. Approximately 16% (n = 84) of the total sample (N = 515) reported using diverted (street) methadone two-three times per week for six months or more, and for an average of 7.8 days (SD = 10.3) within the past month. The group reporting lifetime use of diverted methadone as compared to the group that did not report such use was less likely to use heroin and cocaine in the 30 days prior to admission (ps <.01) and had lower ASI Drug Composite scores (p <.05). Participants in our qualitative sub-sample (n = 22) indicated that street methadone was more widely used than street buprenorphine and that both drugs were largely used as self-medication for detoxification and withdrawal symptoms. Participants reported using low dosages and no injection of either medication was reported.
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Affiliation(s)
- Shannon Gwin Mitchell
- Friends Research Institute, Inc., Social Research Center, 1040 Park Avenue, Suite 103, Baltimore, MD 21201, USA.
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Methadone and buprenorphine prescribing and referral practices in US prison systems: results from a nationwide survey. Drug Alcohol Depend 2009; 105:83-8. [PMID: 19625142 PMCID: PMC2743749 DOI: 10.1016/j.drugalcdep.2009.06.015] [Citation(s) in RCA: 190] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2008] [Revised: 06/11/2009] [Accepted: 06/12/2009] [Indexed: 11/22/2022]
Abstract
BACKGROUND More than 50% of incarcerated individuals have a history of substance use, and over 200,000 individuals with heroin addiction pass through American correctional facilities annually. Opiate replacement therapy (ORT) with methadone or buprenorphine is an effective treatment for opiate dependence and can reduce drug-related disease and recidivism for inmates. Provision of ORT is nevertheless a frequently neglected intervention in the correctional setting. OBJECTIVE AND METHODS We surveyed the 50 state; Washington, District of Columbia (DC); and Federal Department of Corrections' medical directors or their equivalents about their facilities' ORT prescribing policies and referral programs for inmates leaving prison. RESULTS We received responses from 51 of 52 prison systems nationwide. Twenty-eight prison systems (55%) offer methadone to inmates in some situations. Methadone use varies widely across states: over 50% of correctional facilities that offer methadone do so exclusively for pregnant women or for chronic pain management. Seven states' prison systems (14%) offer buprenorphine to some inmates. The most common reason cited for not offering ORT was that facilities "prefer drug-free detoxification over providing methadone or buprenorphine." Twenty-three states' prison systems (45%) provide referrals for some inmates to methadone maintenance programs after release, which increased from 8% in 2003; 15 states' prison systems (29%) provide some referrals to community buprenorphine providers. CONCLUSION Despite demonstrated social, medical, and economic benefits of providing ORT to inmates during incarceration and linkage to ORT upon release, many prison systems nationwide still do not offer pharmacological treatment for opiate addiction or referrals for ORT upon release.
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Mammen K, Bell J. The clinical efficacy and abuse potential of combination buprenorphine–naloxone in the treatment of opioid dependence. Expert Opin Pharmacother 2009; 10:2537-44. [DOI: 10.1517/14656560903213405] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Haney M, Spealman R. Controversies in translational research: drug self-administration. Psychopharmacology (Berl) 2008; 199:403-19. [PMID: 18283437 PMCID: PMC2731701 DOI: 10.1007/s00213-008-1079-x] [Citation(s) in RCA: 224] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2007] [Accepted: 01/11/2008] [Indexed: 11/26/2022]
Abstract
RATIONALE Laboratory animal and human models of drug self-administration are used to evaluate potential pharmacotherapies for drug abuse, yet the utility of these models in predicting clinically useful medications is variable. OBJECTIVE The objective of this study was to track how antagonist, agonist, and partial agonist medication approaches influence heroin and cocaine self-administration by rodents, non-human primates, and humans and to compare these results to clinical outcomes. RESULTS Across species, heroin self-administration was decreased by all three medication approaches, paralleling their demonstrated clinical utility. The heroin data emphasize the importance of assessing a medication's abuse liability preclinically to predict medication abuse and compliance and of considering subject characteristics (e.g., opioid dependence) when interpreting medication effects. For cocaine, the effects of ecopipam, modafinil, and aripiprazole were consistent in the laboratory and clinic, provided that the medications were administered repeatedly before self-administration sessions. Modafinil attenuated cocaine's reinforcing effects in the human laboratory and improved treatment outcome, while ecopipam and aripiprazole increased the reinforcing effects of cocaine and do not appear promising in the clinic. CONCLUSIONS The self-administration model has reliably identified medications to treat opioid dependence, and the recent data with modafinil suggest that the human laboratory model also identifies medications to treat cocaine dependence. There have been numerous false positives when subjective effects are the primary outcome measure, but not when self-administration is the outcome. Factors relevant to the predictive validity of self-administration procedures include medication maintenance and the concurrent assessment of a range of behaviors to determine abuse liability and the specificity of effect.
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Affiliation(s)
- Margaret Haney
- Department of Psychiatry, College of Physicians and Surgeons of Columbia University and the New York State Psychiatric Institute, 1051 Riverside Dr., Unit 120, New York, NY 10032, USA.
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The role of human drug self-administration procedures in the development of medications. Drug Alcohol Depend 2008; 96:1-15. [PMID: 18436394 PMCID: PMC2744317 DOI: 10.1016/j.drugalcdep.2008.03.001] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2007] [Revised: 02/25/2008] [Accepted: 03/02/2008] [Indexed: 11/21/2022]
Abstract
The purpose of this review is to illustrate the utility and value of employing human self-administration procedures in medication development, including abuse liability assessments of novel medications and evaluation of potential pharmacotherapies for substance use disorders. Traditionally, human abuse liability testing has relied primarily on subjective reports describing drug action by use of questionnaires; similarly, drug interactions between putative treatment agents and the drugs of abuse have relied on these measures. Subjective reports are highly valued because they provide qualitative and quantitative information about the characteristics of central and peripheral pharmacodynamic effects as well as safety and tolerability. However, self-administration procedures directly examine the behavior of interest-that is, drug taking. The present paper (1) reviews the most commonly used human self-administration procedures, (2) discusses the concordance of subjective reports and self-administration within the context of medications development for substance use disorders, focusing primarily on illustrative examples from development efforts with opioid and cocaine dependence, and (3) explores the utility of applying self-administration procedures to assess the abuse liability of novel compounds, including "abuse-deterrent" formulations (ADFs). The review will focus on opioid and cocaine dependence because a rich database from both clinical laboratory and clinical trial research exists for these two drug classes. The data reviewed suggest that drug-induced changes in self-administration and subjective effects are not always concordant. Therefore, assessment of self-administration in combination with subjective effects provides a more comprehensive picture that may have improved predictive validity for translating to the clinical setting.
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Leri F. Co-administration of opioid agonists and antagonists in addiction and pain medicine. Expert Opin Pharmacother 2008; 9:1387-96. [DOI: 10.1517/14656566.9.8.1387] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Comer SD, Sullivan MA, Whittington RA, Vosburg SK, Kowalczyk WJ. Abuse liability of prescription opioids compared to heroin in morphine-maintained heroin abusers. Neuropsychopharmacology 2008; 33:1179-91. [PMID: 17581533 PMCID: PMC3787689 DOI: 10.1038/sj.npp.1301479] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abuse of prescription opioid medications has increased dramatically in the United States during the past decade, as indicated by a variety of epidemiological sources. However, few studies have systematically examined the relative reinforcing effects of commonly abused opioid medications. The current double-blind, placebo-controlled in-patient study was designed to compare the effects of intravenously delivered fentanyl (0, 0.0625, 0.125, 0.187, and 0.250 mg/70 kg), oxycodone (0, 6.25, 12.5, 25, and 50 mg/70 kg), morphine (0, 6.25, 12.5, 25, and 50 mg/70 kg), buprenorphine (0, 0.125, 0.5, 2, and 8 mg/70 kg), and heroin (0, 3.125, 6.25, 12.5, and 25 mg/70 kg) in morphine-maintained heroin abusers (N=8 completers maintained on 120 mg per day oral morphine in divided doses (30 mg q.i.d.)). All of the participants received all of the drugs tested; drugs and doses were administered in non-systematic order. All of the drugs produced statistically significant, dose-related increases in positive subjective ratings, such as 'I feel a good drug effect' and 'I like the drug.' In general, the order of potency in producing these effects, from most to least potent, was fentanyl>buprenorphine>or=heroin >morphine=oxycodone. In contrast, buprenorphine was the only drug that produced statistically significant increases in ratings of 'I feel a bad drug effect' and it was the only drug that was not self-administered above placebo levels at any dose tested. These data suggest that the abuse liability of buprenorphine in heroin-dependent individuals may be low, despite the fact that it produces increases in positive subjective ratings. The abuse liabilities of fentanyl, morphine, oxycodone, and heroin, however, appear to be similar under these experimental conditions.
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Affiliation(s)
- Sandra D Comer
- Division on Substance Abuse, New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University, New York, NY 10032, USA.
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Zacny JP, Walker DJ, Drum M, Sells M. Choice of sevoflurane and its subjective and psychomotor effects in light and moderate drinkers. Drug Alcohol Depend 2008; 94:101-8. [PMID: 18077105 PMCID: PMC2288701 DOI: 10.1016/j.drugalcdep.2007.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Revised: 10/18/2007] [Accepted: 10/18/2007] [Indexed: 11/30/2022]
Abstract
BACKGROUND Sevoflurane, an inhalant of the volatile anesthetic class, has neurobiological and behavioral effects in common with abused inhalants and ethanol. We sought to determine if choice for subanesthetic doses of sevoflurane, and its subjective and psychomotor effects, would differ as a function of alcohol-drinking status in healthy volunteers. METHODS The effects of four concentrations of sevoflurane (0, 0.2, 0.4, 0.8% sevoflurane in oxygen) were studied in 16 light drinkers and 16 moderate drinkers. During each of four sessions, subjects sampled a concentration of sevoflurane and 100% O(2) (placebo) for 10 min each. Subjective and psychomotor testing commenced 5 min into each sampling trial. Later, within the session, subjects chose nine times, once every 5 min, among sevoflurane (e.g., "Agent A"), placebo (e.g., "Agent B," 100% O(2)), or neither (and were administered 100% O(2), identified as "drug-free air"). RESULTS Choice for sevoflurane at the 0.4% concentration was significantly higher in the moderate drinkers than in the light drinkers. A number of subjective effects reported during inhalation of sevoflurane were markedly lower in the moderate-drinking group than in the light-drinking group. However, psychomotor impairment induced by sevoflurane was similar in magnitude in both groups. CONCLUSIONS Alcohol-drinking status affected sevoflurane choice. The results are consistent with several studies comparing light and heavier drinkers, using other drugs. Although both drinking groups were similarly impaired by sevoflurane, the moderate drinkers reported less of a subjective response than light drinkers, suggestive of cross-tolerance.
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Affiliation(s)
- James P. Zacny
- Department of Anesthesia and Critical Care The University of Chicago Chicago. Illinois USA
| | - Diana J. Walker
- Department of Anesthesia and Critical Care The University of Chicago Chicago. Illinois USA
| | - Melinda Drum
- Department of Health Studies The University of Chicago Chicago. Illinois USA
| | - Molly Sells
- Department of Anesthesia and Critical Care The University of Chicago Chicago. Illinois USA
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Carrieri MP, Amass L, Lucas GM, Vlahov D, Wodak A, Woody GE. Buprenorphine Use: The International Experience. Clin Infect Dis 2006; 43 Suppl 4:S197-215. [PMID: 17109307 DOI: 10.1086/508184] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The confluence of the heroin injection epidemic and the human immunodeficiency virus (HIV) infection epidemic has increased the call for expanded access to effective treatments for both conditions. Buprenorphine and methadone are now listed on the World Health Organization's Model Essential Drugs List. In France, which has the most extensive experience, buprenorphine has been associated with a dramatic decrease in deaths due to overdose, and buprenorphine diversion appears to be associated with inadequate dosage, social vulnerability, and prescriptions from multiple providers. Other treatment models (in the United States, Australia, Germany, and Italy) and buprenorphine use in specific populations are also reviewed in the present article. In countries experiencing a dual epidemic of heroin use and HIV infection, such as former states of the Soviet Union and other eastern European and Asian countries, access to buprenorphine and methadone may be one potential tool for reducing the spread of HIV infection among injection drug users and for better engaging them in medical care.
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White JM, Lopatko OV. Opioid maintenance: a comparative review of pharmacological strategies. Expert Opin Pharmacother 2006; 8:1-11. [PMID: 17163802 DOI: 10.1517/14656566.8.1.1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The use of opioids outside of medical practice is a significant health problem with important social and political implications. Although treatment of opioid dependence is traditionally focused on heroin users, there is increasing recognition that a large number of people become dependent through the use of prescription opioids. The necessity for long-term treatment has also been increasingly recognised. At present, there are several pharmacotherapies available for maintenance treatment, including drugs that are full agonists at the opioid receptor (e.g., methadone, slow-release oral morphine), a partial agonist (buprenorphine) and an opioid antagonist (naltrexone). This review examines the existing strategies, highlights problems associated with their use and discusses the opportunities for new treatment approaches, particularly the use of long-acting formulations.
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Affiliation(s)
- Jason M White
- Discipline of Pharmacology, University of Adelaide, SA 5005, Australia.
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Sullivan MA, Vosburg SK, Comer SD. Depot naltrexone: antagonism of the reinforcing, subjective, and physiological effects of heroin. Psychopharmacology (Berl) 2006; 189:37-46. [PMID: 16972105 DOI: 10.1007/s00213-006-0509-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Accepted: 07/06/2006] [Indexed: 10/24/2022]
Abstract
RATIONALE Naltrexone is an opioid antagonist that is currently approved as a treatment for opioid and alcohol dependence. Although it is highly effective in completely antagonizing the effects of opioids, medication noncompliance is a difficult obstacle to treatment. Therefore, a sustained-release form of naltrexone may improve treatment outcome. OBJECTIVE The present study was designed to evaluate the time course, safety, and effectiveness of a depot formulation of naltrexone (Depotrex). MATERIALS AND METHODS Five heroin-dependent individuals participated in an 8-week inpatient study. After a 1-week detoxification period, the effects of a range of heroin doses (0, 6.25, 12.5, and 25 mg, i.v.) were examined. Participants then received 384 mg naltrexone base. The effects of heroin were again evaluated for the next 6 weeks. One dose of heroin was tested per day and the entire dose range was tested each week. Doses were administered in non-systematic order. During a morning sample session, participants received a dose of heroin and $20 and subjective, performance, and physiological effects were measured both before and after drug administration. During an afternoon choice session, participants were given the opportunity to choose the sampled heroin dose and/or amount of money using a modified progressive ratio procedure. RESULTS Depot naltrexone antagonized both the reinforcing and subjective effects of heroin for 4-5 weeks. Subjective ratings of withdrawal were reduced after week 2 and throughout the remainder of the study. The effects of heroin on mean trough pupil diameter began to emerge by week 5. There were no clinically significant effects on respiratory or cardiovascular function. CONCLUSIONS The present results extend our previous findings by showing that the reinforcing effects of heroin were reduced for 4-5 weeks after administration of 384 mg depot naltrexone.
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Affiliation(s)
- Maria A Sullivan
- Division on Substance Abuse, New York State Psychiatric Institute and Department of Psychiatry, College of Physicians and Surgeons, Columbia University, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
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Elkader A, Sproule B. Buprenorphine: clinical pharmacokinetics in the treatment of opioid dependence. Clin Pharmacokinet 2006; 44:661-80. [PMID: 15966752 DOI: 10.2165/00003088-200544070-00001] [Citation(s) in RCA: 220] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Buprenorphine is a semi-synthetic opioid derived from thebaine, a naturally occurring alkaloid of the opium poppy, Papaver somniferum. The pharmacology of buprenorphine is unique in that it is a partial agonist at the opioid mu receptor. Buprenorphine undergoes extensive first-pass metabolism and therefore has very low oral bioavailability; however, its bioavailability sublingually is extensive enough to make this a feasible route of administration for the treatment of opioid dependence. The mean time to maximum plasma concentration following sublingual administration is variable, ranging from 40 minutes to 3.5 hours. Buprenorphine has a large volume of distribution and is highly protein bound (96%). It is extensively metabolised by N-dealkylation to norbuprenorphine primarily through cytochrome P450 (CYP) 3A4. The terminal elimination half-life of buprenorphine is long and there is considerable variation in reported values (mean values ranging from 3 to 44 hours). Most of a dose of buprenorphine is eliminated in the faeces, with approximately 10-30% excreted in urine. Naloxone has been added to a sublingual formulation of buprenorphine to reduce the abuse liability of the product. The presence of naloxone does not appear to influence the pharmacokinetics of buprenorphine. Buprenorphine crosses the placenta during pregnancy and also crosses into breast milk. Buprenorphine dosage does not need to be significantly adjusted in patients with renal impairment; however, since CYP3A activity may be decreased in patients with severe chronic liver disease, it is possible that the metabolism of buprenorphine will be altered in these patients. Although there is limited evidence in the literature to date, drugs that are known to inhibit or induce CYP3A4 have the potential to diminish or enhance buprenorphine N-dealkylation. It appears that the interaction between buprenorphine and benzodiazepines is more likely to be a pharmacodynamic (additive or synergistic) than a pharmacokinetic interaction. The relationship between buprenorphine plasma concentration and response in the treatment of opioid dependence has not been well studied. The pharmacokinetic and pharmacodynamic properties of buprenorphine allow it to be a feasible option for substitution therapy in the treatment of opioid dependence.
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Affiliation(s)
- Alexander Elkader
- Centre for Addiction and Mental Health, Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
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