High-potency benzodiazepine misuse in opioid-dependent patients: use naloxone with care

Clinical Pharmacokinetics and Pharmacodynamics of Naloxone

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.

Opioid receptor antagonists reduce motivated wheel-running behavior in mice

We hypothesized that opioid receptor antagonists would inhibit motivated behavior produced by a natural reward. To evaluate motivated responses to a natural reward, mice were given access to running wheels for 71.5 h in a multi-configuration testing apparatus. In addition to a running wheel activity, locomotor activity (outside of the wheel), food and water intake, and access to a food container were measured in the apparatus. Mice were also tested separately for novel-object exploration to investigate whether naloxone affects behavior unrelated to natural reward. In untreated mice wheel running increased from day 1 to day 3. The selective µ-opioid receptor antagonist β-funaltrexamine (β-FNA) (5 mg/kg) slightly decreased wheel running, but did not affect the increase in wheel running from day 1 to day 3. The non-selective opioid receptor antagonist naloxone produced a greater reduction in wheel running than β-FNA and eliminated the increase in wheel running that occurred over time in the other groups. Analysis of food access, locomotor behavior, and behavior in the novel-object test suggested that the reduction in wheel running was selective for this highly reinforcing behavior. These results indicate that opioid receptor antagonism reduces responses to the natural rewarding effects of wheel running and that these effects involve multiple opioid receptors since the non-selective opioid receptor antagonist had greater effects than the selective µ-opioid receptor antagonist. It is possible that at the doses employed, other receptor systems than opioid receptors might be involved, at least in part, in the effect of naloxone and β-FNA.

Metabolic management of accidental intoxication

PURPOSE OF REVIEW

Unintentional intoxication comprises a major chunk of all intoxications. Most patients are in the pediatric age group with another set of patients being the elderly. Substances found to cause accidental intoxication vary from country to country and even within different regions of a country. Frequent reviews of current literature are needed to be abreast of trends.

RECENT FINDINGS

Prescription drugs and household chemicals are major culprits when it comes to accidental intoxication. Acetaminophen, digoxin and metformin are some of the prominent prescription drugs frequently associated with unintentional intoxications. Increasingly alcohol based hand sanitizers are becoming an important etiology of these events, following their increased usage during the COVID-19 pandemic. Pattern recognition to identify class of intoxicant and supportive care including prevention of further absorption and increased excretion are cornerstones of therapy. Antidote when available should be used promptly.

SUMMARY

Knowledge about current epidemiology of accidental intoxications, toxidrome pattern recognition and appropriate antidote usage beside adequate and timely supportive care help in successful management of the unfortunate victim of accidental intoxication.