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Digranes N, Hoeberg E, Lervik A, Hubin A, Nordgreen J, Haga HA. Motor effects of fentanyl in isoflurane-anaesthetized pigs and the subsequent effect of ketanserin or naloxone. Vet Anaesth Analg 2024; 51:491-499. [PMID: 39142980 DOI: 10.1016/j.vaa.2024.07.002] [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: 11/15/2023] [Revised: 06/05/2024] [Accepted: 07/03/2024] [Indexed: 08/16/2024]
Abstract
OBJECTIVE To examine the effect of ketanserin and naloxone on fentanyl-induced motor activity in isoflurane-anaesthetized pigs. STUDY DESIGN Randomized, blinded, prospective two-group study. ANIMALS A group of 12 crossbred pigs weighing 22-31 kg. METHODS Fentanyl was administered to isoflurane-anaesthetized pigs at 7.5 μg kg-1 hour-1 for 40 minutes intravenously, followed by an intravenous injection of naloxone 0.1 mg kg-1 or ketanserin 1 mg kg-1. Electromyography (EMG) and accelerometry were used to record motor unit activity and tremors, respectively. To test the effect of drug administration on motor activity, data from a 5 minute period at baseline, immediately before and after antagonist injection were compared in a mixed model; p < 0.05. RESULTS Results are reported with the median difference, 95% confidence intervals and corresponding p-values in brackets. Fentanyl significantly increased EMG activity [30.51 (1.84-81.02) μV, p = 0.004] and induced tremors [0.09 (0.02-0.18) m s-2, p < 0.001] in 10 of 12 pigs. Ketanserin significantly reduced EMG [32.22 (6.29-136.80) μV, p = 0.001] and tremor [0.10 (0.03-0.15) m s-2, p = 0.007] activity. No significant effect was found for naloxone on EMG [26.76 (-13.28-91.17) μV, p = 0.4] or tremors [0.08 (-0.01-0.19) m s-2, p = 0.08]. CONCLUSIONS AND CLINICAL RELEVANCE Fentanyl can induce motor activity in anaesthetized pigs, with a suggested link to the serotonergic system. This study shows that ketanserin can antagonize this activity, which supports the role of serotonin. This knowledge contributes to the general understanding of the motor effects of fentanyl and especially the problem of tremors in anaesthetized pigs.
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Affiliation(s)
- Nora Digranes
- Department of Companion Animal Clinical Sciences, Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Ås, Norway.
| | - Emma Hoeberg
- Department of Companion Animal Clinical Sciences, Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Ås, Norway
| | | | - Aliaksandr Hubin
- Faculty of Chemistry, Biotechnology and Food Science, Norwegian University of Life Sciences, Ås, Norway
| | - Janicke Nordgreen
- Department of Paraclinical Sciences, Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Ås, Norway
| | - Henning A Haga
- Department of Companion Animal Clinical Sciences, Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Ås, Norway
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2
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Shaykin JD, Denehy ED, Martin JR, Chandler CM, Luo D, Taylor CE, Sunshine MD, Turner JR, Alilain WJ, Prisinzano TE, Bardo MT. Targeting α 1- and α 2-adrenergic receptors as a countermeasure for fentanyl-induced locomotor and ventilatory depression. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 2024; 110:104527. [PMID: 39106924 DOI: 10.1016/j.etap.2024.104527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 07/12/2024] [Accepted: 08/02/2024] [Indexed: 08/09/2024]
Abstract
This study assessed the ability of α1 and α2-adrenergic drugs to decrease fentanyl-induced locomotor and ventilatory depression. Rats were given saline or fentanyl, followed by: (1) naltrexone, (2) naloxone, (3) nalmefene, (4) α1 agonist phenylephrine, (5) α1 antagonist prazosin, (6) α1D antagonist BMY-7378, (7) α2 agonist clonidine, (8) α2 antagonist yohimbine or (9) vehicle. All µ-opioid antagonists dose-dependently reversed fentanyl-induced locomotor and ventilatory depression. While the α1 drugs did not alter the effects of fentanyl, clonidine dose-dependently decreased locomotion and respiration with and without fentanyl. Conversely, yohimbine given at a low dose (0.3-1 mg/kg) stimulated ventilation when given alone and higher doses (>1 mg/kg) partially reversed (∼50 %) fentanyl-induced ventilatory depression, but not locomotor depression. High doses of yohimbine in combination with a suboptimal dose of naltrexone reversed fentanyl-induced ventilatory depression, suggestive of additivity. Yohimbine may serve as an effective adjunctive countermeasure agent combined with naltrexone to rescue fentanyl-induced ventilatory depression.
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Affiliation(s)
- Jakob D Shaykin
- Department of Psychology, University of Kentucky, Lexington, KY, USA
| | - Emily D Denehy
- Department of Psychology, University of Kentucky, Lexington, KY, USA
| | - Jocelyn R Martin
- Department of Psychology, University of Kentucky, Lexington, KY, USA
| | - Cassie M Chandler
- Department of Psychology, University of Kentucky, Lexington, KY, USA
| | - Dan Luo
- College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Chase E Taylor
- Spinal Cord and Brain Injury Research Center (SCoBIRC) and Department of Neuroscience, University of Kentucky, Lexington, KY, USA
| | - Michael D Sunshine
- Spinal Cord and Brain Injury Research Center (SCoBIRC) and Department of Neuroscience, University of Kentucky, Lexington, KY, USA
| | - Jill R Turner
- College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Warren J Alilain
- Spinal Cord and Brain Injury Research Center (SCoBIRC) and Department of Neuroscience, University of Kentucky, Lexington, KY, USA
| | | | - Michael T Bardo
- Department of Psychology, University of Kentucky, Lexington, KY, USA.
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3
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Anand JP, Moore SC, Dixon EE, Perrien Naccarato CM, West JL, Delong LJ, Burgess E, Twarozynski JJ, Traynor JR. Structure-Activity Relationships of the Fentanyl Scaffold: Identification of Antagonists as Potential Opioid Overdose Reversal Agents. ACS Chem Neurosci 2024; 15:2830-2841. [PMID: 38994846 DOI: 10.1021/acschemneuro.4c00203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024] Open
Abstract
Opioid-related overdoses account for almost half of all drug overdose deaths in the United States and cause more preventable deaths every year than car crashes. Fentanyl, a highly potent mu opioid receptor (MOR) agonist and its analogues (fentalogues) are increasingly found in illicit drug samples, both where the primary drug of abuse is an opioid and where it is not. The prevalence of fentalogues in the illicit drug market is thought to be the primary driver of the increased number of opioid-related overdose deaths since 2016. In fact, fentanyl and its analogues are involved in more than 70% of opioid-related overdoses. The standard opioid overdose rescue therapy naloxone is often insufficient to reverse opioid overdoses caused by fentalogue agonists under current treatment paradigms. However, the pharmacology of many fentalogues is unknown. Moreover, within the fentalogue series of compounds, it is possible that antagonists could be identified that might be superior to naloxone as opioid overdose reversal agents. In this report, we explore the pharmacology of 70 fentalogues and identify compounds that behave as MOR antagonists in vitro and demonstrate with one of these reversals of fentanyl-induced respiratory depression in the mouse. Such compounds could provide leads for the development of effective agents for the reversal of opioid overdose.
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Affiliation(s)
- Jessica P Anand
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan 48109, United States
- Edward F. Domino Research Center, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Sierra C Moore
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Emma E Dixon
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan 48109, United States
| | | | - Joshua L West
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan 48109, United States
- Edward F. Domino Research Center, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Lennon J Delong
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Emily Burgess
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan 48109, United States
- Edward F. Domino Research Center, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Jack J Twarozynski
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - John R Traynor
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan 48109, United States
- Edward F. Domino Research Center, University of Michigan, Ann Arbor, Michigan 48109, United States
- Department of Medicinal Chemistry, University of Michigan, Ann Arbor, Michigan 48109, United States
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4
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Fan YZ, Duan YL, Chen CT, Wang Y, Zhu AP. Advances in attenuating opioid-induced respiratory depression: A narrative review. Medicine (Baltimore) 2024; 103:e38837. [PMID: 39029082 DOI: 10.1097/md.0000000000038837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2024] Open
Abstract
Opioids exert analgesic effects by agonizing opioid receptors and activating signaling pathways coupled to receptors such as G-protein and/or β-arrestin. Concomitant respiratory depression (RD) is a common clinical problem, and improvement of RD is usually achieved with specific antagonists such as naloxone; however, naloxone antagonizes opioid analgesia and may produce more unknown adverse effects. In recent years, researchers have used various methods to isolate opioid receptor-mediated analgesia and RD, with the aim of preserving opioid analgesia while attenuating RD. At present, the focus is mainly on the development of new opioids with weak respiratory inhibition or the use of non-opioid drugs to stimulate breathing. This review reports recent advances in novel opioid agents, such as mixed opioid receptor agonists, peripheral selective opioid receptor agonists, opioid receptor splice variant agonists, biased opioid receptor agonists, and allosteric modulators of opioid receptors, as well as in non-opioid agents, such as AMPA receptor modulators, 5-hydroxytryptamine receptor agonists, phosphodiesterase-4 inhibitors, and nicotinic acetylcholine receptor agonists.
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Affiliation(s)
- Yong-Zheng Fan
- The 991st Hospital of Joint Logistic Support Force of People's Liberation Army, Xiangyang, China
| | - Yun-Li Duan
- Xiangyang No. 4 Middle School Compulsory Education Department, Xiangyang, China
| | - Chuan-Tao Chen
- Taihe Country People's Hospital·The Taihe Hospital of Wannan Medical College, Fuyang, China
| | - Yu Wang
- The 991st Hospital of Joint Logistic Support Force of People's Liberation Army, Xiangyang, China
| | - An-Ping Zhu
- The 991st Hospital of Joint Logistic Support Force of People's Liberation Army, Xiangyang, China
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5
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Newman M, Connery H, Kannan S, Gautam A, Hammamieh R, Chakraborty N, Boyd J. Fentanyl Overdose Causes Prolonged Cardiopulmonary Dysregulation in Male SKH1 Mice. Pharmaceuticals (Basel) 2024; 17:941. [PMID: 39065791 PMCID: PMC11279777 DOI: 10.3390/ph17070941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 07/11/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
Fentanyl overdose is a survivable condition that commonly resolves without chronic overt changes in phenotype. While the acute physiological effects of fentanyl overdose, such as opioid-induced respiratory depression (OIRD) and Wooden Chest Syndrome, represent immediate risks of lethality, little is known about longer-term systemic or organ-level impacts for survivors. In this study, we investigated the effects of a single, bolus fentanyl overdose on components of the cardiopulmonary system up to one week post. SKH1 mice were administered subcutaneous fentanyl at the highest non-lethal dose (62 mg/kg), LD10 (110 mg/kg), or LD50 (135 mg/kg), before euthanasia at 40 min, 6 h, 24 h, or 7 d post-exposure. The cerebral cortex, heart, lungs, and plasma were assayed using an immune monitoring 48-plex panel. The results showed significantly dysregulated cytokine, chemokine, and growth factor concentrations compared to time-matched controls, principally in hearts, then lungs and plasma to a lesser extent, for the length of the study, with the cortex largely unaffected. Major significant analytes contributing to variance included eotaxin-1, IL-33, and betacellulin, which were generally downregulated across time. The results of this study suggest that cardiopulmonary toxicity may persist from a single fentanyl overdose and have wide implications for the endurance of the expanding population of survivors.
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Affiliation(s)
- Mackenzie Newman
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA 23298, USA;
- Department of Physiology, Pharmacology and Toxicology, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, WV 26506, USA
| | - Heather Connery
- Department of Physiology, Pharmacology and Toxicology, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, WV 26506, USA
| | - Swapna Kannan
- Walter Reed Army Institute of Research, Silver Spring, MD 20907, USA
| | - Aarti Gautam
- Walter Reed Army Institute of Research, Silver Spring, MD 20907, USA
| | - Rasha Hammamieh
- Walter Reed Army Institute of Research, Silver Spring, MD 20907, USA
| | | | - Jonathan Boyd
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA 23298, USA;
- Department of Physiology, Pharmacology and Toxicology, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, WV 26506, USA
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Cernea M, Nikonov G, Ataiants J, Ştefănuţ C, Abernethy J, Voronkov M. Nalbuphine Potentiates Reversal of Fentanyl Overdose by Naloxone. Pharmaceuticals (Basel) 2024; 17:866. [PMID: 39065717 PMCID: PMC11279547 DOI: 10.3390/ph17070866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 06/14/2024] [Accepted: 06/21/2024] [Indexed: 07/28/2024] Open
Abstract
Developing an effective antidote for fentanyl-induced overdose to achieve timely reversal is an unmet public health need. Previously, we found that naloxone derivative NX90 with mild κ-opioid agonistic properties was three-fold more effective than the parent naloxone in reversing a fentanyl overdose in rats. To investigate whether κ-agonistic properties could indeed augment the robustness of overdose reversal, we evaluated a κ-agonist/µ-antagonist nalbuphine (NB) as well as its combinations with naloxone (NX) in a fentanyl overdose model in rodents. An administration of either NB or NX as single agents at 0.1 mg/kg doses produced a full recovery in 90 ± 9.9 min and 11.4 ± 2.7 min, respectively. A higher dose of NX at 0.2 mg/kg reversed an overdose within 4.8 ± 1.0 min. In contrast to that, the coadministration of NB and NX at 0.1 mg/kg each produced a synergistic effect, with overdose reversal in 3.4 ± 0.2 min. The coadministration of NX and NB at sub-therapeutic doses of 0.05 mg/kg each was also 1.2-fold more effective than NX at 0.2 mg/kg. We further found that co-administration of NB at different doses (0.025, 0.05, 0.1 mg/kg) and ratios (1:4 and 1:1) with NX had differential effects on overdose reversal, cardiorespiratory liabilities, and analgesia.
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Affiliation(s)
- Mihai Cernea
- Department of Pharmacology, Faculty of Veterinary Medicine, University of Agricultural Sciences and Veterinary Medicine, 400372 Cluj-Napoca, Romania; (M.C.)
| | | | - Janna Ataiants
- Dornsife School of Public Health, Drexel University, Philadelphia, PA 19104, USA
| | - Cristina Ştefănuţ
- Department of Pharmacology, Faculty of Veterinary Medicine, University of Agricultural Sciences and Veterinary Medicine, 400372 Cluj-Napoca, Romania; (M.C.)
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7
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Zhao Z, Zhang J, Wang Z, Petrella F. The different doses of sufentanil combined with nalmefene in bronchoscopy: a systematic review and meta-analysis. J Thorac Dis 2024; 16:3956-3966. [PMID: 38983171 PMCID: PMC11228707 DOI: 10.21037/jtd-24-848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 06/21/2024] [Indexed: 07/11/2024]
Abstract
Background Bronchoscopy examination is a common clinical diagnostic method. However, due to its unique operational characteristics, the procedure often induces discomfort and pain in patients. The combined use of sufentanil and nalmefene offers advantages in effectively reversing opioid-induced respiratory depression without compromising analgesic effects. However, a comprehensive analysis report on the combined use of different doses of sufentanil and nalmefene in bronchoscopy examinations has not been reported. The aim of this subject is to investigate the application effects of different doses of sufentanil combined with nalmefene in bronchoscopy. Methods Using computer-based and manual methods to retrieve relevant keywords, we searched the databases of PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang from inception to the present to find studies evaluating the application effects of different doses of sufentanil combined with nalmefene in bronchoscopy examinations. The quality of the included studies was assessed, and meta-analysis was conducted using RevMan 5.3 software. Results A total of six English-language articles, involving randomized controlled trials and reviews, and comprising 774 participants, were finally included. The control group used conventional therapy, whereas the intervention group used different doses of sufentanil combined with nalmefene. Meta-analysis results indicated that compared to conventional therapy, this approach significantly improved vital signs such as systolic blood pressure [SBP; mean difference (MD) =21.44, P<1×10-5] and diastolic blood pressure (DBP; MD =22.52, P<1×10-5), heart rate (HR; MD =25.16, P<1×10-5), and oxygen saturation (SpO2; MD =30.16, P<1×10-5). A total of 4 studies focused on sedative effects, and that of sufentanil combined with nalmefene was significantly superior to conventional therapy (P<1×10-5). Analysis of adverse events showed that the combined therapy had better outcomes in terms of hypertension and tachycardia incidence compared to the control group (P<0.001, P<1×10-5), and Riker sedation-agitation scale (SAS score) was significantly reduced (P<0.05). However, there were no significant differences in other adverse events (P>0.05). Subgroup analysis showed fewer adverse reactions at 0.4 µg/kg sufentanil concentration compared to 0.2 and 0.8 µg/kg, with only hypertension differing significantly. Conclusions In clinical practice, considering the use of sufentanil combined with nalmefene can improve patients' experience during bronchoscopy examinations. However, it should be noted that this approach may not be suitable for all patients, and clinicians need to choose appropriate analgesic and sedative methods for bronchoscopy examinations based on patients' conditions and individual differences. Furthermore, it is important to recognize that this study has some limitations and further research is needed to evaluate the efficacy and safety of this approach in other types of endoscopic examinations, as well as to compare the effects and safety of different drug combinations.
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Affiliation(s)
- Zhanqi Zhao
- Department of Anaesthesiology, the Third Affiliated Hospital of Qiqihar Medical University, Qiqihar, China
| | - Junting Zhang
- Department of Anaesthesiology, the Third Affiliated Hospital of Qiqihar Medical University, Qiqihar, China
| | - Zhongqun Wang
- Department of Anaesthesiology, the Third Affiliated Hospital of Qiqihar Medical University, Qiqihar, China
| | - Francesco Petrella
- Department of Thoracic Surgery, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
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Vu LY, Luo D, Johnson K, Denehy ED, Songrady JC, Martin J, Trivedi R, Alsum AR, Shaykin JD, Chaudhary CL, Woloshin EJ, Kornberger L, Bhuiyan N, Parkin S, Jiang Q, Che T, Alilain W, Turner JR, Bardo MT, Prisinzano TE. Searching for Synthetic Opioid Rescue Agents: Identification of a Potent Opioid Agonist with Reduced Respiratory Depression. J Med Chem 2024; 67:9173-9193. [PMID: 38810170 DOI: 10.1021/acs.jmedchem.4c00333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
While in the process of designing more effective synthetic opioid rescue agents, we serendipitously identified a new chemotype of potent synthetic opioid. Here, we report that conformational constraint of a piperazine ring converts a mu opioid receptor (MOR) antagonist into a potent MOR agonist. The prototype of the series, which we have termed atoxifent (2), possesses potent in vitro agonist activity. In mice, atoxifent displayed long-lasting antinociception that was reversible with naltrexone. Repeated dosing of atoxifent produced antinociceptive tolerance and a level of withdrawal like that of fentanyl. In rats, while atoxifent produced complete loss of locomotor activity like fentanyl, it failed to produce deep respiratory depression associated with fentanyl-induced lethality. Assessment of brain biodistribution demonstrated ample distribution of atoxifent into the brain with a Tmax of approximately 0.25 h. These results indicate enhanced safety for atoxifent-like molecules compared to fentanyl.
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Affiliation(s)
- Loan Y Vu
- Department of Pharmaceutical Sciences, University of Kentucky, Lexington, Kentucky 40506, United States
| | - Dan Luo
- Department of Pharmaceutical Sciences, University of Kentucky, Lexington, Kentucky 40506, United States
- Center for Pharmaceutical Research and Innovation, College of Pharmacy, University of Kentucky, Lexington, Kentucky 40506, United States
| | - Kai Johnson
- Department of Pharmaceutical Sciences, University of Kentucky, Lexington, Kentucky 40506, United States
| | - Emily D Denehy
- Department of Psychology, University of Kentucky, Lexington, Kentucky 40536, United States
| | - Judy C Songrady
- Department of Pharmaceutical Sciences, University of Kentucky, Lexington, Kentucky 40506, United States
| | - Jocelyn Martin
- Department of Psychology, University of Kentucky, Lexington, Kentucky 40536, United States
| | - Riya Trivedi
- Department of Pharmaceutical Sciences, University of Kentucky, Lexington, Kentucky 40506, United States
| | - Alexia R Alsum
- Department of Pharmaceutical Sciences, University of Kentucky, Lexington, Kentucky 40506, United States
| | - Jakob D Shaykin
- Department of Psychology, University of Kentucky, Lexington, Kentucky 40536, United States
| | - Chhabi Lal Chaudhary
- Department of Pharmaceutical Sciences, University of Kentucky, Lexington, Kentucky 40506, United States
- Center for Pharmaceutical Research and Innovation, College of Pharmacy, University of Kentucky, Lexington, Kentucky 40506, United States
| | - Eric J Woloshin
- Department of Pharmaceutical Sciences, University of Kentucky, Lexington, Kentucky 40506, United States
| | - Lindsay Kornberger
- Department of Pharmaceutical Sciences, University of Kentucky, Lexington, Kentucky 40506, United States
| | - Nazmul Bhuiyan
- Department of Pharmaceutical Sciences, University of Kentucky, Lexington, Kentucky 40506, United States
- Center for Pharmaceutical Research and Innovation, College of Pharmacy, University of Kentucky, Lexington, Kentucky 40506, United States
| | - Sean Parkin
- Department of Chemistry, University of Kentucky, Lexington, Kentucky 40506, United States
| | - Qianru Jiang
- Center for Clinical Pharmacology, University of Health Sciences and Pharmacy and Washington University School of Medicine, St. Louis, Missouri 63110, United States
| | - Tao Che
- Center for Clinical Pharmacology, University of Health Sciences and Pharmacy and Washington University School of Medicine, St. Louis, Missouri 63110, United States
| | - Warren Alilain
- Spinal Cord and Brain Injury Research Center (SCoBIRC), College of Medicine, University of Kentucky, Lexington, Kentucky 40536, United States
- Department of Neuroscience, University of Kentucky, Lexington, Kentucky 40536, United States
| | - Jill R Turner
- Department of Pharmaceutical Sciences, University of Kentucky, Lexington, Kentucky 40506, United States
| | - Michael T Bardo
- Department of Psychology, University of Kentucky, Lexington, Kentucky 40536, United States
| | - Thomas E Prisinzano
- Department of Pharmaceutical Sciences, University of Kentucky, Lexington, Kentucky 40506, United States
- Center for Pharmaceutical Research and Innovation, College of Pharmacy, University of Kentucky, Lexington, Kentucky 40506, United States
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9
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Baird A, White SA, Das R, Tatum N, Bisgaard EK. Whole body physiology model to simulate respiratory depression of fentanyl and associated naloxone reversal. COMMUNICATIONS MEDICINE 2024; 4:114. [PMID: 38866911 PMCID: PMC11169242 DOI: 10.1038/s43856-024-00536-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 05/31/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND Opioid use in the United States and abroad is an endemic part of society with yearly increases in overdose rates and deaths. In response, the use of the safe and effective reversal agent, naloxone, is being fielded and used by emergency medical technicians at a greater rate. There is evidence that repeated dosing of a naloxone nasal spray is becoming more common. Despite this we lack repeated dosing guidelines as a function of the amount of opiate the patient has taken. METHODS To measure repeat dosing guidelines, we construct a whole-body model of the pharmacokinetics and dynamics of an opiate, fentanyl on respiratory depression. We then construct a model of nasal deposition and administration of naloxone to investigate repeat dosing requirements for large overdose scenarios. We run a single patient through multiple goal directed resuscitation protocols and measure total naloxone administered. RESULTS Here we show that naloxone is highly effective at reversing the respiratory symptoms of the patient and recommend dosing requirements as a function of the fentanyl amount administered. We show that for increasing doses of fentanyl, naloxone requirements also increase. The rescue dose displays a nonlinear response to the initial opioid dose. This nonlinear response is largely logistic with three distinct phases: onset, rapid acceleration, and a plateau period for doses above 1.2 mg. CONCLUSIONS This paper investigates the total naloxone dose needed to properly reverse respiratory depression associated with fentanyl overdose. We show that the current guidelines for a rescue dose may be much lower than required.
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Affiliation(s)
- Austin Baird
- University of Washington Department of Surgery, Division of Healthcare Simulation Sciences, Seattle, WA, USA.
| | - Steven A White
- Applied Research Associated Southeast Division, Raleigh, NC, USA
| | - Rishi Das
- Applied Research Associated Southeast Division, Raleigh, NC, USA
| | - Nathan Tatum
- Applied Research Associated Southeast Division, Raleigh, NC, USA
| | - Erika K Bisgaard
- University of Washington Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, Seattle, WA, USA
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10
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Moreira TS, Burgraff NJ, Shimoda LA, Takakura AC, Ramirez JM. Cross-journal Call for Papers on "Opioids and Respiratory Depression". Am J Physiol Lung Cell Mol Physiol 2024; 326:L808-L811. [PMID: 38771125 DOI: 10.1152/ajplung.00148.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 05/08/2024] [Indexed: 05/22/2024] Open
Affiliation(s)
- Thiago S Moreira
- Department of Physiology and Biophysics, Instituto de Ciencias Biomedicas, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Nicholas J Burgraff
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington, United States
| | - Larissa A Shimoda
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Ana C Takakura
- Department of Pharmacology, Instituto de Ciencias Biomedicas, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Jan-Marino Ramirez
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington, United States
- Department of Neurological Surgery, University of Washington, Seattle, Washington, United States
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Lile JA, Shellenberg TP, Babalonis S, Hatton KW, Hays LR, Rayapati AO, Stoops WW, Wesley MJ. A dose-ranging study of the physiological and self-reported effects of repeated, rapid infusion of remifentanil in people with opioid use disorder and physical dependence on fentanyl. Psychopharmacology (Berl) 2024; 241:1227-1236. [PMID: 38383903 DOI: 10.1007/s00213-024-06557-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 02/16/2024] [Indexed: 02/23/2024]
Abstract
RATIONALE Understanding mechanisms of drug use decisions will inform the development of treatments for opioid use disorder (OUD). Decision-making experiments using neurobehavioral approaches require many trials or events of interest for statistical analysis, but the pharmacokinetics of most opioids limit dosing in humans. OBJECTIVES This experiment characterized the effects of repeated infusions of the ultra-short acting opioid remifentanil in people with OUD and physical opioid dependence. METHODS An inpatient study using a within-subjects, single-blind, escalating, within-session, pre-post design was conducted. Seven (3 female) subjects were maintained on oral oxycodone (40-60 mg, 4x/day = 160-240 total mg/day) for seven days prior to the dose-ranging session. Subjects received infusions of three ascending remifentanil doses (0.03, 0.1, 0.3 mcg/kg/infusion in 2 subjects; 0.1, 0.3, 1.0 mcg/kg/infusion in 5 subjects) every minute for 40 min per dose, with infusions administered over 5 s to model naturalistic delivery rates. End tidal carbon dioxide, respiration rate, oxygen saturation (SpO2) and heart rate were measured continuously. Blood pressure (BP), pupil diameter and self-reported drug effects were measured every 5 min. RESULTS Pupil diameter, SpO2 and systolic BP decreased, and ratings on prototypic subjective effects questionnaire items increased, as a function of remifentanil dose. The number of infusions held because of sedation or physiological parameters exceeding predetermined cutoffs also increased with dose. CONCLUSIONS This experiment established doses and procedures for the safe delivery of rapid, repeated remifentanil infusions to individuals with OUD and physical fentanyl dependence, which can be applied to the mechanistic study of opioid use decisions.
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Affiliation(s)
- Joshua A Lile
- Department of Behavioral Science, University of Kentucky College of Medicine, Medical Behavioral Science Building, 1100 Veterans Dr., Lexington, KY, 40536, USA.
- Department of Psychology, University of Kentucky College of Arts and Sciences, Kastle Hall, Lexington, KY, 40506, USA.
- Department of Psychiatry, University of Kentucky College of Medicine, 245 Fountain Court, Lexington, KY, 40509, USA.
| | - Thomas P Shellenberg
- Department of Psychology, University of Kentucky College of Arts and Sciences, Kastle Hall, Lexington, KY, 40506, USA
| | - Shanna Babalonis
- Department of Behavioral Science, University of Kentucky College of Medicine, Medical Behavioral Science Building, 1100 Veterans Dr., Lexington, KY, 40536, USA
| | - Kevin W Hatton
- Department of Anesthesiology, University of Kentucky College of Medicine, Chandler Medical Center, 800 Rose St, Lexington, KY, 40536, USA
- Department of Surgery, University of Kentucky College of Medicine, Chandler Medical Center, 800 Rose St, Lexington, KY, 40536, USA
| | - Lon R Hays
- Department of Psychiatry, University of Kentucky College of Medicine, 245 Fountain Court, Lexington, KY, 40509, USA
- Department of Internal Medicine, College of Medicine, University of Kentucky, University Health Service, 830 South Limestone, Lexington, KY, 40536, USA
| | - Abner O Rayapati
- Department of Psychiatry, University of Kentucky College of Medicine, 245 Fountain Court, Lexington, KY, 40509, USA
| | - William W Stoops
- Department of Behavioral Science, University of Kentucky College of Medicine, Medical Behavioral Science Building, 1100 Veterans Dr., Lexington, KY, 40536, USA
- Department of Psychology, University of Kentucky College of Arts and Sciences, Kastle Hall, Lexington, KY, 40506, USA
- Department of Psychiatry, University of Kentucky College of Medicine, 245 Fountain Court, Lexington, KY, 40509, USA
| | - Michael J Wesley
- Department of Behavioral Science, University of Kentucky College of Medicine, Medical Behavioral Science Building, 1100 Veterans Dr., Lexington, KY, 40536, USA
- Department of Psychology, University of Kentucky College of Arts and Sciences, Kastle Hall, Lexington, KY, 40506, USA
- Department of Psychiatry, University of Kentucky College of Medicine, 245 Fountain Court, Lexington, KY, 40509, USA
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12
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Lemen PM, Garrett DP, Thompson E, Aho M, Vasquez C, Park JN. High-dose naloxone formulations are not as essential as we thought. Harm Reduct J 2024; 21:93. [PMID: 38741224 PMCID: PMC11089786 DOI: 10.1186/s12954-024-00994-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 03/31/2024] [Indexed: 05/16/2024] Open
Abstract
Naloxone is an effective FDA-approved opioid antagonist for reversing opioid overdoses. Naloxone is available to the public and can be administered through intramuscular (IM), intravenous (IV), and intranasal spray (IN) routes. Our literature review investigates the adequacy of two doses of standard IM or IN naloxone in reversing fentanyl overdoses compared to newer high-dose naloxone formulations. Moreover, our initiative incorporates the experiences of people who use drugs, enabling a more practical and contextually-grounded analysis. The evidence indicates that the vast majority of fentanyl overdoses can be successfully reversed using two standard IM or IN dosages. Exceptions include cases of carfentanil overdose, which necessitates ≥ 3 doses for reversal. Multiple studies documented the risk of precipitated withdrawal using ≥ 2 doses of naloxone, notably including the possibility of recurring overdose symptoms after resuscitation, contingent upon the half-life of the specific opioid involved. We recommend distributing multiple doses of standard IM or IN naloxone to bystanders and educating individuals on the adequacy of two doses in reversing fentanyl overdoses. Individuals should continue administration until the recipient is revived, ensuring appropriate intervals between each dose along with rescue breaths, and calling emergency medical services if the individual is unresponsive after two doses. We do not recommend high-dose naloxone formulations as a substitute for four doses of IM or IN naloxone due to the higher cost, risk of precipitated withdrawal, and limited evidence compared to standard doses. Future research must take into consideration lived and living experience, scientific evidence, conflicts of interest, and the bodily autonomy of people who use drugs.
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Affiliation(s)
- Paige M Lemen
- Tennessee Harm Reduction, 1989 Madison Avenue, 7, Memphis, TN, 38104, USA.
- University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Daniel P Garrett
- Tennessee Harm Reduction, 1989 Madison Avenue, 7, Memphis, TN, 38104, USA
| | - Erin Thompson
- Harm Reduction Innovation Lab, Rhode Island Hospital, Providence, RI, USA
| | - Megan Aho
- Harm Reduction Innovation Lab, Rhode Island Hospital, Providence, RI, USA
| | - Christina Vasquez
- Harm Reduction Innovation Lab, Rhode Island Hospital, Providence, RI, USA
- The Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Ju Nyeong Park
- Harm Reduction Innovation Lab, Rhode Island Hospital, Providence, RI, USA
- The Warren Alpert Medical School, Brown University, Providence, RI, USA
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13
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Saari TI, Strang J, Dale O. Clinical Pharmacokinetics and Pharmacodynamics of Naloxone. Clin Pharmacokinet 2024; 63:397-422. [PMID: 38485851 PMCID: PMC11052794 DOI: 10.1007/s40262-024-01355-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 04/29/2024]
Abstract
Naloxone is a World Health Organization (WHO)-listed essential medicine and is the first choice for treating the respiratory depression of opioids, also by lay-people witnessing an opioid overdose. Naloxone acts by competitive displacement of opioid agonists at the μ-opioid receptor (MOR). Its effect depends on pharmacological characteristics of the opioid agonist, such as dissociation rate from the MOR receptor and constitution of the victim. Aim of treatment is a balancing act between restoration of respiration (not consciousness) and avoidance of withdrawal, achieved by titration to response after initial doses of 0.4-2 mg. Naloxone is rapidly eliminated [half-life (t1/2) 60-120 min] due to high clearance. Metabolites are inactive. Major routes for administration are intravenous, intramuscular, and intranasal, the latter primarily for take-home naloxone. Nasal bioavailability is about 50%. Nasal uptake [mean time to maximum concentration (Tmax) 15-30 min] is likely slower than intramuscular, as reversal of respiration lag behind intramuscular naloxone in overdose victims. The intraindividual, interindividual and between-study variability in pharmacokinetics in volunteers are large. Variability in the target population is unknown. The duration of action of 1 mg intravenous (IV) is 2 h, possibly longer by intramuscular and intranasal administration. Initial parenteral doses of 0.4-0.8 mg are usually sufficient to restore breathing after heroin overdose. Fentanyl overdoses likely require higher doses of naloxone. Controlled clinical trials are feasible in opioid overdose but are absent in cohorts with synthetic opioids. Modeling studies provide valuable insight in pharmacotherapy but cannot replace clinical trials. Laypeople should always have access to at least two dose kits for their interim intervention.
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Affiliation(s)
- Teijo I Saari
- Department of Anaesthesiology and Intensive Care, University of Turku, Turku, Finland
- Division of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland
| | - John Strang
- National Addiction Centre, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, SE5 8BB, UK
| | - Ola Dale
- Department of Circulation and Medical Imaging, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.
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14
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Newman M, Lynch C, Connery H, Goldsmith W, Nurkiewicz T, Raylman R, Boyd J. Fentanyl overdose: Temporal effects and prognostic factors in SKH1 mice. Basic Clin Pharmacol Toxicol 2024; 134:460-471. [PMID: 38284460 PMCID: PMC10939806 DOI: 10.1111/bcpt.13984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/09/2024] [Accepted: 01/12/2024] [Indexed: 01/30/2024]
Abstract
Fentanyl exposure and overdose are growing concerns in public health and occupational safety. This study aimed to establish parameters of fentanyl lethality in SKH1 mice for future overdose research. Lethality was determined using the up-down procedure, with subjects monitored post-administration using pulse oximetry (5 min) and then whole-body plethysmography (40 min). Following the determination of subcutaneous dose-response, [18F]Fluorodeoxyglucose positron emission tomography (18 F-FDG PET) was performed after LD10 fentanyl at 40 min, 6 h, 24 h or 7 days post-dose. LD10 and LD50 were observed to be 110 and 135 mg/kg, respectively, and consistent with four-parameter logistic fit values of 111.2 and 134.6 mg/kg (r2 = 0.9996). Overdose (LD10 or greater) yielded three distinct cardiovascular groups: survival, non-survival with blood oxygen saturation (SpO2) minimum ≥37% and non-survival with SpO2 <37%. Breaths per minute, minute volume and inspiratory quotient were significantly different between surviving and non-surviving animals for up to 40 min post-injection. 18 F-FDG PET revealed decreased glucose uptake in the heart, lungs and brain for up to 24 h. These findings provide critical insights into fentanyl lethality in SKH1 mice, including non-invasive respiratory effects and organ-specific impacts that are invaluable for future translational studies investigating the temporal effects of fentanyl overdose.
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Affiliation(s)
- Mackenzie Newman
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
- Department of Orthopaedics, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Cayla Lynch
- Department of Physiology, Pharmacology and Toxicology, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Heather Connery
- Department of Physiology, Pharmacology and Toxicology, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - William Goldsmith
- Department of Physiology, Pharmacology and Toxicology, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Center for Inhalation Toxicology (iTOX), West Virginia University School of Medicine, Morgantown, WV, USA
| | - Timothy Nurkiewicz
- Department of Physiology, Pharmacology and Toxicology, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Center for Inhalation Toxicology (iTOX), West Virginia University School of Medicine, Morgantown, WV, USA
| | - Raymond Raylman
- Department of Radiology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Jonathan Boyd
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
- Department of Orthopaedics, West Virginia University School of Medicine, Morgantown, West Virginia, USA
- Department of Physiology, Pharmacology and Toxicology, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Center for Inhalation Toxicology (iTOX), West Virginia University School of Medicine, Morgantown, WV, USA
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
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15
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Watkins J, Aradi P, Hahn R, Katona I, Mackie K, Makriyannis A, Hohmann AG. CB 1 Cannabinoid Receptor Agonists Induce Acute Respiratory Depression in Awake Mice. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.03.12.584260. [PMID: 38558988 PMCID: PMC10980063 DOI: 10.1101/2024.03.12.584260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Recreational use of synthetic cannabinoid agonists (i.e., "Spice" compounds) that target the Cannabinoid Type 1 receptor (CB 1 ) can cause respiratory depression in humans. However, Δ 9 -tetrahydrocannabinol (THC), the major psychoactive phytocannabinoid in cannabis, is not traditionally thought to interact with CNS control of respiration, based largely upon sparse labeling of CB1 receptors in the medulla and few reports of clinically significant respiratory depression following cannabis overdose. The respiratory effects of CB 1 agonists have rarely been studied in vivo , suggesting that additional inquiry is required to reconcile the conflict between conventional wisdom and human data. Here we used whole body plethysmography to examine the respiratory effects of the synthetic high efficacy CB 1 agonist CP55,940, and the low efficacy CB 1 agonist Δ 9 -tetrahydrocannabinol in male and female mice. CP55,940 and THC, administered systemically, both robustly suppressed minute ventilation. Both cannabinoids also produced sizable reductions in tidal volume, decreasing both peak inspiratory and expiratory flow - measures of respiratory effort. Similarly, both drugs reduced respiratory frequency, decreasing both inspiratory and expiratory time while markedly increasing expiratory pause, and to a lesser extent, inspiratory pause. Respiratory suppressive effects occurred at lower doses in females than in males, and at many of the same doses shown to produce cardinal behavioral signs of CB 1 activation. We next used RNAscope in situ hybridization to localize CB 1 mRNA to glutamatergic neurons in the medullary pre-Bötzinger Complex, a critical nucleus in controlling respiration. Our results show that, contrary to previous conventional wisdom, CB 1 mRNA is expressed in glutamatergic neurons in a brain region essential for breathing and CB 1 agonists can cause significant respiratory depression.
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16
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Feasel MG, Moran TS, Cheng BC, Averick S. Are carfentanil and acrylfentanyl naloxone resistant? Front Psychiatry 2024; 15:1359851. [PMID: 38445085 PMCID: PMC10912486 DOI: 10.3389/fpsyt.2024.1359851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 01/25/2024] [Indexed: 03/07/2024] Open
Abstract
The rapid rise in deaths since 2012 due to opioid poisoning is correlated with the proliferation of potent synthetic opioid agonists such as fentanyl, acrylfentanyl, and carfentanil. The efficacy of frontline antidotes such as naloxone in reversing such poisoning events has been questioned, and the possibility of naloxone-resistant synthetic opioids has been raised. In this manuscript, we applied in vitro techniques to establish the median effective inhibitory concentrations for fentanyl, acrylfentanyl, and carfentanil and subsequently evaluate naloxone's ability to reverse agonist-receptor interactions.
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Affiliation(s)
- Michael G. Feasel
- Defense Advanced Research Projects Agency (DARPA), Biological Technologies Office (BTO), Arlington, VA, United States
| | - Theodore S. Moran
- U.S. Army DEVCOM Chemical and Biological Center, Aberdeen, MD, United States
| | - Boyle C. Cheng
- Neuroscience Institute, Allegheny Health Network, Pittsburgh, PA, United States
| | - Saadyah Averick
- Neuroscience Institute, Allegheny Health Network, Pittsburgh, PA, United States
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17
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Song D, Crouse B, Vigliaturo J, Wu MM, Heimisdottir D, Kassick AJ, Averick SE, Raleigh MD, Pravetoni M. Multivalent Vaccination Strategies Protect against Exposure to Polydrug Opioid and Stimulant Mixtures in Mice and Rats. ACS Pharmacol Transl Sci 2024; 7:363-374. [PMID: 38357285 PMCID: PMC10863445 DOI: 10.1021/acsptsci.3c00228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/19/2023] [Accepted: 12/01/2023] [Indexed: 02/16/2024]
Abstract
Illicit drug mixtures containing opioids and stimulants have been responsible for the majority of fatal drug overdoses among occasional users, and those with either opioid use disorder (OUD) or substance use disorder (SUD). As a complementary strategy to current pharmacotherapies, active immunization with conjugate vaccines has been proposed as a viable intervention to treat OUD as well as other SUD for which there are either limited or no treatment options. Vaccination against opioids and stimulants could help address the limitations of current medications (e.g., patient access, compliance, misuse liability, and safety) by providing an additional tool to prevent drug misuse and/or overdoses. However, more research is needed to fully understand the potential benefits and limitations of using vaccines to treat SUD and overdose and to inform us on how to deploy this strategy in the field. Previous reports have shown promise by combining two vaccines into bivalent vaccine formulations to concurrently target multiple drugs. Here, multiple individual candidate monovalent vaccines were incrementally combined in multivalent vaccine formulations to simultaneously target fentanyl, carfentanil, oxycodone, heroin, methamphetamine, and their analogs or metabolites. Bi-, tri-, and quadrivalent vaccine formulations induced the formation of independent serum antibody responses against their respective opioid targets and selectively attenuated the distribution of each individual drug to the brain in mice and rats. Results indicate that a single injection of an admixed multivalent vaccine formulation may be more effective than coinjecting multiple monovalent vaccines at multiple sites. Finally, adding a methamphetamine conjugate vaccine to an quadrivalent opioid vaccine in a pentavalent formulation did not interfere with the production of effective antiopioid IgG antibodies. Multivalent vaccines could provide multifaceted, yet selective, protection against polydrug use and exposure.
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Affiliation(s)
- Daihyun Song
- Department
of Pharmacology, University of Minnesota
Medical School, Minneapolis, Minnesota 55455, United States
| | - Bethany Crouse
- Department
of Pharmacology, University of Minnesota
Medical School, Minneapolis, Minnesota 55455, United States
- School
of Veterinary Population Medicine, University
of Minnesota, St. Paul, Minnesota 55455, United States
| | - Jennifer Vigliaturo
- Department
of Pharmacology, University of Minnesota
Medical School, Minneapolis, Minnesota 55455, United States
| | - Mariah M. Wu
- Department
of Pharmacology, University of Minnesota
Medical School, Minneapolis, Minnesota 55455, United States
- School
of Veterinary Population Medicine, University
of Minnesota, St. Paul, Minnesota 55455, United States
| | - Dagny Heimisdottir
- Department
of Pharmacology, University of Minnesota
Medical School, Minneapolis, Minnesota 55455, United States
| | - Andrew J. Kassick
- Neuroscience
Disruptive Research Lab, Allegheny Health
Network Research Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, United States
| | - Saadyah E. Averick
- Neuroscience
Disruptive Research Lab, Allegheny Health
Network Research Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, United States
- Neuroscience
Institute, Allegheny Health Network, Allegheny
General Hospital, Pittsburgh, Pennsylvania 15212, United States
| | - Michael D. Raleigh
- Department
of Pharmacology, University of Minnesota
Medical School, Minneapolis, Minnesota 55455, United States
| | - Marco Pravetoni
- Department
of Pharmacology, University of Minnesota
Medical School, Minneapolis, Minnesota 55455, United States
- Department
of Psychiatry and Behavioral Sciences, University
of Washington School of Medicine, Seattle, Washington 98195, United States
- University
of Washington Center for Medication Development for Substance Use
Disorders; Garvey Institute for Brain Solutions, Seattle,Washington 98195, United States
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18
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Tipping AD, Nowels M, Moore C, Samples H, Crystal S, Olfson M, Williams AR, Heaps-Woodruff J. Association of medications for opioid use disorder with reduced risk of repeat opioid overdose in Medicaid: A cohort study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 157:209218. [PMID: 37984564 PMCID: PMC10922317 DOI: 10.1016/j.josat.2023.209218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 06/03/2023] [Accepted: 11/13/2023] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Following a nonfatal opioid overdose, patients are at high risk for repeat overdose. The objective of this study was to examine the association of MOUD after nonfatal opioid overdose with risk of repeat overdose in the following year. METHODS This retrospective cohort study analyzed Missouri Medicaid claims from July 2012 to December 2021. The study identified opioid overdoses occurring between 2013 and 2020 using diagnosis codes for opioid poisoning in an inpatient or emergency department setting. The study implemented Cox models with a time-varying covariate for post-overdose receipt of MOUD. RESULTS During the study period, MOUD receipt after overdose more than tripled, from 4.8 % to 18.9 %. Overall, only 12.1 % of patients received MOUD in the year after index. MOUD during follow-up was associated with significantly lower risk of repeat overdose (HR = 0.34, 95 % CI = 0.14-0.82). Out of 3017 individuals meeting inclusion criteria, 13.6 % had a repeat opioid overdose within 1 year. Repeat overdose risk was higher for those whose index overdose involved heroin or synthetic opioids (HR = 1.71, 95 % CI = 1.35-2.15), but MOUD was associated with significantly reduced risk in this group (HR = 0.34, 95 % CI = 0.13-0.92). CONCLUSIONS MOUD receipt was associated with reduced risk of repeat overdose. Those whose index overdoses involved heroin or synthetic opioids were at greater risk of repeat overdose, but MOUD was associated with reduced risk in this group.
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Affiliation(s)
- Andrew D Tipping
- Missouri Institute of Mental Health, University of Missouri - St. Louis, 1 University Blvd, St. Louis, MO 63121, USA.
| | - Molly Nowels
- Center for Health Services Research, Institute for Health, Rutgers University, 112 Paterson Street, New Brunswick, NJ 08901, USA.
| | - Clara Moore
- Missouri Institute of Mental Health, University of Missouri - St. Louis, 1 University Blvd, St. Louis, MO 63121, USA.
| | - Hillary Samples
- Center for Health Services Research, Institute for Health, Rutgers University, 112 Paterson Street, New Brunswick, NJ 08901, USA.
| | - Stephen Crystal
- Center for Health Services Research, Institute for Health, Rutgers University, 112 Paterson Street, New Brunswick, NJ 08901, USA; School of Social Work, Rutgers University, 536 George Street, New Brunswick, NJ 08901, USA.
| | - Mark Olfson
- Vagelos College of Physicians and Surgeons, 630 W 168th St, Columbia University, New York, NY 10032, USA; Mailman School of Public Health, Columbia University, 722 W 168th St., New York, NY 10032, USA.
| | - Arthur Robinson Williams
- Department of Psychiatry, New York State Psychiatric Institute, Columbia University Medical Center, 1051 Riverside Dr., New York, NY 10032, USA.
| | - Jodi Heaps-Woodruff
- Missouri Institute of Mental Health, University of Missouri - St. Louis, 1 University Blvd, St. Louis, MO 63121, USA.
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19
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Rademeyer KM, R Nass S, Jones AM, Ohene-Nyako M, Hauser KF, McRae M. Fentanyl dysregulates neuroinflammation and disrupts blood-brain barrier integrity in HIV-1 Tat transgenic mice. J Neurovirol 2024; 30:1-21. [PMID: 38280928 PMCID: PMC11232468 DOI: 10.1007/s13365-023-01186-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 10/29/2023] [Accepted: 11/16/2023] [Indexed: 01/29/2024]
Abstract
Opioid overdose deaths have dramatically increased by 781% from 1999 to 2021. In the setting of HIV, opioid drug abuse exacerbates neurotoxic effects of HIV in the brain, as opioids enhance viral replication, promote neuronal dysfunction and injury, and dysregulate an already compromised inflammatory response. Despite the rise in fentanyl abuse and the close association between opioid abuse and HIV infection, the interactive comorbidity between fentanyl abuse and HIV has yet to be examined in vivo. The HIV-1 Tat-transgenic mouse model was used to understand the interactive effects between fentanyl and HIV. Tat is an essential protein produced during HIV that drives the transcription of new virions and exerts neurotoxic effects within the brain. The Tat-transgenic mouse model uses a glial fibrillary acidic protein (GFAP)-driven tetracycline promoter which limits Tat production to the brain and this model is well used for examining mechanisms related to neuroHIV. After 7 days of fentanyl exposure, brains were harvested. Tight junction proteins, the vascular cell adhesion molecule, and platelet-derived growth factor receptor-β were measured to examine the integrity of the blood brain barrier. The immune response was assessed using a mouse-specific multiplex chemokine assay. For the first time in vivo, we demonstrate that fentanyl by itself can severely disrupt the blood-brain barrier and dysregulate the immune response. In addition, we reveal associations between inflammatory markers and tight junction proteins at the blood-brain barrier.
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Affiliation(s)
- Kara M Rademeyer
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, 23298, U.S.A
| | - Sara R Nass
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, Richmond, VA, U.S.A
| | - Austin M Jones
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, 23298, U.S.A
| | - Michael Ohene-Nyako
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, Richmond, VA, U.S.A
| | - Kurt F Hauser
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, Richmond, VA, U.S.A
| | - MaryPeace McRae
- Department of Neuroscience, School of Medicine, University of Virginia, Charlottesville, VA, 22908, U.S.A..
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20
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Li M, Pagare PP, Ma H, St Onge CM, Mendez RE, Gillespie JC, Stevens DL, Dewey WL, Selley DE, Zhang Y. Molecular Pharmacology Profiling of Phenylfentanil and Its Analogues to Understand the Putative Involvement of an Adrenergic Mechanism in Fentanyl-Induced Respiratory Depression. J Med Chem 2024; 67:603-619. [PMID: 38156970 DOI: 10.1021/acs.jmedchem.3c01801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
While there are approved therapeutics to treat opioid overdoses, the need for treatments to reverse overdoses due to ultrapotent fentanyls remains unmet. This may be due in part to an adrenergic mechanism of fentanyls in addition to their stereotypical mu-opioid receptor (MOR) effects. Herein, we report our efforts to further understanding of the functions these distinct mechanisms impart. Employing the known MOR neutral antagonist phenylfentanil as a lead, 17 analogues were designed based on the concept of isosteric replacement. To probe mechanisms of action, these analogues were pharmacologically evaluated in vitro and in vivo, while in silico modeling studies were also conducted on phenylfentanil. While it did not indicate MOR involvement in vivo, phenylfentanil yielded respiratory minute volumes similar to those caused by fentanyl. Taken together with molecular modeling studies, these results indicated that respiratory effects of fentanyls may also correlate to inhibition of both α1A- and α1B-adrenergic receptors.
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Affiliation(s)
- Mengchu Li
- Department of Medicinal Chemistry, School of Pharmacy, Virginia Commonwealth University, 800 East Leigh Street, Richmond, Virginia 23298, United States
| | - Piyusha P Pagare
- Department of Medicinal Chemistry, School of Pharmacy, Virginia Commonwealth University, 800 East Leigh Street, Richmond, Virginia 23298, United States
| | - Hongguang Ma
- Department of Medicinal Chemistry, School of Pharmacy, Virginia Commonwealth University, 800 East Leigh Street, Richmond, Virginia 23298, United States
| | - Celsey M St Onge
- Department of Medicinal Chemistry, School of Pharmacy, Virginia Commonwealth University, 800 East Leigh Street, Richmond, Virginia 23298, United States
| | - Rolando E Mendez
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, 410 North 12th Street, Richmond, Virginia 23298, United States
| | - James C Gillespie
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, 410 North 12th Street, Richmond, Virginia 23298, United States
| | - David L Stevens
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, 410 North 12th Street, Richmond, Virginia 23298, United States
| | - William L Dewey
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, 410 North 12th Street, Richmond, Virginia 23298, United States
| | - Dana E Selley
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, 410 North 12th Street, Richmond, Virginia 23298, United States
| | - Yan Zhang
- Department of Medicinal Chemistry, School of Pharmacy, Virginia Commonwealth University, 800 East Leigh Street, Richmond, Virginia 23298, United States
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, 410 North 12th Street, Richmond, Virginia 23298, United States
- Institute for Drug and Alcohol Studies, 203 East Cary Street, Richmond, Virginia 23298, United States
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21
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Bremer PT, Burke EL, Barrett AC, Desai RI. Investigation of monoclonal antibody CSX-1004 for fentanyl overdose. Nat Commun 2023; 14:7700. [PMID: 38052779 PMCID: PMC10698161 DOI: 10.1038/s41467-023-43126-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 11/01/2023] [Indexed: 12/07/2023] Open
Abstract
The opioid crisis in the United States is primarily driven by the highly potent synthetic opioid fentanyl leading to >70,000 overdose deaths annually; thus, new therapies for fentanyl overdose are urgently needed. Here, we present the first clinic-ready, fully human monoclonal antibody CSX-1004 with picomolar affinity for fentanyl and related analogs. In mice CSX-1004 reverses fentanyl antinociception and the intractable respiratory depression caused by the ultrapotent opioid carfentanil. Moreover, toxicokinetic evaluation in a repeat-dose rat study and human tissue cross-reactivity study reveals a favorable pharmacokinetic profile of CSX-1004 with no safety-related issues. Using a highly translational non-human primate (NHP) model of respiratory depression, we demonstrate CSX-1004-mediated protection from repeated fentanyl challenges for 3-4 weeks. Furthermore, treatment with CSX-1004 produces up to a 15-fold potency reduction of fentanyl in NHP respiration, antinociception and operant responding assays without affecting non-fentanyl opioids like oxycodone. Taken together, our data establish the feasibility of CSX-1004 as a promising candidate medication for preventing and reversing fentanyl-induced overdose.
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Affiliation(s)
| | - Emily L Burke
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Behavioral Biology Program, Integrative Neurochemistry Laboratory, McLean Hospital, Belmont, MA, USA
| | | | - Rajeev I Desai
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Behavioral Biology Program, Integrative Neurochemistry Laboratory, McLean Hospital, Belmont, MA, USA
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22
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Acosta-Mares P, Violante-Soria V, Browne T, Cruz SL. Xylazine potentiates the lethal but not the rewarding effects of fentanyl in mice. Drug Alcohol Depend 2023; 253:110993. [PMID: 37883846 DOI: 10.1016/j.drugalcdep.2023.110993] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 10/12/2023] [Accepted: 10/14/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Fentanyl is commonly laced with xylazine. People who use this combination report heightened effects, but it also increases death risk. Although no medication has been approved to counteract overdoses produced by fentanyl and xylazine, naloxone is frequently used. This paper studies the preclinical rewarding and lethal effects of fentanyl combined with xylazine and the efficacy of yohimbine or naloxone to prevent death. METHODS Male Swiss Webster mice were treated with (in mg/kg, i.p.) xylazine (0.3, 1, 3, or 5.6), fentanyl (0.01, 0.3, or 0.1), or 1 xylazine plus 0.01 (non-effective) or 0.1 (effective) fentanyl doses during the conditioned-place preference (CPP) test. In addition, independent groups received (in mg/kg, i.p.): xylazine (31.6, 60, 74.2, or 100), fentanyl (3.1 or 10), or both substances at two doses: 31.6 xylazine + 3.1 fentanyl, or 60 xylazine + 10 fentanyl to analyze lethal effects. We determined whether yohimbine or naloxone (each medication tested at 10 or 30mg/kg) could prevent the lethality produced by fentanyl/xylazine combinations. Female mice were also tested in key experiments. RESULTS Xylazine neither induced CPP nor altered fentanyl's rewarding effects. In contrast, lethality was potentiated when fentanyl was combined with xylazine. Naloxone, but not yohimbine, effectively prevented the lethality of the fentanyl/xylazine combinations. CONCLUSIONS At the doses tested, xylazine does not increase the rewarding effect of fentanyl on the CPP in male mice but potentiates the risk of fatal overdose in male and female mice. A high naloxone dose prevents death induced by coadministration of fentanyl and xylazine in both sexes.
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Affiliation(s)
- Palmira Acosta-Mares
- Department of Pharmacobiology, Center for Research and Advanced Studies (Cinvestav), Mexico City, Mexico
| | - Valeria Violante-Soria
- Department of Pharmacobiology, Center for Research and Advanced Studies (Cinvestav), Mexico City, Mexico
| | - Thom Browne
- Colombo Plan Secretariat, Drug Advisory Program, Colombo, Sri Lanka
| | - Silvia L Cruz
- Department of Pharmacobiology, Center for Research and Advanced Studies (Cinvestav), Mexico City, Mexico.
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23
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Tawil M, El Marj N, Monday K, Gitto L. The Recent Rise of Eutylone Intoxications in Onondaga County and Surrounding Counties. Am J Forensic Med Pathol 2023; 44:278-284. [PMID: 37788152 DOI: 10.1097/paf.0000000000000888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
ABSTRACT Eutylone is an emerging synthetic stimulant that is quickly gaining popularity due to its affordability and wide availability. A recent surge has been observed in Upstate New York. This study presents a retrospective review of deaths in which eutylone was identified in postmortem samples from January 2018 to December 2021 in the electronic database of the Onondaga County medical examiner's office in Syracuse, NY. Of the 176 subjects who met the study criteria, 128 (73%) were male and 48 (27%) were female, with a mean age of 37.6 years. Most of the subjects were listed as White (89%), followed by African American (9%). Most of the cases had multiple medical comorbidities (89%), with anxiety and hypertension being the most common illnesses. Chromatography/mass spectrometry was used to perform a qualitative analysis of femoral blood and urine samples to detect multiple drugs, including eutylone. Substance abuse disorder was present in 135 (77%) cases, with opiates and cocaine being the most common additional drugs detected. The most common cause and manner of death were drug toxicity and accident, in 137 (78%) and 143 (81%) cases, respectively. Overall, the study suggests that eutylone is a growing concern in Upstate New York, and its use is increasing in prevalence. Policymakers and health care providers should take steps to address this emerging issue and prevent further harm to individuals and communities affected by drug overdose.
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Affiliation(s)
- Michel Tawil
- From the Department of Pathology, SUNY Upstate Medical University, Syracuse, NY
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24
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Powers N, Massena C, Crouse B, Smith M, Hicks L, Evans JT, Miller S, Pravetoni M, Burkhart D. Self-Adjuvanting TLR7/8 Agonist and Fentanyl Hapten Co-Conjugate Achieves Enhanced Protection against Fentanyl Challenge. Bioconjug Chem 2023; 34:1811-1821. [PMID: 37758302 PMCID: PMC10587865 DOI: 10.1021/acs.bioconjchem.3c00347] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/12/2023] [Indexed: 10/03/2023]
Abstract
Currently approved pharmacotherapies for opioid use disorders (OUDs) and overdose reversal agents are insufficient to slow the spread of OUDs due to the proliferation of fentanyl. This is evident in the 31% rise in drug overdose deaths from 2019 to 2022, with rates increasing from 21.6 to 28.3 overdoses per 100,000 deaths. Vaccines are a potential alternative or adjunct therapy for the treatment of several substance use disorders (nicotine, cocaine) but have shown limited clinical success due to suboptimal antibody titers. In this study, we demonstrate that coconjugation of a Toll-like receptor 7/8 (TLR7/8) agonist (UM-3006) alongside a fentanyl-based hapten (F1) on the surface of the carrier protein cross-reactive material 197 (CRM) significantly increased generation of high-affinity fentanyl-specific antibodies. This demonstrated enhanced protection against fentanyl challenges relative to an unconjugated (admix) adjuvant control in mice. Inclusion of aluminum hydroxide (alum) adjuvant further increased titers and enhanced protection, as determined by analysis of fentanyl concentration in serum and brain tissue. Collectively, our findings present a promising approach to enhance the efficacy of antiopioid vaccines, underscoring the need for extensive exploration of TLR7/8 agonist conjugates as a compelling strategy to combat opioid use disorders.
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Affiliation(s)
- Noah Powers
- Center
for Translational Medicine, Department of Biomedical and Pharmaceutical
Sciences, University of Montana, 32 Campus Drive, Skaggs Building, Missoula, Montana 59801, United States
| | - Casey Massena
- Center
for Translational Medicine, Department of Biomedical and Pharmaceutical
Sciences, University of Montana, 32 Campus Drive, Skaggs Building, Missoula, Montana 59801, United States
| | - Bethany Crouse
- Department
of Pharmacology, University of Minnesota, Minneapolis, Minnesota 55455, United States
| | - Mira Smith
- Center
for Translational Medicine, Department of Biomedical and Pharmaceutical
Sciences, University of Montana, 32 Campus Drive, Skaggs Building, Missoula, Montana 59801, United States
| | - Linda Hicks
- Center
for Translational Medicine, Department of Biomedical and Pharmaceutical
Sciences, University of Montana, 32 Campus Drive, Skaggs Building, Missoula, Montana 59801, United States
| | - Jay T. Evans
- Center
for Translational Medicine, Department of Biomedical and Pharmaceutical
Sciences, University of Montana, 32 Campus Drive, Skaggs Building, Missoula, Montana 59801, United States
| | - Shannon Miller
- Center
for Translational Medicine, Department of Biomedical and Pharmaceutical
Sciences, University of Montana, 32 Campus Drive, Skaggs Building, Missoula, Montana 59801, United States
| | - Marco Pravetoni
- Department
of Psychiatry and Behavioral Sciences, University
of Washington School of Medicine, Seattle, Washington 98195, United States
| | - David Burkhart
- Center
for Translational Medicine, Department of Biomedical and Pharmaceutical
Sciences, University of Montana, 32 Campus Drive, Skaggs Building, Missoula, Montana 59801, United States
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25
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Neumueller SE, Buiter N, Hilbert G, Grams K, Taylor R, Desalvo J, Hodges GL, Hodges MM, Pan LG, Lewis SJ, Forster HV, Hodges MR. Effects of sub-lethal doses of fentanyl on vital physiologic functions and withdrawal-like behaviors in adult goats. Front Physiol 2023; 14:1277601. [PMID: 37885800 PMCID: PMC10598602 DOI: 10.3389/fphys.2023.1277601] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023] Open
Abstract
Synthetic opioids like fentanyl have improved the standard of care for many patients in the clinical setting, but their abuse leads to tens of thousands of overdose deaths annually. The current opioid epidemic underscores a critical need for insights into the physiological effects of fentanyl on vital functions. High doses of opioids in small mammals cause opioid-induced respiratory depression (OIRD) leading to hypoventilation, hypoxemia, and hypercapnia. In addition, opioids can also increase the alveolar to arterial oxygen (A-a) gradient and airway dysfunction. However, little is known about the physiologic effects of sub-lethal doses of opioids in large mammals. Here we report the effects of a sub-lethal dose range of fentanyl (25-125 μg/kg; IV) on vital physiologic functions over 90 min (min) and withdrawal-like behaviors over the subsequent 4 h (h) in adult female goats (n = 13). Fentanyl induced decreases in breathing frequency in the first few min post-injection, but then led to a sustained increase in tidal volume, total ventilation, and blood pressure with a reduced heart rate for ≥90 min. These ventilatory changes resulted in time-dependent arterial hypocapnia and hypoxemia and an increased alveolar to arterial oxygen gradient ∼30 min post-injection indicative of impaired gas exchange in the lung. The predominant effects of fentanyl on breathing were stimulatory, underscored by an increased rate of rise of the diaphragm muscle activity and increased activation of upper airway, intercostal and abdominal muscles. Beginning 90 min post-injection we also quantified withdrawal-like behaviors over 4 h, demonstrating dose- and time-dependent increases in locomotor, biting, itching, and pawing behaviors. We conclude that fentanyl at sublethal doses induces multiple physiologic and behavior changes that emerge along different time courses suggesting multiple independent mechanisms underlying effects of opioids.
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Affiliation(s)
- Suzanne E. Neumueller
- Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Nicole Buiter
- Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Grace Hilbert
- Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Kirstyn Grams
- Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Reiauna Taylor
- Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - John Desalvo
- Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Grace L. Hodges
- Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Madeline M. Hodges
- Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Lawrence G. Pan
- Department of Physical Therapy, Marquette University, Milwaukee, WI, United States
| | - Stephen J. Lewis
- Departments of Pediatrics and Pharmacology, Case Western Reserve University, Cleveland, OH, United States
| | - Hubert V. Forster
- Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States
- Zablocki Veterans Affairs Medical Center, Milwaukee, WI, United States
| | - Matthew R. Hodges
- Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States
- Neuroscience Research Center, Medical College of Wisconsin, Milwaukee, WI, United States
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26
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Butelman ER, Huang Y, Epstein DH, Shaham Y, Goldstein RZ, Volkow ND, Alia-Klein N. Overdose mortality rates for opioids and stimulant drugs are substantially higher in men than in women: state-level analysis. Neuropsychopharmacology 2023; 48:1639-1647. [PMID: 37316576 PMCID: PMC10517130 DOI: 10.1038/s41386-023-01601-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/25/2023] [Accepted: 05/01/2023] [Indexed: 06/16/2023]
Abstract
Drug overdoses from opioids and stimulants are a major cause of mortality in the United States. It is unclear if there are stable sex differences in overdose mortality for these drugs across states, whether these differ across the lifespan, and if so, whether they can be accounted for by different levels of drug misuse. This was a state-level analysis of epidemiological data on overdose mortality, across 10-year age bins (age range: 15-74), using the CDC WONDER platform for decedents in the United States in 2020-1. The outcome measure was rate of overdose death (per 100,000) for: synthetic opioids (e.g., fentanyl), heroin, psychostimulants with potential for misuse (e.g., methamphetamine), and cocaine. Multiple linear regressions controlled for ethnic-cultural background, household net worth, and sex-specific rate of misuse (from NSDUH, 2018-9). For all these drug categories, males had greater overall overdose mortality than females, after controlling for rates of drug misuse. The mean male/female sex ratio of mortality rate was relatively stable across jurisdictions: synthetic opioids (2.5 [95% CI, 2.4-7]), heroin, (2.9 [95% CI, 2.7-3.1], psychostimulants (2.4 [95% CI, 2.3-5]), and cocaine (2.8 [95% CI, 2.6-9]). With data stratified in 10-year age bins, the sex difference generally survived adjustment (especially in the 25-64 age range). Results indicate that males are significantly more vulnerable than females to overdose deaths caused by opioid and stimulant drugs, taking into account differing state-level environmental conditions and drug misuse levels. These results call for research into diverse biological, behavioral, and social factors that underlie sex differences in human vulnerability to drug overdose.
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Affiliation(s)
- Eduardo R Butelman
- Neuropsychoimaging of Addiction and Related Conditions Research Program, Departments of Psychiatry and Neuroscience Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Yuefeng Huang
- Neuropsychoimaging of Addiction and Related Conditions Research Program, Departments of Psychiatry and Neuroscience Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Yavin Shaham
- National Institute on Drug Abuse (NIDA), Baltimore, MD, USA
| | - Rita Z Goldstein
- Neuropsychoimaging of Addiction and Related Conditions Research Program, Departments of Psychiatry and Neuroscience Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nora D Volkow
- National Institute on Drug Abuse (NIDA), Baltimore, MD, USA
| | - Nelly Alia-Klein
- Neuropsychoimaging of Addiction and Related Conditions Research Program, Departments of Psychiatry and Neuroscience Icahn School of Medicine at Mount Sinai, New York, NY, USA
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27
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Burgraff NJ, Baertsch NA, Ramirez JM. A comparative examination of morphine and fentanyl: unravelling the differential impacts on breathing and airway stability. J Physiol 2023; 601:4625-4642. [PMID: 37778015 DOI: 10.1113/jp285163] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/30/2023] [Indexed: 10/03/2023] Open
Abstract
This study provides an in-depth analysis of the distinct consequences of the opioid drugs morphine and fentanyl during opioid-induced respiratory depression (OIRD). We explored the physiological implications of both drugs on ventilation and airway patency in anaesthetized mice. Our results revealed a similar reduction in respiratory frequency with equivalent scaled dosages of fentanyl and morphine, though the onset of suppression was more rapid with fentanyl. Additionally, fentanyl resulted in transient airflow obstructions during the inspiratory cycle, which were absent following morphine administration. Notably, these fentanyl-specific obstructions were eliminated with tracheostomy, implicating the upper airways as a major factor contributing to fentanyl-induced respiratory depression. We further demonstrate that bronchodilators salbutamol and adrenaline effectively reversed these obstructions, highlighting the bronchi's contribution to fentanyl-induced airflow obstruction. Our study also uncovered a significant reduction in sighs during OIRD, which were eliminated by fentanyl and markedly reduced by morphine. Finally, we found that fentanyl-exposed mice had reduced survival under hypoxic conditions compared to mice given morphine, demonstrating that fentanyl becomes more lethal in the context of hypoxaemia. Our findings shed light on the distinct and profound impacts of these opioids on respiration and airway stability and lay the foundation for improved opioid use guidelines and more effective OIRD prevention strategies. KEY POINTS: Both morphine and fentanyl significantly suppressed respiratory frequency, but the onset of suppression was faster with fentanyl. Also, while both drugs increased tidal volume, this effect was more pronounced with fentanyl. Fentanyl administration resulted in transient obstructions during the inspiratory phase, suggesting its unique impact on airway stability. This obstruction was not observed with morphine. The fentanyl-induced obstructions were reversed by administering bronchodilators such as salbutamol and adrenaline. This suggests a possible therapeutic strategy for mitigating the adverse airway effects of fentanyl. Both drugs reduced the frequency of physiological sighs, a key mechanism to prevent alveolar collapse. However, fentanyl administration led to a complete cessation of sighs, while morphine only reduced their occurrence. Fentanyl-treated mice showed a significantly reduced ability to survive under hypoxic conditions compared to those administered morphine. This indicates that the impacts of hypoxaemia during opioid-induced respiratory depression can vary based on the opioid used.
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Affiliation(s)
- Nicholas J Burgraff
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Nathan A Baertsch
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Jan-Marino Ramirez
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
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28
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Knauss ZT, Hearn CJ, Hendryx NC, Aboalrob FS, Mueller-Figueroa Y, Damron DS, Lewis SJ, Mueller D. Fentanyl-induced reward seeking is sex and dose dependent and is prevented by D-cysteine ethylester. Front Pharmacol 2023; 14:1241578. [PMID: 37795030 PMCID: PMC10546209 DOI: 10.3389/fphar.2023.1241578] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/06/2023] [Indexed: 10/06/2023] Open
Abstract
Introduction: Despite their inclination to induce tolerance, addictive states, and respiratory depression, synthetic opioids are among the most effective clinically administered drugs to treat severe acute/chronic pain and induce surgical anesthesia. Current medical interventions for opioid-induced respiratory depression (OIRD), wooden chest syndrome, and opioid use disorder (OUD) show limited efficacy and are marked by low success in the face of highly potent synthetic opioids such as fentanyl. D-Cysteine ethylester (D-CYSee) prevents OIRD and post-treatment withdrawal in male/female rats and mice with minimal effect on analgesic status. However, the potential aversive or rewarding effects of D-CYSee have yet to be fully characterized and its efficacy could be compromised by interactions with opioid-reward pathology. Methods: Using a model of fentanyl-induced conditioned place preference (CPP), this study evaluated 1) the dose and sex dependent effects of fentanyl to induce rewarding states, and 2) the extent to which D-CYSee alters affective state and the acquisition of fentanyl-induced seeking behaviors. Results: Fentanyl reward-related effects were found to be dose and sex dependent. Male rats exhibited a range-bound dose response centered at 5 µg/kg. Female rats exhibited a CPP only at 50 µg/kg. This dose was effective in 25% of females with the remaining 75% showing no significant CPP at any dose. Pretreatment with 100 mg/kg, but not 10 mg/kg, D-CYSee prevented acquisition of fentanyl seeking in males while both doses were effective at preventing acquisition in females. Discussion: These findings suggest that D-CYSee is an effective co-treatment with prescribed opioids to reduce the development of OUD.
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Affiliation(s)
- Zackery T. Knauss
- Department of Biological Sciences, Kent State University, Kent, OH, United States
| | - Caden J. Hearn
- Department of Biological Sciences, Kent State University, Kent, OH, United States
| | - Nathan C. Hendryx
- Department of Biological Sciences, Kent State University, Kent, OH, United States
| | - Fanan S. Aboalrob
- Department of Biological Sciences, Kent State University, Kent, OH, United States
| | | | - Derek S. Damron
- Department of Biological Sciences, Kent State University, Kent, OH, United States
| | - Stephen J. Lewis
- Department of Pediatrics, Division of Pulmonology, Allergy, and Immunology, Case Western Reserve University, Cleveland, OH, United States
| | - Devin Mueller
- Department of Biological Sciences, Kent State University, Kent, OH, United States
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29
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van Lemmen M, Florian J, Li Z, van Velzen M, van Dorp E, Niesters M, Sarton E, Olofsen E, van der Schrier R, Strauss DG, Dahan A. Opioid Overdose: Limitations in Naloxone Reversal of Respiratory Depression and Prevention of Cardiac Arrest. Anesthesiology 2023; 139:342-353. [PMID: 37402248 DOI: 10.1097/aln.0000000000004622] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
Opioids are effective analgesics, but they can have harmful adverse effects, such as addiction and potentially fatal respiratory depression. Naloxone is currently the only available treatment for reversing the negative effects of opioids, including respiratory depression. However, the effectiveness of naloxone, particularly after an opioid overdose, varies depending on the pharmacokinetics and the pharmacodynamics of the opioid that was overdosed. Long-acting opioids, and those with a high affinity at the µ-opioid receptor and/or slow receptor dissociation kinetics, are particularly resistant to the effects of naloxone. In this review, the authors examine the pharmacology of naloxone and its safety and limitations in reversing opioid-induced respiratory depression under different circumstances, including its ability to prevent cardiac arrest.
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Affiliation(s)
- Maarten van Lemmen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeffrey Florian
- Division of Applied Regulatory Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Zhihua Li
- Division of Applied Regulatory Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Monique van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Eveline van Dorp
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Elise Sarton
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik Olofsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - David G Strauss
- Division of Applied Regulatory Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
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30
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Lemen PM, Garrett DP, Thompson E, Aho M, Vasquez C, Park JN. High-Dose Naloxone Formulations Are Not as Essential as We Thought. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.07.23293781. [PMID: 37645849 PMCID: PMC10462226 DOI: 10.1101/2023.08.07.23293781] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Naloxone is a U.S. Food and Drug Administration (FDA) approved opioid antagonist for reversing opioid overdoses. Naloxone is available to the public, and can be administered through intramuscular (IM), intravenous (IV), and intranasal spray (IN) routes. Our literature review aimed to improve understanding regarding the adequacy of the regularly distributed two doses of low-dose IM or IN naloxone in effectively reversing fentanyl overdoses and whether high-dose naloxone formulations (HDNF) formulations are an optimal solution to this problem. Moreover, our initiative incorporated the perspectives and experiences of people who use drugs (PWUD), enabling a more practical and contextually-grounded analysis. We began by discussing the knowledge and perspectives of Tennessee Harm Reduction, a small peer-led harm reduction organization. A comprehensive literature review was then conducted to gather relevant scholarly works on the subject matter. The evidence indicates that, although higher doses of naloxone have been administered in both clinical and community settings, the vast majority of fentanyl overdoses can be successfully reversed using standard IM dosages with the exception of carfentanil overdoses and other more potent fentanyl analogs, which necessitate three or more doses for effective reversal. Multiple studies documented the risk of precipitated withdrawal using high doses of naloxone. Notably, the possibility of recurring overdose symptoms after resuscitation exists, contingent upon the half-life of the specific opioid. Considering these findings and the current community practice of distributing multiple doses, we recommend providing at least four standard doses of IN or IM naloxone to each potential bystander, and training them to continue administration until the recipient achieves stability, ensuring appropriate intervals between each dose. Based on the evidence, we do not recommend HDNF in the place of providing four doses of standard naloxone due to the higher cost, risk of precipitated withdrawal and limited evidence compared to standard IN and IM. All results must be taken into consideration with the inclusion of the lived experiences, individual requirements, and consent of PWUD as crucial factors. It is imperative to refrain from formulating decisions concerning PWUD in their absence, as their participation and voices should be integral to the decision-making process.
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31
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Shao W, Zeng Z, Star A. An Ultrasensitive Norfentanyl Sensor Based on a Carbon Nanotube-Based Field-Effect Transistor for the Detection of Fentanyl Exposure. ACS APPLIED MATERIALS & INTERFACES 2023; 15:37784-37793. [PMID: 37523478 PMCID: PMC10416144 DOI: 10.1021/acsami.3c05958] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/14/2023] [Indexed: 08/02/2023]
Abstract
The opioid crisis is a worldwide public health crisis that has affected millions of people. In recent years, synthetic opioids, primarily illicit fentanyl, have become the primary driver of overdose deaths. There is a great need for a highly sensitive, portable, and inexpensive analytical tool that can quickly indicate the presence and relative threat of fentanyl. In this work, we develop a semiconductor enriched (sc-) single-walled carbon nanotube (SWCNT)-based field-effect transistor (FET) biosensor functionalized with norfentanyl antibodies for the sensitive detection of norfentanyl, the primary inactive metabolite of fentanyl, in urine samples. Different sensor configurations were explored in order to obtain the most optimized sensing results. Moreover, by employing the "reduced" antibody, we achieved orientated immobilization of the norfentanyl antibody and thus brought the antigen-antibody interaction closer to the sensor surface, further improving the sensitivity. The reported norfentanyl biosensors have a limit of detection in the fg/mL region in both calibration samples and synthetic urine samples, showing ultrasensitivity and high reliability.
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Affiliation(s)
- Wenting Shao
- Department
of Chemistry, University of Pittsburgh, Pittsburgh, Pennsylvania 15260, United States
| | - Zidao Zeng
- Department
of Chemistry, University of Pittsburgh, Pittsburgh, Pennsylvania 15260, United States
| | - Alexander Star
- Department
of Chemistry, University of Pittsburgh, Pittsburgh, Pennsylvania 15260, United States
- Department
of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, United States
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32
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Elder HJ, Walentiny DM, Beardsley PM. Theophylline reverses oxycodone's but not fentanyl's respiratory depression in mice while caffeine is ineffective against both opioids. Pharmacol Biochem Behav 2023; 229:173601. [PMID: 37414364 PMCID: PMC10599235 DOI: 10.1016/j.pbb.2023.173601] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 07/02/2023] [Accepted: 07/03/2023] [Indexed: 07/08/2023]
Abstract
RATIONALE The opioid epidemic remains a pressing public health crisis in the United States. Most of these overdose deaths are a result of lethal respiratory depression. In recent years the increasing incidence of opioid-involved overdose deaths has been driven by fentanyl, which is more resistant to adequate reversal by naloxone (NARCAN ®) than semi-synthetic or classical morphinan predecessors like oxycodone and heroin. For this and other reasons (e.g., precipitating withdrawal) non-opioidergic pharmacotherapies to reverse opioid-depressed respiration are needed. Methylxanthines are a class of stimulant drugs including caffeine and theophylline which exert their effects primarily via adenosine receptor antagonism. Evidence suggests methylxanthines can stimulate respiration by enhancing neural activity in respiratory nuclei in the pons and medulla independent of opioid receptors. This study aimed to determine whether caffeine and theophylline can stimulate respiration in mice when depressed by fentanyl and oxycodone. METHODS Whole-body plethysmography was used to characterize fentanyl and oxycodone's effects on respiration and their reversal by naloxone in male Swiss Webster mice. Next, caffeine and theophylline were tested for their effects on basal respiration. Finally, each methylxanthine was evaluated for its ability to reverse similar levels of respiratory depression induced by fentanyl or oxycodone. RESULTS AND CONCLUSIONS Oxycodone and fentanyl dose-dependently reduced respiratory minute volume (ml/min; MVb) that was reversible by naloxone. Caffeine and theophylline each significantly increased basal MVb. Theophylline, but not caffeine, completely reversed oxycodone-depressed respiration. In contrast, neither methylxanthine elevated fentanyl-depressed respiration at the doses tested. Despite their limited efficacy for reversing opioid-depressed respiration when administered alone, the methylxanthines safety, duration, and mechanism of action supports further evaluation in combination with naloxone to augment its reversal of opioid-depressed respiration.
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Affiliation(s)
- Harrison J Elder
- Department of Pharmacology & Toxicology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - D Matthew Walentiny
- Department of Pharmacology & Toxicology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Patrick M Beardsley
- Department of Pharmacology & Toxicology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA; Center for Biomarker Research & Precision Medicine, Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA.
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Zoorob R, Uptegrove L, Park BL. Case Report of Very-Low-Dose Fentanyl Causing Fentanyl-Induced Chest Wall Rigidity. Cureus 2023; 15:e43788. [PMID: 37731415 PMCID: PMC10508708 DOI: 10.7759/cureus.43788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2023] [Indexed: 09/22/2023] Open
Abstract
Wooden chest syndrome (WCS) is a rare phenomenon of opioid-induced skeletal muscle rigidity causing respiratory failure and inability to ventilate. The most common opioid associated with WCS is the synthetic opioid fentanyl. Fentanyl has been called the deadliest drug in America. With the use of fentanyl in critical care units and operation rooms, it is important to better understand fentanyl's side effects and predisposing factors of WCS. The symptoms of WCS are often seen in lower fentanyl doses than what would cause apnea. In this case report, we present a case of WCS with an extremely low dose of fentanyl, i.e., 50 μcg (0.49 μcg/kg), in an 80-year-old patient with a medical history significant for chronic inflammatory demyelinating polyneuropathy (CIDP) and Guillain-Barré syndrome (GBS).
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Affiliation(s)
- Ronza Zoorob
- Anesthesia, Lake Erie College of Osteopathic Medicine, Indiana, USA
| | - Logan Uptegrove
- Anesthesia, Lake Erie College of Osteopathic Medicine, Indiana, USA
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34
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Crouse B, Miller SM, Muelken P, Hicks L, Vigliaturo JR, Marker CL, Guedes AGP, Pentel PR, Evans JT, LeSage MG, Pravetoni M. A TLR7/8 agonist increases efficacy of anti-fentanyl vaccines in rodent and porcine models. NPJ Vaccines 2023; 8:107. [PMID: 37488109 PMCID: PMC10366150 DOI: 10.1038/s41541-023-00697-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/22/2023] [Indexed: 07/26/2023] Open
Abstract
Opioid use disorders (OUD) and overdose are public health threats worldwide. Widespread access to highly potent illicit synthetic opioids such as fentanyl is driving the recent rise in fatal overdoses. Vaccines containing fentanyl-based haptens conjugated to immunogenic carrier proteins offer a long-lasting, safe, and cost-effective strategy to protect individuals from overdose upon accidental or deliberate exposure to fentanyl and its analogs. Prophylactic or therapeutic active immunization with an anti-fentanyl vaccine induces the production of fentanyl-specific antibodies that bind the drug in the blood and prevent its distribution to the brain, which reduces its reinforcing effects and attenuates respiratory depression and bradycardia. To increase the efficacy of a lead anti-fentanyl vaccine, this study tested whether the incorporation of synthetic toll-like receptor (TLR) 4 and TLR7/8 agonists as vaccine adjuvants would increase vaccine efficacy against fentanyl challenge, overdose, and self-administration in either rats or Hanford miniature pigs. Formulation of the vaccine with a nucleolipid TLR7/8 agonist enhanced its immunogenicity and efficacy in preventing fentanyl-induced respiratory depression, analgesia, bradycardia, and self-administration in either rats or mini-pigs. These studies support the use of TLR7/8 adjuvants in vaccine formulations to improve their clinical efficacy against OUD and potentially other substance use disorders (SUD).
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Affiliation(s)
- Bethany Crouse
- Department of Pharmacology, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Veterinary Population Medicine, University of Minnesota, St. Paul, MN, USA
- HealthPartners Institute, Research and Evaluation Division, 8170 33rd Ave S, Bloomington, MN, 55425, USA
| | - Shannon M Miller
- Department of Biomedical and Pharmaceutical Sciences, Center for Translational Medicine, University of Montana, Missoula, MT, USA
- Inimmune Corporation, Missoula, MT, USA
| | - Peter Muelken
- Department of Medicine, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Linda Hicks
- Department of Biomedical and Pharmaceutical Sciences, Center for Translational Medicine, University of Montana, Missoula, MT, USA
| | - Jennifer R Vigliaturo
- Department of Pharmacology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Cheryl L Marker
- Department of Pharmacology, University of Minnesota Medical School, Minneapolis, MN, USA
- Luvo Bioscience, 7500W. Henrietta Road, Rush, NY, 14543, USA
| | - Alonso G P Guedes
- Department of Veterinary Clinical Sciences, University of Minnesota, St. Paul, MN, USA
| | - Paul R Pentel
- Department of Pharmacology, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Medicine, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Jay T Evans
- Department of Biomedical and Pharmaceutical Sciences, Center for Translational Medicine, University of Montana, Missoula, MT, USA
- Inimmune Corporation, Missoula, MT, USA
| | - Mark G LeSage
- Department of Pharmacology, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Medicine, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
- Department of Psychology, University of Minnesota, Minneapolis, MN, USA
| | - Marco Pravetoni
- Department of Pharmacology, University of Minnesota Medical School, Minneapolis, MN, USA.
- Center for Immunology, University of Minnesota Medical School, Minneapolis, MN, USA.
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA.
- Center for Medication Development for Substance Use Disorders, Seattle, WA, USA.
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35
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Oh YJ, Kim Y, Lee C, Kim DC, Doo A. The effects of the administration sequence and the type of hypnotics on the development of remifentanil-induced chest wall rigidity: a randomized controlled trial. BMC Anesthesiol 2023; 23:195. [PMID: 37291507 PMCID: PMC10249238 DOI: 10.1186/s12871-023-02154-5] [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: 03/10/2023] [Accepted: 05/26/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Research on remifentanil-induced chest wall rigidity is limited. Furthermore, its incidence is unknown, and the clinical factors influencing its development remain unclear. This prospective, double-blind, randomized controlled trial aimed to investigate the effects of the administration sequence of hypnotics and remifentanil as well as the type of hypnotic administered on the development of remifentanil-induced chest wall rigidity. METHODS A total of 125 older patients aged [Formula: see text] 65 years, who were scheduled to undergo elective surgery under general anesthesia, were enrolled in this study. Participants were randomly assigned to one of four groups; Thio-Remi, Pro-Remi, Remi-Thio, or Remi-Pro. After confirming the loss of consciousness and achieving a target effect-site concentration of 3 ng/mL remifentanil, the development of remifentanil-induced chest wall rigidity was evaluated. RESULTS The incidence of chest wall rigidity was significantly higher in the remifentanil-hypnotic group than in the hypnotic-remifentanil (opposite sequence) group (55.0% vs. 21.7%, P < 0.001). Logistic regression analysis revealed that remifentanil-hypnotic administration was a significant predictor of the development of chest wall rigidity (crude odds ratio 4.42, 95% confidence interval 1.99; 9.81, P < 0.001). CONCLUSIONS Pretreatment with hypnotics potentially reduces the development of chest wall rigidity during the induction of balanced anesthesia with remifentanil in older patients. TRIAL REGISTRATION This article was registered at WHO International Clinical Trials Registry Platform (Trial number: KCT0006542).
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Affiliation(s)
- Yu Jin Oh
- Department of Anesthesiology and Pain Medicine, Jeonbuk National University Medical School and Hospital, 20, Geonji-Ro, Deokjin-Gu, Jeonju, Jeollabuk-Do, 54907, South Korea
| | - Yesull Kim
- Department of Anesthesiology and Pain Medicine, Jeonbuk National University Medical School and Hospital, 20, Geonji-Ro, Deokjin-Gu, Jeonju, Jeollabuk-Do, 54907, South Korea
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
| | - Chanhong Lee
- Department of Anesthesiology and Pain Medicine, Jeonbuk National University Medical School and Hospital, 20, Geonji-Ro, Deokjin-Gu, Jeonju, Jeollabuk-Do, 54907, South Korea
| | - Dong-Chan Kim
- Department of Anesthesiology and Pain Medicine, Jeonbuk National University Medical School and Hospital, 20, Geonji-Ro, Deokjin-Gu, Jeonju, Jeollabuk-Do, 54907, South Korea
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
| | - Aram Doo
- Department of Anesthesiology and Pain Medicine, Jeonbuk National University Medical School and Hospital, 20, Geonji-Ro, Deokjin-Gu, Jeonju, Jeollabuk-Do, 54907, South Korea.
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea.
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36
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Acevedo-Canabal A, Grim TW, Schmid CL, McFague N, Stahl EL, Kennedy NM, Bannister TD, Bohn LM. Hyperactivity in Mice Induced by Opioid Agonists with Partial Intrinsic Efficacy and Biased Agonism Administered Alone and in Combination with Morphine. Biomolecules 2023; 13:935. [PMID: 37371516 DOI: 10.3390/biom13060935] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/25/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
Opioid analgesics such as morphine and fentanyl induce mu-opioid receptor (MOR)-mediated hyperactivity in mice. Herein, we show that morphine, fentanyl, SR-17018, and oliceridine have submaximal intrinsic efficacy in the mouse striatum using 35S-GTPγS binding assays. While all of the agonists act as partial agonists for stimulating G protein coupling in striatum, morphine, fentanyl, and oliceridine are fully efficacious in stimulating locomotor activity; meanwhile, the noncompetitive biased agonists SR-17018 and SR-15099 produce submaximal hyperactivity. Moreover, the combination of SR-17018 and morphine attenuates hyperactivity while antinociceptive efficacy is increased. The combination of oliceridine with morphine increases hyperactivity, which is maintained over time. These findings provide evidence that noncompetitive agonists at MOR can be used to suppress morphine-induced hyperactivity while enhancing antinociceptive efficacy; moreover, they demonstrate that intrinsic efficacy measured at the receptor level is not directly proportional to drug efficacy in the locomotor activity assay.
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Affiliation(s)
- Agnes Acevedo-Canabal
- Department of Molecular Medicine, The Herbert Wertheim UF Scripps Institute for Biomedical Innovation and Technology, Jupiter, FL 33458, USA
| | - Travis W Grim
- Department of Molecular Medicine, The Herbert Wertheim UF Scripps Institute for Biomedical Innovation and Technology, Jupiter, FL 33458, USA
| | - Cullen L Schmid
- Department of Molecular Medicine, The Herbert Wertheim UF Scripps Institute for Biomedical Innovation and Technology, Jupiter, FL 33458, USA
| | - Nina McFague
- Department of Molecular Medicine, The Herbert Wertheim UF Scripps Institute for Biomedical Innovation and Technology, Jupiter, FL 33458, USA
| | - Edward L Stahl
- Department of Molecular Medicine, The Herbert Wertheim UF Scripps Institute for Biomedical Innovation and Technology, Jupiter, FL 33458, USA
| | - Nicole M Kennedy
- Department of Molecular Medicine, The Herbert Wertheim UF Scripps Institute for Biomedical Innovation and Technology, Jupiter, FL 33458, USA
| | - Thomas D Bannister
- Department of Molecular Medicine, The Herbert Wertheim UF Scripps Institute for Biomedical Innovation and Technology, Jupiter, FL 33458, USA
| | - Laura M Bohn
- Department of Molecular Medicine, The Herbert Wertheim UF Scripps Institute for Biomedical Innovation and Technology, Jupiter, FL 33458, USA
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37
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Kelly E, Sutcliffe K, Cavallo D, Ramos-Gonzalez N, Alhosan N, Henderson G. The anomalous pharmacology of fentanyl. Br J Pharmacol 2023; 180:797-812. [PMID: 34030211 DOI: 10.1111/bph.15573] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/27/2021] [Accepted: 05/12/2021] [Indexed: 11/26/2022] Open
Abstract
Fentanyl is a key therapeutic, used in anaesthesia and pain management. It is also increasingly used illicitly and is responsible for a large and growing number of opioid overdose deaths, especially in North America. A number of factors have been suggested to contribute to fentanyl's lethality, including rapid onset of action, in vivo potency, ligand bias, induction of muscle rigidity and reduced sensitivity to reversal by naloxone. Some of these factors can be considered to represent 'anomalous' pharmacological properties of fentanyl when compared with prototypical opioid agonists such as morphine. In this review, we examine the nature of fentanyl's 'anomalous' properties, to determine whether there is really a pharmacological basis to support the existence of such properties, and also discuss whether such properties are likely to contribute to overdose deaths involving fentanyls. LINKED ARTICLES: This article is part of a themed issue on Advances in Opioid Pharmacology at the Time of the Opioid Epidemic. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v180.7/issuetoc.
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Affiliation(s)
- Eamonn Kelly
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
| | - Katy Sutcliffe
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
| | - Damiana Cavallo
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
| | | | - Norah Alhosan
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
| | - Graeme Henderson
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
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38
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Bateman JT, Saunders SE, Levitt ES. Understanding and countering opioid-induced respiratory depression. Br J Pharmacol 2023; 180:813-828. [PMID: 34089181 PMCID: PMC8997313 DOI: 10.1111/bph.15580] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 05/06/2021] [Accepted: 05/23/2021] [Indexed: 02/06/2023] Open
Abstract
Respiratory depression is the proximal cause of death in opioid overdose, yet the mechanisms underlying this potentially fatal outcome are not well understood. The goal of this review is to provide a comprehensive understanding of the pharmacological mechanisms of opioid-induced respiratory depression, which could lead to improved therapeutic options to counter opioid overdose, as well as other detrimental effects of opioids on breathing. The development of tolerance in the respiratory system is also discussed, as are differences in the degree of respiratory depression caused by various opioid agonists. Finally, potential future therapeutic agents aimed at reversing or avoiding opioid-induced respiratory depression through non-opioid receptor targets are in development and could provide certain advantages over naloxone. By providing an overview of mechanisms and effects of opioids in the respiratory network, this review will benefit future research on countering opioid-induced respiratory depression. LINKED ARTICLES: This article is part of a themed issue on Advances in Opioid Pharmacology at the Time of the Opioid Epidemic. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v180.7/issuetoc.
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Affiliation(s)
- Jordan T Bateman
- Department of Pharmacology & Therapeutics, University of Florida, Gainesville, Florida, USA
| | - Sandy E Saunders
- Department of Pharmacology & Therapeutics, University of Florida, Gainesville, Florida, USA
| | - Erica S Levitt
- Department of Pharmacology & Therapeutics, University of Florida, Gainesville, Florida, USA
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, Florida, USA
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Butelman ER, Huang Y, Epstein DH, Shaham Y, Goldstein RZ, Volkow ND, Alia-Klein N. Overdose mortality rates for opioids or stimulants are higher in males than females, controlling for rates of drug misuse: State-level data. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.01.20.23284833. [PMID: 36711659 PMCID: PMC9882660 DOI: 10.1101/2023.01.20.23284833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Importance Drug overdoses from opioids like fentanyl and heroin and stimulant drugs such as methamphetamine and cocaine are a major cause of mortality in the United States, with potential sex differences across the lifespan. Objective To determine overdose mortality for specific drug categories across the lifespan of males and females, using a nationally representative state-level sample. Design State-level analyses of nationally representative epidemiological data on overdose mortality for specific drug categories, across 10-year age bins (age range: 15-74). Setting Population-based study of Multiple Cause of Death 2020-2021 data from the Centers of Disease Control and Prevention (CDC WONDER platform). Participants Decedents in the United States in 2020-2021. Main outcome measures The main outcome measure was sex-specific rates of overdose death (per 100,000) for: synthetic opioids excluding methadone (ICD-10 code: T40.4; predominantly fentanyl), heroin (T40.1), psychostimulants with potential for misuse, excluding cocaine (T43.6, predominantly methamphetamine; labeled "psychostimulants" hereafter), and cocaine (T40.5). Multiple regression analyses were used to control for ethnic-cultural background, household net worth, and sex-specific rate of misuse of the relevant substances (from the National Survey on Drug Use and Health, 2018-2019). Results For each of the drug categories assessed, males had greater overall overdose mortality than females, after controlling for rates of drug misuse. The mean male/female sex ratio of mortality rate for the separate drug categories was relatively stable across jurisdictions: synthetic opioids (2.5 [95%CI, 2.4-2.7]), heroin, (2.9 [95%CI, 2.7-3.1], psychostimulants (2.4 [95%CI, 2.3-2.5]), and cocaine (2.8 [95%CI, 2.6-2.9]). With data stratified in 10-year age bins, the sex difference generally survived adjustment for state-level ethnic-cultural and economic variables, and for sex-specific misuse of each drug type (especially for bins in the 25-64 age range). For synthetic opioids, the sex difference survived adjustment across the lifespan (i.e., 10-year age bins ranging from 15-74), including adolescence, adulthood and late adulthood. Conclusions and Relevance The robustly greater overdose mortality in males versus females for synthetic opioids (predominantly fentanyl), heroin, and stimulant drugs including methamphetamine and cocaine indicate that males who misuse these drugs are significantly more vulnerable to overdose deaths. These results call for research into diverse biological, behavioral, and social factors that underlie sex differences in human vulnerability to drug overdose.
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Affiliation(s)
- Eduardo R Butelman
- Neuropsychoimaging of Addiction and Related Conditions Research Program, Departments of Psychiatry and Neuroscience Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yuefeng Huang
- Neuropsychoimaging of Addiction and Related Conditions Research Program, Departments of Psychiatry and Neuroscience Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Yavin Shaham
- National Institute on Drug Abuse (NIDA), Baltimore, MD
| | - Rita Z Goldstein
- Neuropsychoimaging of Addiction and Related Conditions Research Program, Departments of Psychiatry and Neuroscience Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nora D Volkow
- National Institute on Drug Abuse (NIDA), Baltimore, MD
| | - Nelly Alia-Klein
- Neuropsychoimaging of Addiction and Related Conditions Research Program, Departments of Psychiatry and Neuroscience Icahn School of Medicine at Mount Sinai, New York, NY
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40
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Chamoun K, Chevillard L, Hajj A, Callebert J, Mégarbane B. Mechanisms of Neurorespiratory Toxicity Induced by Fentanyl Analogs—Lessons from Animal Studies. Pharmaceuticals (Basel) 2023; 16:ph16030382. [PMID: 36986482 PMCID: PMC10051837 DOI: 10.3390/ph16030382] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 02/26/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
In 2020, fentanyl and its analogs contributed to ~65% of drug-attributed fatalities in the USA, with a threatening increasing trend during the last ten years. These synthetic opioids used as potent analgesics in human and veterinary medicine have been diverted to recreational aims, illegally produced and sold. Like all opioids, central nervous system depression resulting from overdose or misuse of fentanyl analogs is characterized clinically by the onset of consciousness impairment, pinpoint miosis and bradypnea. However, contrasting with what observed with most opioids, thoracic rigidity may occur rapidly with fentanyl analogs, contributing to increasing the risk of death in the absence of immediate life support. Various mechanisms have been proposed to explain this particularity associated with fentanyl analogs, including the activation of noradrenergic and glutamatergic coerulospinal neurons and dopaminergic basal ganglia neurons. Due to the high affinities to the mu-opioid receptor, the need for more elevated naloxone doses than usually required in morphine overdose to reverse the neurorespiratory depression induced by fentanyl analogs has been questioned. This review on the neurorespiratory toxicity of fentanyl and analogs highlights the need for specific research focused on these agents to better understand the involved mechanisms of toxicity and develop dedicated strategies to limit the resulting fatalities.
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Affiliation(s)
- Karam Chamoun
- Inserm, UMR-S1144, Paris Cité University, 75006 Paris, France
- Faculty of Pharmacy, Saint-Joseph University, Beirut 1100, Lebanon
- Laboratory of Pharmacology, Clinical Pharmacy, and Medicine Quality Control, Saint-Joseph University, Beirut 1100, Lebanon
| | | | - Aline Hajj
- Faculty of Pharmacy, Saint-Joseph University, Beirut 1100, Lebanon
- Laboratory of Pharmacology, Clinical Pharmacy, and Medicine Quality Control, Saint-Joseph University, Beirut 1100, Lebanon
- Research Center, Quebec University Hospital, Laval University, Québec, QC G1V 0A6, Canada
| | - Jacques Callebert
- Inserm, UMR-S1144, Paris Cité University, 75006 Paris, France
- Laboratory of Biochemistry and Molecular Biology, AP-HP, Lariboisière Hospital, 75010 Paris, France
| | - Bruno Mégarbane
- Inserm, UMR-S1144, Paris Cité University, 75006 Paris, France
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Federation of Toxicology APHP, 75010 Paris, France
- Correspondence:
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41
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Fusaroli M, Pelletti G, Giunchi V, Pugliese C, Bartolucci M, Necibi EN, Raschi E, De Ponti F, Pelotti S, Poluzzi E. Deliberate Self-Poisoning: Real-Time Characterization of Suicidal Habits and Toxidromes in the Food and Drug Administration Adverse Event Reporting System. Drug Saf 2023; 46:283-295. [PMID: 36689131 PMCID: PMC9869307 DOI: 10.1007/s40264-022-01269-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2022] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Deliberate self-poisoning (DSP) using drugs is the preferred method of suicide at a global level. Its investigation is hampered by limited sample sizes and data reliability. We investigate the role of the US FDA Adverse Event Reporting System (FAERS), a consolidated pharmacovigilance database, in outlining DSP habits and toxidromes. METHODS We retrieved cases of 'intentional overdose' and 'poisoning deliberate' from the FAERS (January 2004-December 2021). Using descriptive and disproportionality analyses, we estimated temporal trends, potential risk factors, toxidromes, case-fatality rates and lethal doses (LDs) for the most frequently reported drugs. RESULTS We retrieved 42,103 DSP cases (17% fatal). Most cases were submitted in winter. Reports of DSP involved younger people, psychiatric conditions, and alcohol use, compared with non-DSP, and fatality was higher in men and older patients. Suspected drugs were mainly antidepressants, analgesics, and antipsychotics. Multiple drug intake was recorded in more than 50% of the reports, especially analgesics, psychotropics, and cardiovascular agents. The most frequently reported drugs were paracetamol, promethazine, amlodipine, quetiapine, and metformin. We estimated LD25 for paracetamol (150 g). CONCLUSION Worldwide coverage of the FAERS complements existing knowledge about DSP and may drive tailored prevention measures to timely address the DSP phenomenon and prevent intentional suicides.
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Affiliation(s)
- Michele Fusaroli
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Guido Pelletti
- Legal Medicine Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Valentina Giunchi
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Chiara Pugliese
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Mattia Bartolucci
- Department of Statistical Sciences, University of Bologna, Bologna, Italy
| | - Elena Narmine Necibi
- School of Emergency Medicine, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Emanuel Raschi
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Fabrizio De Ponti
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Susi Pelotti
- Legal Medicine Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Elisabetta Poluzzi
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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42
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Tammen AJ, Brescia D, Jonas D, Hodges JL, Keith P. Fentanyl-Induced Rigid Chest Syndrome in Critically Ill Patients. J Intensive Care Med 2023; 38:196-201. [PMID: 35854410 DOI: 10.1177/08850666221115635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Opioid induced chest wall rigidity was first described in the early 1950s during surgical anesthesia and has often been referred to as fentanyl induced rigid chest syndrome (FIRCS). It has most commonly been described in the setting of procedural sedation and bronchoscopy, characterized by pronounced abdominal and thoracic rigidity, asynchronous ventilation, and respiratory failure. FIRCS has been infrequently described in the setting of continuous analgesia in critically ill adult patients. We postulate that FIRCS can occur in this setting and is likely under recognized, leading to increased morbidity and mortality. METHODS Patients admitted to the intensive care unit with suspected FIRCS were included in this retrospective analysis. The objective of this analysis is to describe the clinical presentation and treatment strategies for FIRCS. RESULTS Forty-two patients exhibiting symptoms of FIRCS were included in this analysis. Twenty-two of the forty-two patients with descriptive documentation had evidence of thoracic or abdominal rigidity on examination (52.4%). Twelve of sixteen (75%) patients treated solely with naloxone had documented ventilator compliance following intervention, compared to six of eleven (55%) managed with cisatracurium alone. Nine of twelve patients who ultimately received naloxone after initial treatment with cisatracurium had documented ventilator compliance following naloxone administration (75%). Standard interventions, including sedation optimization and ventilator adjustments were attempted to rule out and treat other potential causes of dyssynchrony. In most cases, the administration of naloxone resulted in appropriate compliance with both ventilator and patient-initiated breaths, suggesting the ventilator dyssynchrony was due to fentanyl. CONCLUSIONS This is the largest case series to date describing FIRCS in the intensive care setting. Recognition and prompt management is necessary for improved patient outcomes. Research is needed to increase awareness and recognition, identify patient risk factors, and analyze the efficacy and safety of interventions.
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Affiliation(s)
| | - Donald Brescia
- 427363Novant Health Presbyterian Medical Center, Charlotte, NC, USA
| | - Dan Jonas
- 427363Novant Health Presbyterian Medical Center, Charlotte, NC, USA
| | - Jeremy L Hodges
- 14358Novant Health Forsyth Medical Center, Winston-Salem, NC, USA
| | - Philip Keith
- 8511Lexington Medical Center, West Columbia, SC, USA
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43
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Elder HJ, Varshneya NB, Walentiny DM, Beardsley PM. Amphetamines modulate fentanyl-depressed respiration in a bidirectional manner. Drug Alcohol Depend 2023; 243:109740. [PMID: 36608481 PMCID: PMC9881117 DOI: 10.1016/j.drugalcdep.2022.109740] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 12/12/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The opioid epidemic remains one of the most pressing public health crises facing the United States. Fentanyl and related synthetic opioid agonists have largely driven the rising rates of associated overdose deaths, in part, because of their surreptitious use as substitutes for other opioids and as adulterants in psychostimulants. Deaths involving opioids typically result from lethal respiratory depression, and it is currently unknown how co-use of psychostimulants with opioids affects respiratory toxicity. Considering psychostimulant overdoses have increased over 3-fold since 2013, and half of those co-involved opioids, this is a cardinal question. METHODS Naloxone, d-amphetamine (AMPH), and (±)-methamphetamine (METH) were evaluated for their effects on basal and fentanyl-depressed respiration. Minute volume (MVb) was measured in awake, freely moving mice via whole-body plethysmography to quantify fentanyl-induced respiratory depression and its modulation by dose ranges of each test drug. RESULTS Naloxone immediately reversed respiratory depression induced by fentanyl only at the highest dose tested (10 mg/kg). Both AMPH and METH exhibited bidirectional effects on MVb under basal conditions, producing significant (p ≤ 0.05) depressions then elevations of respiration as dose increased. Under depressed conditions the bidirectional effects of AMPH and METH on respiration were exaggerated, exacerbating and then reversing fentanyl-induced depression as dose increased. CONCLUSIONS These results indicate that co-use of amphetamines with fentanyl may worsen respiratory depression, but conversely, monoaminergic components of the amphetamines may possibly be exploited to mitigate fentanyl overdose.
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Affiliation(s)
- Harrison J Elder
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Neil B Varshneya
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA; Center for Drug Evaluation and Research, Food and Drug Administration, United States Department of Health and Human Services, Silver Spring, MD, USA
| | - D Matthew Walentiny
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Patrick M Beardsley
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA; Center for Biomarker Research & Precision Medicine, Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA.
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44
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Baruah U, Gaur H, Saigal D, Pandey D. Wooden chest syndrome: A curious case of fentanyl induced rigidity in adults. Indian J Anaesth 2022; 66:881-882. [PMID: 36654889 PMCID: PMC9842087 DOI: 10.4103/ija.ija_171_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022] Open
Affiliation(s)
- Udismita Baruah
- Department of Anaesthesiology and Critical Care, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India
| | - Himanshu Gaur
- Department of Anaesthesiology and Critical Care, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India
| | - Deepti Saigal
- Department of Anaesthesiology and Critical Care, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India,Address for correspondence: Dr. Deepti Saigal, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India. E-mail:
| | - Dimple Pandey
- Department of Anaesthesiology and Critical Care, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India
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45
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Hicks D, Baehr C, Silva-Ortiz P, Khaimraj A, Luengas D, Hamid FA, Pravetoni M. Advancing humanized monoclonal antibody for counteracting fentanyl toxicity towards clinical development. Hum Vaccin Immunother 2022; 18:2122507. [PMID: 36194773 PMCID: PMC9746415 DOI: 10.1080/21645515.2022.2122507] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/19/2022] [Accepted: 09/04/2022] [Indexed: 12/15/2022] Open
Abstract
Innovative therapies to complement current treatments are needed to curb the growing incidence of fatal overdoses related to synthetic opioids. Murine and chimeric monoclonal antibodies (mAb) specific for fentanyl and its analogs have demonstrated pre-clinical efficacy in preventing and reversing drug-induced toxicity in rodent models. However, mAb-based therapeutics require extensive engineering as well as in vitro and in vivo characterization to advance to first-in-human clinical trials. Here, novel murine anti-fentanyl mAbs were selected for development based on affinity for fentanyl, and efficacy in counteracting the pharmacological effects of fentanyl in mice. Humanization and evaluation of mutations designed to eliminate predicted post-translational modifications resulted in two humanized mAbs that were effective at preventing fentanyl-induced pharmacological effects in rats. These humanized mAbs showed favorable biophysical properties with respect to aggregation and hydrophobicity by chromatography-based assays, and thermostability by dynamic scanning fluorimetry. These results collectively support that the humanized anti-fentanyl mAbs developed herein warrant further clinical development for treatment of fentanyl toxicity.
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Affiliation(s)
- Dustin Hicks
- Department of Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Carly Baehr
- Department of Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Pedro Silva-Ortiz
- Department of Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Aaron Khaimraj
- Department of Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Diego Luengas
- Department of Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Fatima A. Hamid
- Department of Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Marco Pravetoni
- Department of Pharmacology, University of Minnesota, Minneapolis, MN, USA
- Center for Immunology, University of Minnesota, Minneapolis, MN, USA
- School of Medicine, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
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46
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Haile CN, Baker MD, Sanchez SA, Lopez Arteaga CA, Duddupudi AL, Cuny GD, Norton EB, Kosten TR, Kosten TA. An Immunconjugate Vaccine Alters Distribution and Reduces the Antinociceptive, Behavioral and Physiological Effects of Fentanyl in Male and Female Rats. Pharmaceutics 2022; 14:2290. [PMID: 36365109 PMCID: PMC9694531 DOI: 10.3390/pharmaceutics14112290] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 09/15/2023] Open
Abstract
Fentanyl (FEN) is a potent synthetic opioid associated with increasing incidence of opioid use disorder (OUD) and fatal opioid overdose. Vaccine immunotherapy for FEN-associated disorders may be a viable therapeutic strategy. Here, we expand and confirm our previous study in mice showing immunological and antinociception efficacy of our FEN vaccine administered with the adjuvant dmLT. In this study, immunized male and female rats produced significant levels of anti-FEN antibodies that were highly effective at neutralizing FEN-induced antinociception in the tail flick assay and hot plate assays. The vaccine also decreased FEN brain levels following drug administration. Immunization blocked FEN-induced, but not morphine-induced, rate-disrupting effects on schedule-controlled responding. Vaccination prevented decreases on physiological measures (oxygen saturation, heart rate) and reduction in overall activity following FEN administration in male rats. The impact of FEN on these measures was greater in unvaccinated male rats compared to unvaccinated female rats. Cross-reactivity assays showed anti-FEN antibodies bound to FEN and sufentanil but not to morphine, methadone, buprenorphine, or oxycodone. These data support further clinical development of this vaccine to address OUD in humans.
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Affiliation(s)
- Colin N. Haile
- Department of Psychology & TIMES, University of Houston, Houston, TX 77204, USA
| | - Miah D. Baker
- Department of Psychology & TIMES, University of Houston, Houston, TX 77204, USA
| | - Sergio A. Sanchez
- Department of Psychology & TIMES, University of Houston, Houston, TX 77204, USA
| | | | - Anantha L. Duddupudi
- Department of Pharmacological & Pharmaceutical Sciences, University of Houston, Houston, TX 77204, USA
| | - Gregory D. Cuny
- Department of Pharmacological & Pharmaceutical Sciences, University of Houston, Houston, TX 77204, USA
| | - Elizabeth B. Norton
- Department of Microbiology & Immunology, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Thomas R. Kosten
- Menninger Department of Psychiatry, Baylor College of Medicine, Houston, TX 77030, USA
- The Michael E DeBakey Veteran’s Affairs Medical Center, Houston, TX 77030, USA
| | - Therese A. Kosten
- Department of Psychology & TIMES, University of Houston, Houston, TX 77204, USA
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47
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Skulberg AK, Tylleskär I, Dale O. Naloxone administration-no balance without titration. Addiction 2022; 117:2750-2751. [PMID: 35589622 DOI: 10.1111/add.15947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 05/06/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Arne Kristian Skulberg
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway.,Divison of Pre-hospital Services, Oslo Universitetssykehus, Oslo, Norway
| | - Ida Tylleskär
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Emergency Medicine and Pre-Hospital Services, St Olavs Hospital University Hospital in Trondheim, Trondheim, Norway
| | - Ola Dale
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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Acute treatment with the glucagon-like peptide-1 receptor agonist, liraglutide, reduces cue- and drug-induced fentanyl seeking in rats. Brain Res Bull 2022; 189:155-162. [PMID: 36031011 DOI: 10.1016/j.brainresbull.2022.08.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/17/2022] [Accepted: 08/24/2022] [Indexed: 12/18/2022]
Abstract
Opioid Use Disorder (OUD) is a chronic relapsing disorder that has severe negative impacts on the individual, the family, and the community at large. In 2021, opioids contributed to nearly 70% of all drug overdose deaths in the United States. This rise in opioid related deaths coincides with a significant rise in the use of fentanyl, a synthetic opioid that is 150 times more potent than morphine. Furthermore, this overdose trend has spared no demographic and costs the nation an estimated $51.2 billion annually. Thus, it is imperative to better understand the underlying mechanisms of OUD in an effort to identify new treatment targets. Using animal models, studies have shown that rats readily self-administer heroin and increase seeking following exposure to cues for drug, the drug itself, or stress. We have shown that treatment with the glucagon-like peptide-1 receptor (GLP-1R) agonist, liraglutide, can reduce heroin taking and seeking behavior in rats. Therefore, using our rodent model, we established a fentanyl self-administration paradigm to test whether acute treatment with the GLP-1R agonist also can reduce fentanyl seeking in fentanyl experienced rats. The results showed that rats readily self-administer fentanyl (2.5 ug/kg) intravenously, with marked individual differences in drug taking behavior. As with other drugs of abuse tested, rats exhibited high seeking behavior when challenged with a drug-related cue or, after a period of extinction, the drug itself. Here, acute treatment with the GLP-1R agonist, liraglutide (0.3mg/kg s.c.), was found to attenuate both cue-induced fentanyl seeking and drug-induced reinstatement of fentanyl seeking with the same efficacy as the currently approved partial opioid agonist, buprenorphine. Taken together, these data suggest that a known satiety signal, GLP-1, may serve as an effective non-opioid alternative for the treatment of OUD.
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49
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Bass SB, Kelly PJA, Pandit-Kerr S, Pilla J, Morris K, Larsen E, Wisdom JP, Torralva PR. “It's my frenemy”: A qualitative exploration of knowledge and perceptions of fentanyl use during the COVID-19 pandemic in people who use drugs at a syringe services program in Philadelphia, PA. Front Public Health 2022; 10:882421. [PMID: 35937263 PMCID: PMC9353520 DOI: 10.3389/fpubh.2022.882421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/29/2022] [Indexed: 11/13/2022] Open
Abstract
Background Exacerbated by the COVID-19 pandemic and the proliferation of fentanyl and fentanyl analogs, overdose deaths have surged in the United States, making it important to understand how individuals who use drugs experience and perceive the risks of fentanyl use and how it has changed during the COVID-19 pandemic. Methods Twenty clients from a Philadelphia syringe services program completed a questionnaire and in-depth interview about their fentanyl experiences from January to March 2021. These interviews were transcribed and analyzed using thematic analysis methods. Results Sixty percent of participants were female and racial/ethnic minority. Participants indicated they believed fentanyl use accounted for most Philadelphia opioid-related overdoses and understood that fentanyl was different from other opioids. Fentanyl use was characterized as “all-consuming” by taking over lives and inescapable. While most perceived their risk of fentanyl overdose as high, there was low interest in and reported use of harm reduction strategies such as fentanyl test strips. The COVID-19 pandemic was noted to have negative effects on fentanyl availability, use and overdose risk, as well as mental health effects that increase drug use. Conclusions The divide between perceived risk and uptake of protective strategies could be driven by diminished self-efficacy as it relates to acting on and engaging with resources available at the syringe services program and represents a potential intervention target for harm reduction intervention uptake. But the COVID-19 pandemic has exacerbated risks due to fentanyl use, making an effective, accessible, and well-timed intervention important to address the disconnect between perceived overdose risk and use of preventive behaviors.
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Affiliation(s)
- Sarah Bauerle Bass
- Department of Social and Behavioral Sciences, Temple University College of Public Health, Philadelphia, PA, United States
- Risk Communication Laboratory, Temple University College of Public Health, Philadelphia, PA, United States
- *Correspondence: Sarah Bauerle Bass
| | - Patrick J. A. Kelly
- Risk Communication Laboratory, Temple University College of Public Health, Philadelphia, PA, United States
| | | | - Jenine Pilla
- Department of Social and Behavioral Sciences, Temple University College of Public Health, Philadelphia, PA, United States
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50
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Antoniou T, Men S, Tadrous M, Leece P, Munro C, Gomes T. Impact of a publicly funded pharmacy-dispensed naloxone program on fatal opioid overdose rates: A population-based study. Drug Alcohol Depend 2022; 236:109473. [PMID: 35523113 DOI: 10.1016/j.drugalcdep.2022.109473] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Studies examining the impact of pharmacy-dispensed naloxone programs on fatal opioid overdose rates are lacking. We examined the impact of the publicly funded Ontario Naloxone Program for Pharmacies (ONPP), implemented in June 2016, on provincial rates of opioid overdose deaths. METHODS We conducted a population-based interrupted time-series study between July 1, 2012 and December 31, 2018. We considered a parsimonious model with terms for time, ONPP implementation, and time following the ONPP implementation. Models were adjusted for population characteristics, number of pharmacies and rate of naloxone distributed through non-pharmacy sites within provincial public health units. RESULTS In the parsimonious model, the ONPP was associated with a non-significant 9% reduction in the level of fatal opioid overdoses (rate ratio [RR] 0.91; 95% confidence interval [CI] 0.79-1.06), a finding that was most pronounced in regions in the lowest tertile of implementation (RR 0.75; 95% CI 0.62-0.91). Following multivariable adjustment, there was an increase in the level (RR 1.06; 95% CI 0.94-1.19) and slope change (RR 1.06; 95% CI 1.02-1.10) of fatal overdose rates. CONCLUSION The ONPP is insufficient as a single intervention to meaningfully reduce rates of fatal opioid overdoses during a period in which the cause of these deaths shifted from prescription opioids to highly potent fentanyl analogs. Access to additional harm reduction, treatment, and other interventions is necessary to prevent deaths and optimize the health of people who use drugs.
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Affiliation(s)
- Tony Antoniou
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada; Department of Family and Community Medicine, Unity Health, Toronto, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Ontario Drug Policy Research Network, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada.
| | | | - Mina Tadrous
- ICES, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Women's College Research Institute, Toronto, Ontario, Canada
| | - Pamela Leece
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Public Health Ontario, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Charlotte Munro
- Ontario Drug Policy Research Network, Toronto, Ontario, Canada
| | - Tara Gomes
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada; Ontario Drug Policy Research Network, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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