An overview of abuse-deterrent opioids and recommendations for practical patient care

Exploration of a Novel Terpolymer Nanoparticle System for the Prevention of Alcohol-Induced Dose Dumping

Alcohol-induced dose dumping (AIDD) remains a serious challenge in the controlled delivery of high potency drugs, such as opioids, which requires extensive investigation and innovative solutions. Current technologies rely on ethanol-insoluble excipients, such as guar gum and sodium alginate, to counteract the increased solubility of hydrophobic polymeric excipients in ethanol. However, these excipients pose several shortcomings, such as high viscosity of coating dispersion, high solution temperature, rapid gelation, and heterogeneity of resulted film. In this work, we explored the application of a cross-linked terpolymer nanoparticle (TPN) as an alcohol-resistant excipient in a water-insoluble controlled release film of ethylcellulose (EC) for the prevention of AIDD. Herein, we optimized the composition of TPN using a central composite design (CCD) to minimize swelling and weight loss of TPN-EC film in the presence of 20% ethanol. The optimized TPN showed a negligible effect on the viscosity of the coating dispersion, while guar gum increased the viscosity by 76-fold. Permeability studies in a pH 1.2 media containing 0% or 40% v/v ethanol revealed that cationic drugs (propranolol HCl, diltiazem HCl, and naloxone HCl (an opioid receptor-binding model drug)) exhibited significantly lower permeability ratios (P40%/P0%) than un-ionized drugs (theophylline and salicylic acid). FTIR analysis indicated an increase in ionic hydrogen bonding between TPN and the cationic drug in the presence of ethanol. These results suggest that drug-polymer-solvent interactions play an important role in alcohol-independent drug permeability through the TPN-EC film. By leveraging the drug permeability altering capability of the TPN-EC system, the release of cationic drugs in hydroethanolic media appeared to be suppressed, suggesting a promising new mechanism of alcohol resistance.

Review of Opioid Abuse-Deterrent Formulations: Impact and Barriers to Access

The misuse and abuse of opioid analgesics continue to pose a serious public health concern, but for some patients, opioids remain an important analgesic option. Extended-release (ER) opioid formulations are effective for treating chronic pain and are supported by multiple 12-week efficacy studies. ER opioids often contain a high opioid content, and similar to immediate-release (IR) formulations, are subject to abuse, misuse, and diversion. Unintentional misuse may also occur when ER formulations are manipulated for medicinal administration, such as crushing a dose for easier oral intake. As part of a multipronged strategy designed to fight the opioid epidemic, abuse-deterrent formulations (ADFs) were developed to deter misuse, abuse, and diversion of opioids by making manipulation more difficult and nonoral routes of administration less rewarding. Although ADF opioids have been shown to decrease rates of abuse and diversion, they are not equally effective in terms of deterring manipulation for abuse or misuse. Xtampza ER utilizes DETERx technology, which allows it to retain ER characteristics when chewed or crushed, making it the only ER opioid without a boxed warning against these types of manipulation. OxyContin was also developed as an ADF but uses RESISTEC technology, making the tablet hard to crush and viscous in aqueous solutions. ADF utilization has been hampered by patient access issues, including high prices due to lack of insurance coverage. Postmarket real-world studies demonstrate lower rates of abuse, misuse, and diversion for ADF ER opioids compared with non-ADF formulations. However, similar studies comparing abuse-related effectiveness and health care costs for ADF opioids are warranted if clinicians are expected to utilize these potentially safer opioid formulations. These studies would support further education surrounding the benefits and utilization of ADFs and manipulation potential of different ADFs.

Precautions in the management of opioid agonist therapy: from target population characteristics to new formulations and post-marketing monitoring - a focus on the Italian system

Opioid use disorder (OUD) is a serious medical condition with vast social, health and economic impact. Individuals with OUD are prescribed opioid agonist therapies, such as methadone, levomethadone, buprenorphine or naloxone/buprenorphine, to reduce the risks associated with illegal substance abuse, eventually leading to opioid use abstinence. The OUD population has peculiar frailties, mainly related to the psychiatric sphere, which may jeopardize their therapeutic course. Amongst the possible phenomena that may contribute to treatment failure, opioid agonist therapy misuse and diversion are of utmost importance, leading to serious repercussions for patients as well as for national health systems. To minimize the consequences related to these practices, it is necessary to implement cross-cutting precautions, from the formulation of abuse-deterrent drugs to the implementation of a national monitoring system that oversees the health situation and signals when action is needed. Based on these premises, this article focuses on data and insights concerning the Italian territory.

Medication safety education in nursing research: Text network analysis and topic modeling

OBJECTIVES

This study aimed to identify the knowledge structure of medication safety nursing education literature by developing schematic diagrams of the relationship between keywords from a macro perspective. This study also identifies the research topics and trends over time.

DESIGN

This quantitative content study used text network analysis to explore keywords and research topics using topic modeling within the medication safety nursing education literature.

DATA SOURCES

PubMed, EMBASE, and Cochrane databases were used to search for the medication safety nursing education literature published until December 2021.

METHODS

Keywords from 2085 articles were examined using text network analysis and topic modeling with NetMiner 4.4.3.

RESULTS

The keywords with the most frequency and the highest networking degree in centrality were "patient," "medication," "program," "nurse," and "care." The emerging keywords assessed by time periods were identified; the first phase ("heart failure," "insulin," "chemotherapy," and "infusion"), the second phase ("medication errors," "staff," and "information"), the third phase ("program," "management," and "data"). The results of topic modeling were as follows: safe medication administration, safe medication reconciliation process, medication education for patients, medication errors in nursing practice, and multidisciplinary teamwork for medication safety.

CONCLUSION

These findings will help nursing researchers and educators to understand the trends and insights for medication safety education and educate future nurses to provide safer nursing care.

Self-regulated Anti-Overdose Crush and Extraction-Resistant Drug Delivery System to Combat Opioid Overdose Crisis

Pharmaceutical opioid dosage forms are commonly misused via an oral route in non-manipulated form, i.e., overdose in intact form, or manipulated form, i.e., after crushing the dosage form, and also via the non-oral route in manipulated form, particularly the parenteral or nasal route. To assess the self-regulated anti-overdose property, crushing strength, extractability, and syringeability of the developed drug delivery system by in vitro laboratory studies. Tapentadol HCl drug particulates fabricated using different polymers were assessed for extractability studies in 25 ml of water at room temperature (RT) and at > 90°C. Crushing strength was assessed by grinding the drug particulates in a mortar and pestle and a coffee grinder for 1 min. For syringeability, an attempt was made to withdraw the drug mixture using a 1 ml insulin syringe for 1 min. To assess the self-regulated anti-overdose property, in vitro dissolution testing on a single-capsule per dissolution vessel (normal condition) and four-capsules per dissolution vessel (overdose condition) was performed. POLYOX, Natrosol, and Blanose-containing drug particles retarded drug extraction by > 80% at RT and > 90°C. After 1 min of grinding in a mortar and pestle and a coffee grinder, crushed POLYOX-containing drug particulates were retained at > 99% on the ASTM-170# screen. The attempt to withdraw the viscous mixture of drug formulation prepared with 5 ml of water for 1 min using a 1 ml insulin syringe was unsuccessful. In dissolution studies, more than 90% of the drug was released in normal conditions, and more than 90% of the drug was retarded in overdose conditions. In vitro laboratory studies demonstrate that the developed self-regulated anti-overdose crush-resistant drug delivery system may deter misuse via oral and non-oral routes.

Abuse-Deterrent Opioids: A Survey of Physician Beliefs, Behaviors, and Psychology

Objective

Evaluate beliefs and behaviors pertaining to abuse-deterrent opioids (ADFs).

Design

Survey in 2019 by invitation to all licensed physicians.

Setting

Commonwealth of Kentucky.

Participants

374 physicians.

Methods

Descriptive statistics, and hypothesis test that early adopter prescribers would have greater endorsement of opioid risk management.

Results

Of all prescribers, 55% believed all opioid analgesics should have ADF requirements (15% were unsure); 74% supported mandating insurance coverage. Only one-third considered whether an opioid was ADF when prescribing, motivated by patient family diversion (94%) and societal supply reduction (88%). About half believed ADFs were equally effective in preventing abuse by intact swallowing, injection, chewing, snorting, smoking routes. Only 4% of OxyContin prescribers chose it primarily because of ADF properties. Instead, the most common reason (33%) was being started by another prescriber. A quarter of physicians chose not to prescribe ADFs because of heroin switching potential. Early adopters strongly believed ADFs were effective in reducing abuse (PR 3.2; 95% CI 1.5, 6.6) compared to mainstream physicians. Early-adopter risk-management practices more often included tools increasing agency and measurement: urine drug screens (PR 2.0; 1.3, 3.1), risk screening (PR 1.3; 0.94, 1.9). While nearly all respondents (96%) felt that opioid abuse was a problem in the community, only 57% believed it was a problem among patients in their practice. Attribution theory revealed an externalization of opioid abuse problems that deflected blame from patients on to family members.

Conclusions

The primary motivator for prescribing ADFs was preventing diversion by family members, not patient-level abuse concerns.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40122-021-00343-z.

Abuse Deterrent Formulations in Constraining the Abuse Potential of Prescription Medicines: A Myth or Truth

BACKGROUND

Diverse pain killers used for the management of varied categories of pain are being misused in order to have extreme pleasant effect by a large number of populations. To overcome the misuse of prescription drugs, regulatory bodies have given stress on development of abuse resistance.

METHODS

We studied numerous literatures: (1) Research and review papers including the guidelines for pain management, abuse, and abuse deterrence; (2) Description and categorization of pain along with the management approaches; (3) advantages and disadvantages of the abuse deterrent formulations were described.

RESULTS

Abuse deterrent formulations are the contemporary remedial treatment for pain with reduced prospects of being abused. But these comprise the huge expense in contrast to the generic drugs as well as the non-deterrent branded equivalents.

CONCLUSION

Many challenges are faced throughout the development of abuse deterrent formulations. These formulations displayed substantial drop in abuse incidences but it may lead to other modes of abuse which may prove more harmful for the users.

Oxycodone in the Opioid Epidemic: High 'Liking', 'Wanting', and Abuse Liability

It is estimated that nearly a third of people who abuse drugs started with prescription opioid medicines. Approximately, 11.5 million Americans used prescription drugs recreationally in 2016, and in 2018, 46,802 Americans died as the result of an opioid overdose, including prescription opioids, heroin, and illicitly manufactured fentanyl (National Institutes on Drug Abuse (2020) Opioid Overdose Crisis. https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis . Accessed 06 June 2020). Yet physicians will continue to prescribe oral opioids for moderate-to-severe pain in the absence of alternative therapeutics, underscoring the importance in understanding how drug choice can influence detrimental outcomes. One of the opioid prescription medications that led to this crisis is oxycodone, where misuse of this drug has been rampant. Being one of the most highly prescribed opioid medications for treating moderate-to-severe pain as reflected in the skyrocketed increase in retail sales of 866% between 1997 and 2007, oxycodone was initially suggested to be less addictive than morphine. The false-claimed non-addictive formulation of oxycodone, OxyContin, further contributed to the opioid crisis. Abuse was often carried out by crushing the pills for immediate burst release, typically by nasal insufflation, or by liquefying the pills for intravenous injection. Here, we review oxycodone pharmacology and abuse liability as well as present the hypothesis that oxycodone may exhibit a unique pharmacology that contributes to its high likability and abuse susceptibility. We will discuss various mechanisms that likely contribute to the high abuse rate of oxycodone including clinical drug likability, pharmacokinetics, pharmacodynamics, differences in its actions within mesolimbic reward circuity compared to other opioids, and the possibility of differential molecular and cellular receptor interactions that contribute to its selective effects. We will also discuss marketing strategies and drug difference that likely contributes to the oxycodone opioid use disorders and addiction.

Long-term Safety and Tolerability of NKTR-181 in Patients with Moderate to Severe Chronic Low Back Pain or Chronic Noncancer Pain: A Phase 3 Multicenter, Open-Label, 52-Week Study (SUMMIT-08 LTS)

OBJECTIVE

To evaluate the long-term safety of NKTR-181, a novel mu-opioid receptor agonist that may have reduced human abuse potential, in patients with moderate to severe chronic low back pain (CLBP) or other chronic noncancer pain (CNP).

DESIGN

Uncontrolled, multicenter, open-label, long-term study of NKTR-181 comprised of three periods: screening (≤21 days), treatment (52 weeks), and safety follow-up (∼14 days after the last dose of NKTR-181).

SETTING

Multicenter, long-term clinical research study.

METHODS

NKTR-181 administered at doses of 100-600 mg twice daily (BID) was evaluated in opioid-naïve and opioid-experienced patients. Patients were enrolled de novo or following completion of the randomized, placebo-controlled phase 3 efficacy study (SUMMIT-07). Safety assessments included adverse event documentation, measurements of opioid withdrawal, and clinical laboratory tests. Effectiveness was assessed using the modified Brief Pain Inventory Short Form (mBPI-SF).

RESULTS

The study enrolled 638 patients. The most frequently reported treatment-emergent adverse events (TEAEs) were constipation (26%) and nausea (12%). Serious TEAEs, reported in 5% of patients, were deemed by investigators to be unrelated to NKTR-181. There were no deaths or reported cases of respiratory depression. A sustained reduction in mBPI-SF pain intensity and pain interference from baseline to study termination was observed throughout treatment. Only 2% of patients discontinued NKTR-181 due to lack of efficacy, and 11% discontinued due to treatment-related AEs. NKTR-181 doses of up to 600 mg BID were generally well tolerated, and patients experienced low rates of opioid-related adverse events.

CONCLUSIONS

The study results support the premise that NKTR-181 is a safe and effective option for patients with moderate to severe CLBP or CNP.

Variation in Abuse-Deterrent Formulation Opioid Prescribing in California, Florida, and Kentucky in 2018

PURPOSE

Abuse-deterrent formulation (ADF) opioid analgesics have been developed as a means to address prescription opioid abuse. ADF opioid use in clinical practice is not well described in the literature. This study characterizes ADF opioid prescribing patterns in 3 diverse states.

METHODS

This study used data from prescription drug monitoring programs (PDMPs) in California, Florida, and Kentucky. The sample includes all ADF opioid prescriptions for patients ≥18 years old during the study period (CY 2018). Standardized prescribing rates were calculated by age, sex, and county rurality. The ADF opioid prescribing rate was calculated per 1,000 adult recipients of opioid analgesics.

FINDINGS

The rate of ADF prescribing per 1,000 adult recipients of opioid analgesics was nearly twice as high in Florida (14.57; 95% CI: 14.44-14.69) than in California (8.30; 95% CI: 8.22-8.37) or Kentucky (8.20; 95% CI: 8.01-8.39). ADF prescribing rates were highest among adults ages 55-74 years and among males. ADF opioid prescribing in rural counties represented a greater proportion of total patients using opioid analgesics than in metro counties in California (RR 1.40; CI: 1.28-1.53). Opposite and less pronounced variation was observed in Kentucky (RR 0.93; 95% CI: 0.88-0.98), and a significant difference was not observed in Florida (RR 0.68; 95% CI: 0.38-1.19).

CONCLUSIONS

There were significant differences in the ADF prescribing rates among the 3 states and in rural versus metro counties within 2 states. ADF opioid prescribing by age and sex showed similar trends within states. Further research is needed to elucidate contextual factors which may lead to prescribing variation.

Technologies for Opioid Use Disorder Management: Mobile App Search and Scoping Review

Background

Advances in technology engender the investigation of technological solutions to opioid use disorder (OUD). However, in comparison to chronic disease management, the application of mobile health (mHealth) to OUD has been limited.

Objective

The overarching aim of our research was to design OUD management technologies that utilize wearable sensors to provide continuous monitoring capabilities. The objectives of this study were to (1) document the currently available opioid-related mHealth apps, (2) review past and existing technology solutions that address OUD, and (3) discuss opportunities for technological withdrawal management solutions.

Methods

We used a two-phase parallel search approach: (1) an app search to determine the availability of opioid-related mHealth apps and (2) a scoping review of relevant literature to identify relevant technologies and mHealth apps used to address OUD.

Results

The app search revealed a steady rise in app development, with most apps being clinician-facing. Most of the apps were designed to aid in opioid dose conversion. Despite the availability of these apps, the scoping review found no study that investigated the efficacy of mHealth apps to address OUD.

Conclusions

Our findings highlight a general gap in technological solutions of OUD management and the potential for mHealth apps and wearable sensors to address OUD.

Abuse-deterrent opioid analgesics: a guide for clinicians

The US FDA has encouraged the development of abuse-deterrent formulations (ADFs) of opioid analgesics as one component in a comprehensive effort to combat prescription opioid abuse. Guidance issued by the FDA outlines three types of premarket studies for evaluating abuse deterrence: laboratory-based in vitro manipulation and extraction studies, pharmacokinetic studies and human abuse potential studies. After approval, postmarket studies are needed to evaluate the impact of an ADF product on abuse in real-world settings. This review summarizes the regulatory issues involved in the development of ADF opioids and clarifies abuse-deterrence claims in product labels, in order to assist clinicians in critically evaluating the available evidence pertaining to the abuse-deterrent features of opioid analgesics.

Who Are Dispensed the Bulk Amount of Prescription Opioids?

Background: Excessive and non-medical use of prescription opioids is a public health crisis in many settings. This study examined the distribution of user types based on duration of use, trends in and associated factors of dispensing of prescription opioids in New South Wales and Victoria, Australia. Methods: 10% sample of unit-record data of four-year dispensing of prescription opioids was analysed. Quantities dispensed were computed in defined daily dose (DDD). Multilevel models examined factors associated with the duration of dispensing and the quantity dispensed in local government areas. Results: Overall, 53% were single-quarter, 37.3% medium-episodic (dispensed 2–6 quarters), 5% long-episodic (dispensed 7–11 quarters) and 5% were chronic users (dispensed 12–14 quarters). More than 80% of opioids in terms of DDD/1000 people/day were dispensed to long-episodic and chronic users. Codeine and oxycodone were most popular items—both in terms of number of users and quantity dispensed. Duration of dispensing was significantly higher for women than men. Dispensing quantity and duration increased with increasing age and residence in relatively poor neighborhoods. Conclusions: Although only 5% were chronic users, almost 60% of opioids (in DDD/1000 people/day) were dispensed to them. Given that chronic use is linked to adverse health outcomes, and there is a progression toward chronic use, tailored interventions are required for each type of users.