Use of urinary naloxone levels in a single provider practice: a case study

BACKGROUND

Urine drug monitoring for medications for opioid use disorder (MOUD) such as buprenorphine can help to support treatment adherence. The practice of introducing unconsumed medication directly into urine (known as "spiking" samples) has been increasingly recognized as a potential means to simulate treatment adherence. In the laboratory, examination of the ratios of buprenorphine and its metabolite, norbuprenorphine, has been identified as a mechanism to identify "spiked" samples. Urine levels of naloxone may also be a novel marker in cases where the combination buprenorphine-naloxone product has been administered. This case study, which encompasses one provider's practice spanning two sites, represents a preliminary report on the utility of using urinary naloxone as an indicator of "spiked" urine toxicology samples. Though only a case study, this represents the largest published evaluation of patients' naloxone levels to date.

CASE PRESENTATION

Over a 3-month period across two practice sites, we identified 1,223 patient samples with recorded naloxone levels, spanning a range of 0 to 12,161 ng/ml. The average naloxone level was 633.65 ng/ml with the majority (54%) of samples < 300 ng/ml. 8.0% of samples demonstrated extreme values of naloxone (> 2000 ng/ml). One practice site, which had increased evidence of specimen tampering at collections, had a greater percent of extreme naloxone levels (>  2000 ng/ml) at 9.3% and higher average naloxone level (686.8 ng/ml), in contrast to a second site (570.9 ng/ml; 6.4% at > 2000 ng/ml) that did not have known reports of specimen tampering.

CONCLUSIONS

We postulate that naloxone may serve as an additional flag to identify patient "spiking" of urine samples with use of the combination product of buprenorphine-naloxone.

Detection of naltrexone and naltrexol in patients prescribed Embeda®

no abstract

Quantitation of Buprenorphine, Norbuprenorphine, Buprenorphine Glucuronide, Norbuprenorphine Glucuronide, and Naloxone in Urine by LC-MS/MS

Buprenorphine is an opioid drug that has been used to treat opioid dependence on an outpatient basis, and is also prescribed for managing moderate to severe pain. Some formulations of buprenorphine also contain naloxone to discourage misuse. The major metabolite of buprenorphine is norbuprenorphine. Both compounds are pharmacologically active and both are extensively metabolized to their glucuronide conjugates, which are also active metabolites. Direct quantitation of the glucuronide conjugates in conjunction with free buprenorphine, norbuprenorphine, and naloxone in urine can distinguish compliance with prescribed therapy from specimen adulteration intended to mimic compliance with prescribed buprenorphine. This chapter quantitates buprenorphine, norbuprenorphine, their glucuronide conjugates and naloxone directly in urine by liquid chromatography tandem mass spectrometry (LC-MS/MS). Urine is pretreated with formic acid and undergoes solid phase extraction (SPE) prior to analysis by LC-MS/MS.

Preliminary buprenorphine sublingual tablet pharmacokinetic data in plasma, oral fluid, and sweat during treatment of opioid-dependent pregnant women

BACKGROUND

Buprenorphine is currently under investigation as a pharmacotherapy to treat pregnant women for opioid dependence. This research evaluates buprenorphine (BUP), norbuprenophine (NBUP), buprenorphine-glucuronide (BUP-Gluc), and norbuprenorphine-glucuronide (NBUP-Gluc) pharmacokinetics after high-dose (14-20 mg) BUP sublingual tablet administration in three opioid-dependent pregnant women.

METHODS

Oral fluid and sweat specimens were collected in addition to plasma specimens for 24 hours during gestation weeks 28 or 29 and 34, and 2 months after delivery. Time to maximum concentration was not affected by pregnancy; however, BUP and NBUP maximum concentration and area under the curve at 0 to 24 hours tended to be lower during pregnancy compared with postpartum levels.

RESULTS

Statistically significant but weak positive correlations were found for BUP plasma and OF concentrations and BUP/NBUP ratios in plasma and oral fluid. Statistically significant negative correlations were observed for times of specimen collection and BUP and NBUP oral fluid/plasma ratios. BUP-Gluc and NBUP-Gluc were detected in only 5% of oral fluid specimens. In sweat, BUP and NBUP were detected in only four of 25 (12 or 24 hours) specimens in low concentrations (less than 2.4 ng/patch).

CONCLUSION

These preliminary data describe BUP and metabolite pharmacokinetics in pregnant women and suggest that, like methadone, upward dose adjustments may be needed with advancing gestation.

Open-label dose-finding trial of buprenorphine implants (Probuphine) for treatment of heroin dependence

Buprenorphine, a mu-opioid receptor partial agonist, has been shown to be safe and effective for treatment of opioid dependence. A novel implantable formulation of buprenorphine (Probuphine), using a polymer matrix sustained-release technology, has been developed to offer treatment for opioid dependence while minimizing risks of patient noncompliance and illicit diversion. The goal of the current study was to conduct an initial, open-label, evaluation of the safety, pharmacokinetics, and efficacy of two doses of Probuphine in subjects with opioid dependence maintained on sublingual buprenorphine. Two doses of Probuphine were evaluated in 12 heroin-dependent volunteers switched from daily sublingual buprenorphine dosing to either two or four Probuphine implants based upon their buprenorphine daily maintenance dose of 8 mg or 16 mg respectively, and were monitored for 6 months. Probuphine implants provided continuous steady state delivery of buprenorphine until their removal at 6 months. Withdrawal symptoms and craving remained low throughout the 6 months. For the 12 subjects, an average of 59% of urines were opioid-negative across the 6 month treatment period. Injection site reactions were present in half of patients, but none were serious. No safety concerns were evident. These results suggest that Probuphine implants offer significant promise for enhancing delivery of effective opioid substitution treatment while minimizing risk for abuse of medication.

Disposition of naltrexone after intravenous bolus administration in Wistar rats, low-alcohol-drinking rats and high-alcohol-drinking rats

Reports have shown that interspecies differences in the metabolism and pharmacokinetics of naltrexone are a rule rather than exception. However, there is paucity of information on the disposition of naltrexone in selectively bred rat lines that reliably exhibit high and low voluntary alcohol consumption, and are often used to study alcohol-drinking behavior. We have characterized the pharmacokinetic profiles of naltrexone in selectively bred rat lines: high-alcohol-drinking (HAD-1) and low-alcohol-drinking (LAD-1) rats as well as the native Wistar strain. This study was carried out to establish a baseline pharmacokinetic profile of naltrexone in these rats prior to evaluating its pharmacokinetic profile in polymeric controlled-release formulations in our laboratory. The hypothesis is that alcohol-preferring and non-alcohol-preferring lines of rats should differ in the disposition of intravenously administered naltrexone. Naltrexone administration and blood collection were via the jugular vein. In a parallel experiment, naltrexone was administered via the jugular vein, but urine was collected using the Nalgene metabolic cage system. Data were analyzed by a noncompartmental approach. Results show a high clearance that is close to or higher than hepatic blood flow in all groups (Wistar > LAD-1 > HAD-1, but with a statistically significant difference only between Wistar and HAD-1). Volume of distribution (approximately 2.5-3 l/kg) and the half-life (approximately 1 h) were similar. Urinary elimination of naltrexone was small, but also showed differences between the rats: HAD-1 > LAD-1 > Wistar, but with a statistically significant difference only between HAD-1 and Wistar rats. This study has therefore established the baseline disposition characteristics of naltrexone in these strains of rats.

[Determination of buprenorphine in urine]

Buprenorphine is one of the drugs used for treatment of opioid-dependent patients enrolled in rehabilitation programs in Norway. Buprenorphine is metabolized in the liver by cytochrome P450 to the active metabolite norbuprenorphine, and further to buprenorphine-glucuronide and norbuprenorphine-glucuronide. The Division of Forensic Toxicology and Drug Abuse at the Norwegian Institute of Public Health has during the past 5 years received an increasing number of urine samples for buprenorphine analysis. All urine samples with question of buprenorphine have since August 2005 been analysed with a new method, which analyses the glucuronides of buprenorphine and norbuprenorphine in urine. This method is fast and simple and saves time and resources in our routine laboratory.

Quantitative LC–MS determination of strychnine in urine after ingestion of a Strychnos nux-vomica preparation and its consequences in doping control

A simple, fast and sensitive method for the quantitative determination of strychnine residues in urine has been developed and validated. The method consists of a liquid-liquid extraction step with ethyl acetate at pH 9.2, followed by LC-MS/MS in positive atmospheric pressure chemical ionization (APCI)-mode. The method is linear in the range of 1-100 ng/mL and allows for the determination of strychnine at sub-toxicological concentrations. The accuracy of the method ranged from 1.3% to 4.4%. The method was used to determine the excretion profile of strychnine after the ingestion of an over-the-counter herbal preparation of Strychnos nux-vomica. Each volunteer ingested a dose equivalent to 380 micro g of strychnine. This dose is lower than the prescription dose but results in the detection of strychnine for over 24-h post administration. Maximum detected urinary concentrations ranged from 22.6 to 176 ng/mL. The results of this study show that the use of this type of preparation by athletes can lead to a positive doping case.

The In Vivo Glucuronidation of Buprenorphine and Norbuprenorphine Determined by Liquid Chromatography-Electrospray Ionization-Tandem Mass Spectrometry

The opioid partial agonist medication, buprenorphine (BUP), and its primary metabolite, norbuprenorphine (NBUP), are extensively glucuronidated. Sensitive analytical methods that include determination of buprenorphine-3-glucuronide (BUPG) and norbuprenorphine-3-glucuronide (NBUPG) are needed to more fully understand the metabolism and pharmacokinetics of buprenorphine. A method has now been developed that uses solid-phase extraction followed by liquid chromatography-electrospray ionization-tandem mass spectrometry. BUP-d4, NBUP-d3, and morphine-3-glucuronide-d3 were used as internal standards. The lower limit of quantitation was 0.1 and 0.5 ng/mL for each of the analytes in 1-mL of human plasma and urine, respectively, except for NBUP in urine in which it was 2.5 ng/mL. The analytes were stable under the following conditions: plasma and urine at room temperature, up to 20 hours; plasma and urine at -20 degrees C for 119 and 85 days, respectively; plasma freeze-thaw, up to 3 cycles; processed sample, up to 96 hours at -20 degrees C and up to 48 hours on the autosampler; stock solutions at room temperature and at -20 degrees C, up to 6 hours and 128 days, respectively. In plasma collected from 5 subjects on maintenance daily sublingual doses of 16 mg BUP and 4 mg naloxone, respective 0- to 24-hour areas under the curve were 32, 88, 26, and 316 ng/mL x h for BUP, NBUP, BUPG, and NBUPG. In urine samples respective percent of daily dose excreted in the 24-hour urine were 0.014%, 1.89%, 1.01%, and 7.76%. This method allowed us to determine that NBUPG is a major metabolite present in plasma and urine of BUP. Because urinary elimination is limited ( approximately 11% of daily dose), the role of NBUPG in total clearance of buprenorphine is not yet known.

NOVEL METABOLITES OF BUPRENORPHINE DETECTED IN HUMAN LIVER MICROSOMES AND HUMAN URINE

The in vitro metabolism of buprenorphine was investigated to explore new metabolic pathways and identify the cytochromes P450 (P450s) responsible for the formation of these metabolites. The resulting metabolites were identified by liquid chromatography-electrospray ionization-tandem mass spectrometry. In addition to norbuprenorphine, two hydroxylated buprenorphine (M1 and M2) and three hydroxylated norbuprenorphine (M3, M4, and M5) metabolites were produced by human liver microsomes (HLMs), with hydroxylation occurring at the tert-butyl group (M1 and M3) and at unspecified site(s) on the ring moieties (M2, M4, and M5). Time course and other data suggest that buprenorphine is N-dealkylated to form norbuprenorphine, followed by hydroxylation to form M3; buprenorphine is hydroxylated to form M1 and M2, followed by N-dealkylation to form M3 and M4 or M5. The involvement of selected P450s was investigated using cDNA-expressed P450s coupled with scaling models, chemical inhibition, monoclonal antibody (MAb) analysis, and correlation studies. The major enzymes involved in buprenorphine elimination and norbuprenorphine and M1 formation were P450s 3A4, 3A5, 3A7, and 2C8, whereas 3A4, 3A5, and 3A7 produced M3 and M5. Based on MAb analysis and chemical inhibition, the contribution of 2C8 was higher in HLMs with higher 2C8 activity, whereas 3A4/5 played a more important role in HLMs with higher 3A4/5 activity. Examination of human urine from subjects taking buprenorphine showed the presence of M1 and M3; most of M1 was conjugated, whereas 60 to 70% of M3 was unconjugated.

The development and application of a rapid gas chromatography-mass spectrometry method to monitor buprenorphine withdrawal protocols

There are several drug therapies that can be used to treat opiate abuse. One such treatment that is currently gaining wide acceptance is the use of the combined agonist/antagonist drug buprenorphine. As with all long-term treatments, there is a potential for compliance issues to arise, which establishes the need for a technique to facilitate the monitoring of individuals prescribed buprenorphine. One such method has been developed and applied to the routine monitoring of buprenorphine and its primary metabolite in urine. The method was found to be sensitive (limits of detection of 1.0 ng/mL for both buprenorphine and norbuprenorphine), reproducible and linear up to 2000 ng/mL. This article describes the application of this method to the analysis of specimens collected from subjects prescribed a reducing low-dose buprenorphine regimen (10.0-0.4 mg per day) for acute opiate detoxification. A significant relationship between the daily dose and the mean creatinine-corrected concentration of buprenorphine in the urine was observed, together with a relatively stable relationship between the ratio of the urinary concentrations of norbuprenorphine to buprenorphine across the dose range studied.

Determination of methylnaltrexone in clinical samples by solid-phase extraction and high-performance liquid chromatography for a pharmacokinetics study

A high-performance liquid chromatographic (HPLC) method with electrochemical detection and solid-phase extraction (SPE) using cartridges of weak cation-exchange capacity as the primary retention mechanism is described for the separation and determination of methylnaltrexone (MNTX) in small clinical samples of plasma or urine. The procedure was performed using a Phenomenex Prodigy ODS-2, 5 microm, 150x3.2 mm analytical column and 50 mM potassium acetate buffer, with 11% methanol as organic modifier at pH* 4.5 at a flow-rate of 0.5 ml/min. The detection potential was 700 mV. The six-point standard calibration curves were linear over three consecutive days in the range from 2 to 100 ng/ml. The average goodness of fit (r) was 0.9993. The lower limit of detection (LOD) and limit of quantification (LOQ) were found to be 2.0 and 5.0 ng/ml, respectively. At the LOQ, the coefficient of variation for the entire method was 8.0% and the accuracy was 10.0% (n = 10). Recovery of the drug from plasma was in the region of 94%. The method was applied to a pharmacokinetics study of methylnaltrexone after subcutaneous administration and in numerous assays of analytes in blood plasma and urine. The pharmacokinetics parameters for a single dose of 0.1 or 0.3 mg/kg in plasma were C(max) = 110 (+/-55) and 287 (+/-101) ng/ml and t(max) = 16.7 (+/-10.8) and 20.0 (+/-9.5) min, respectively. The method is simple, yet sensitive for the detection and determination of methylnaltrexone in biological samples at the level of the physiological response.

GC-MS confirmation of codeine, morphine, 6-acetylmorphine, hydrocodone, hydromorphone, oxycodone, and oxymorphone in urine

A procedure for the simultaneous confirmation of codeine, morphine, 6-acetylmorphine, hydrocodone, hydromorphone, oxycodone, and oxymorphone in urine specimens by gas chromatography-mass spectrometry (GC-MS) is described. After the addition of nalorphine and naltrexone as the two internal standards, the urine is hydrolyzed overnight with beta-glucuronidase from E. coli. The urine is adjusted to pH 9 and extracted with 8% trifluoroethanol in methylene dichloride. After evaporating the organic, the residue is sequentially derivatized with 2% methoxyamine in pyridine, then with propionic anhydride. The ketone groups on hydrocodone, hydromorphone, oxycodone, oxymorphone, and naltrexone are converted to their respective methoximes. Available hydroxyl groups on the O3 and O6 positions are converted to propionic esters. After a brief purification step, the extracts are analyzed by GC-MS using full scan electron impact ionization. Nalorphine is used as the internal standard for codeine, morphine, and 6-acetylmorphine; naltrexone is used as the internal standard for the 6-keto-opioids. The method is linear to 2000 ng/mL for the 6-keto-opioids and to 5000 ng/mL for the others. The limit of quantitation is 25 ng/mL in hydrolyzed urine. Day-to-day precision at 300 and 1500 ng/mL ranged between 6 and 10.9%. The coefficients of variation for 6-acetylmorphine were 12% at both 30 and 150 ng/mL. A list of 38 other basic drugs or metabolites detected by this method is tabulated.

A survey of drugs of abuse testing by clinical laboratories in the United Kingdom. Steering Committee for the UK-External Quality Assessment Scheme for Therapeutic Drug Assays

An external quality assessment survey of testing facilities in UK clinical laboratories for the detection of drugs of abuse was made with nine freeze-dried samples of urine containing representative drugs with their metabolites from the following seven classes; amphetamines and stimulants, barbiturates, cannabinoids, cocaine, minor tranquillisers, opiates and non-opiate narcotics. Reports were received from 120 laboratories. Thirty six per cent of laboratories reported on all seven drug classes and 71% on the five classes excluding cannabinoids and cocaine. A single drug screening technique was used by 32% of laboratories whilst 46% were able to perform tests by both immunological and chromatographic techniques. There was a mean level of false positive reporting of 4.3% and an observed level of false negative reports of 8.4%, the latter underestimating the true frequency. The minor tranquillisers, cocaine and benzoyl ecgonine were the most frequently missed analytes. Several false reports had important potential implications for patient care.

Variations in demethylation of N-methylnaltrexone in mice, rats, dogs, and humans

1. Rats and mice have a greater capacity than dogs or humans to N-demethylate the quaternary ammonium compound, N-methylnaltrexone. 2. In dogs, following the i.v. administration of N-[14C-methyl]methylnaltrexone, 50% of the radioactivity was excreted in the urine and an additional 30% in the faeces within 120 h. 3. In humans following the i.v. administration of 14C-N-methylnaltrexone, 40-60% of the radioactivity was excreted in the urine within the first 24 h. The plasma radioactivity-time curves indicated a biphasic decay and a short distribution phase between 6 and 9 min. with a longer elimination phase between 238 and 1320 min.

Disposition and metabolism of codorphone in the rat, dog, and man

The disposition and metabolism of codorphone, 17-cyclopropyl-methyl-4,5 alpha-8 beta-ethyl-3-methoxymorphinan-6-one (I), a new narcotic antagonist, analgesic agent, have been studied in the rat, dog, and man. Rats and dogs were given single 100- and 50-mg/kg po doses, respectively, of I-3H; human volunteers received single 10- to 30-mg doses of unlabeled I po. The compound appeared to be well absorbed in the three species. In rats the highest levels of radioactivity were in liver, adrenals, kidneys, spleen, and lungs. Excretion was primarily fecal in rats and dogs. In man about 50% of the dose appeared in the 24-hr urine. I was about 95% metabolized by each species. The major metabolites in rats resulted from 3- and/or 17-dealkylation. Metabolism in dogs was characterized primarily by 17-dealkylation. The major pathways of I metabolism in man were 17-dealkylation and 6-reduction. In the three species significant glucuronic acid conjugation of metabolites occurred.

General procedure for the isolation and identification of 6-alpha- and 6-beta-hydroxy metabolites of narcotic agonists and antagonists with a hydromorphone structure

In order to aid in the elucidation of the metabolism of drugs containing the hydromorphone structure, a method is described for isolation from urine, separation and identification of the 6-alpha- and 6-beta-hydroxy metabolites. The samples were acid-hydrolyzed, extracted, and separated by thin-layer chromatography. The zone containing the hydroxy metabolites was removed and the compounds were re-extracted and analyzed by gas-liquid chromatography (GLC). Silylation of the extract was necessary in most cases for optimum GLC resolution of the alpha- and beta-hydroxy epimers. To demonstrate application of this method, the urine of guinea-pigs and rats which had received a single 40-mg dose of naloxone subcutaneously was analyzed. Analysis indicated a alpha/beta ratio of 0.41 for the guinea-pig. In contrast, the amount of 6-alpha-naloxol found in the urine of the rat was negligible in comparison with the 6-beta-hydroxy metabolite, indicating a species difference in the stereospecificity of the drug-metabolizing enzyme.

Long acting delivery systems for narcotic antagonists II: release rates of naltrexone from poly(lactic acid) composites

Parallel in vitro and in vivo release rates of tritiated naltrexone from poly(lactic acid) composites were studied. The in vitro release of naltrexone was 67% of the dose over a 35-day test period, while the in vivo release was only 24% within 70 days. Apparently, an exchange of the tritium for the hydrogen of the body water takes place, indicating that urinary excretion radioactivity is not a reliable measure for estimating the naltrexone released. Naltrexone-poly(lactic acid) composites showed effective blocking action to morphine in rats (24 days), dogs (29 days), monkeys (20 days), and mice (21 days).