Present and Emerging Concepts in Opioid Drug Discovery
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Janet Robishaw, PhD Senior Associate Dean for Research Chair and Professor, Biomedical Science Florida Atlantic University Charles E. Schmidt College of Medicine Disclosures and Conflicts • I have no actual or potential conflict of interest in relation to this program/presentation. • Research support: Robishaw, MPI Robishaw, MPI R01 DA044015 R01 HL134015 Genetic Predictors of Opioid Addiction Genetic Heterogeneity of Sleep Apnea 2017-2022 2016-2021 Robishaw, PI Robishaw, MPI R01 GM114665 R01 GM111913 Novel Aspects of Golf Signaling GPCR Variants in Complex Diseases 2015-2019 2015-2019 Learning Objectives 1. Review the scope and root cause of opioid use disorder 2. Discuss the effects of opioid medications on the brain and body 3. Stress the importance of clinical judgement and discovery to address the opioid crisis 4. Highlight the clinical implications between opioid use disorder and heroin abuse Two Endemic Problems Chronic Pain Opioid Use Disorder Debilitating disorder Chronic, relapsing disorder 100 million Americans 2 million Americans Costs $630 billion dollars per year Costs $80 billion per year #1 presenting complaint to doctors # 1 cause of accidental death #1 reason for lost productivity #1 driver of heroin epidemic #1 treatment –opioid medications ? treatment Pain Relief and “Addiction” Share A Common Mechanism of Action m-Opioid Receptor Brain Regions Involved in Pleasure and Reward Increase dopamine release Brain Regions Involved in Pain Perception Brainstem Involved in Respiratory Control Spinal Cord Involved in Pain Transmission Prevent ascending transmission Turn on descending inhibitory systems These receptors are dispersed Inhibit peripheral nocioceptors throughout the body, thereby accounting for their differential Body effects on pain and reward paths. -
Biased Versus Partial Agonism in the Search for Safer Opioid Analgesics
molecules Review Biased versus Partial Agonism in the Search for Safer Opioid Analgesics Joaquim Azevedo Neto 1 , Anna Costanzini 2 , Roberto De Giorgio 2 , David G. Lambert 3 , Chiara Ruzza 1,4,* and Girolamo Calò 1 1 Department of Biomedical and Specialty Surgical Sciences, Section of Pharmacology, University of Ferrara, 44121 Ferrara, Italy; [email protected] (J.A.N.); [email protected] (G.C.) 2 Department of Morphology, Surgery, Experimental Medicine, University of Ferrara, 44121 Ferrara, Italy; [email protected] (A.C.); [email protected] (R.D.G.) 3 Department of Cardiovascular Sciences, Anesthesia, Critical Care and Pain Management, University of Leicester, Leicester LE1 7RH, UK; [email protected] 4 Technopole of Ferrara, LTTA Laboratory for Advanced Therapies, 44122 Ferrara, Italy * Correspondence: [email protected] Academic Editor: Helmut Schmidhammer Received: 23 July 2020; Accepted: 23 August 2020; Published: 25 August 2020 Abstract: Opioids such as morphine—acting at the mu opioid receptor—are the mainstay for treatment of moderate to severe pain and have good efficacy in these indications. However, these drugs produce a plethora of unwanted adverse effects including respiratory depression, constipation, immune suppression and with prolonged treatment, tolerance, dependence and abuse liability. Studies in β-arrestin 2 gene knockout (βarr2( / )) animals indicate that morphine analgesia is potentiated − − while side effects are reduced, suggesting that drugs biased away from arrestin may manifest with a reduced-side-effect profile. However, there is controversy in this area with improvement of morphine-induced constipation and reduced respiratory effects in βarr2( / ) mice. Moreover, − − studies performed with mice genetically engineered with G-protein-biased mu receptors suggested increased sensitivity of these animals to both analgesic actions and side effects of opioid drugs. -
Hydromorphone
Hydromorphone WHAT IS HYDROMORPHONE? sedation, and reduced anxiety. It may also cause Hydromorphone belongs to a class of drugs mental clouding, changes in mood, nervousness, called “opioids,” which includes morphine. It and restlessness. It works centrally (in the has an analgesic potency of two to eight times brain) to reduce pain and suppress cough. greater than that of morphine and has a rapid Hydromorphone use is associated with both onset of action. physiological and psychological dependence. WHAT IS ITS ORIGIN? What is its effect on the body? Hydromorphone is legally manufactured and Hydromorphone may cause: distributed in the United States. However, • Constipation, pupillary constriction, urinary retention, users can obtain hydromorphone from nausea, vomiting, respiratory depression, dizziness, forged prescriptions, “doctor-shopping,” impaired coordination, loss of appetite, rash, slow or theft from pharmacies, and from friends and rapid heartbeat, and changes in blood pressure acquaintances. What are its overdose effects? What are the street names? Acute overdose of hydromorphone can produce: Common street names include: Severe respiratory depression, drowsiness • D, Dillies, Dust, Footballs, Juice, and Smack progressing to stupor or coma, lack of skeletal muscle tone, cold and clammy skin, constricted What does it look like? pupils, and reduction in blood pressure and heart Hydromorphone comes in: rate • Tablets, capsules, oral solutions, and injectable Severe overdose may result in death due to formulations respiratory depression. How is it abused? Which drugs cause similar effects? Users may abuse hydromorphone tablets by Drugs that have similar effects include: ingesting them. Injectable solutions, as well as • Heroin, morphine, hydrocodone, fentanyl, and tablets that have been crushed and dissolved oxycodone in a solution may be injected as a substitute for heroin. -
Pain Therapy E Are There New Options on the Horizon?
Best Practice & Research Clinical Rheumatology 33 (2019) 101420 Contents lists available at ScienceDirect Best Practice & Research Clinical Rheumatology journal homepage: www.elsevierhealth.com/berh 4 Pain therapy e Are there new options on the horizon? * Christoph Stein a, , Andreas Kopf b a Department of Experimental Anesthesiology, Charite Campus Benjamin Franklin, D-12200 Berlin, Germany b Department of Anesthesiology and Intensive Care Medicine, Charite Campus Benjamin Franklin, D-12200 Berlin, Germany abstract Keywords: Opioid crisis This article reviews the role of analgesic drugs with a particular Chronic noncancer pain emphasis on opioids. Opioids are the oldest and most potent drugs Chronic nonmalignant pain for the treatment of severe pain, but they are burdened by detri- Opioid mental side effects such as respiratory depression, addiction, Opiate sedation, nausea, and constipation. Their clinical application is Inflammation undisputed in acute (e.g., perioperative) and cancer pain, but their Opioid receptor long-term use in chronic pain has met increasing scrutiny and has Misuse Abuse contributed to the current opioid crisis. We discuss epidemiolog- Bio-psycho-social ical data, pharmacological principles, clinical applications, and research strategies aiming at novel opioids with reduced side effects. © 2019 Elsevier Ltd. All rights reserved. The opioid epidemic The treatment of pain remains a huge challenge in clinical medicine and public health [1,2]. Pain is the major symptom in rheumatoid (RA) and osteoarthritis (OA) [3,4]. Both are chronic conditions that are not linked to malignant disease, and pain can occur even in the absence of inflammatory signs (see chapter “Pain without inflammation”). Unfortunately, there is a lack of fundamental knowledge about the management of chronic noncancer pain. -
Developments in Opioid Drugs
Spotlight on drugs Developments in opioid Advanced courses 2019 analgesics Dr Andrew Wilcock DM FRCP [email protected] 1 2 1 2 Outline of talk • background – cancer pain / strong opioids Background • pharmacology • new approaches (as we go) • summary • discussion/questions. 3 4 Opioids WHO analgesic ladder for cancer pain • central to the management of moderate–severe acute pain and cancer pain. 5 6 1 Broad-spectrum analgesia Opioids: why improve? Ultimate aim to: • improve efficacy • eliminate / reduce risk of undesirable effects, e.g.: – constipation – dependence – respiratory depression – sedation – tolerance. 7 8 Opioids: chemical classification Pharmacology 9 10 Opioid: receptors Four main types: • μ • κ • δ • opioid-receptor-like 1 (OPRL-1) – opioid-related nociceptin receptor 1 – nociceptin opioid peptide (NOP) – nociceptin/orphanin FQ (N/OFQ). 11 12 2 Opioid: receptors Opioids Generally: • μ-opioid receptor clinically most relevant for analgesia and undesirable effects • Centrally: dorsal horn, higher centres – pre-synaptic: inhibit release of neurotransmitters – post-synaptic: hyperpolarize neurone • Peripherally: nerve endings, DRG, (immune cells) – inflammation upregulates opioid receptors 13 14 15 16 New approaches for opioid analgesics 17 18 3 New approaches for opioid analgesics Include: 1. Broad-spectrum 2. Injury-targeted 1. ‘Broad-spectrum’ opioid agonists 3. Biased agonists Not exhaustive list, but main finds when searching the literature. Gunther T et al. (2018); Chan HCS et al. (2017) 19 20 ‘Broad-spectrum’ opioid agonists Differential analgesic and UE of opioid receptors Targeting multiple receptors may have synergistic analgesic effects & lower UE • μ most important analgesia / UE • selective κ and δ agonists – limited analgesia / own UE – κ (e.g. -
Pre - PA Allowance Age 12 Years of Age Or Older – Ultracet (Tramadol and Acetaminophen) and Codeine/APAP Products
OPIOID IR COMBO DRUGS Apadaz* (benzhydrocodone-acetaminophen), Codeine-acetaminophen, Dvorah* (dihydrocodeine-caffeine-acetaminophen*), Hydrocodone-acetaminophen, Hydrocodone- acetaminophen solution 10-325mg*, Hydrocodone-ibuprofen, Nalocet* (oxycodone- acetaminophen*), Oxycodone-acetaminophen, Oxycodone-aspirin, Oxycodone-ibuprofen, Primlev*/Prolate* (oxycodone-acetaminophen*), Tramadol-acetaminophen, Trezix (dihydrocodeine-caffeine-acetaminophen) *Prior authorization for certain non-covered formulations applies only to formulary exceptions Pre - PA Allowance Age 12 years of age or older – Ultracet (tramadol and acetaminophen) and Codeine/APAP products Quantity Patients 18 years or older will be able to fill the Pre-PA Allowance after they have filled an initial 7 day supply of IR opioid therapy or if they have been on IR or ER opioid therapy in the last 180 days Patients age 17 and under will require a PA after they have filled a 3 day supply of the Pre- PA Allowance Patients with opioid addiction treatment or methadone in the last 30 days will not be eligible for Pre-PA Allowance Immediate Release Tablets or Capsules ≤ 50 MME/day Medication Strength Quantity Limit Codeine/APAP soln 120-12 mg/5 mL Hydrocodone/APAP soln 7.5/325 mg/15 mL 5400 mL per 90 days Hydrocodone/APAP elixir 10/300 mg/15 mL Oxycodone/APAP soln 5-325 mg/5 mL 3000 mL per 90 days Hydrocodone/ibuprofen 5/200 mg, 7.5/200 mg, 10/200 mg 270 units per 90 days Oxycodone/ibuprofen 5/400 mg Oxycodone/APAP 10/325 mg Codeine/APAP 60/300 mg Hydrocodone/APAP 7.5/300 mg, 7.5/325 -
Measuring Ligand Efficacy at the Mu- Opioid Receptor Using A
RESEARCH ARTICLE Measuring ligand efficacy at the mu- opioid receptor using a conformational biosensor Kathryn E Livingston1,2, Jacob P Mahoney1,2, Aashish Manglik3, Roger K Sunahara4, John R Traynor1,2* 1Department of Pharmacology, University of Michigan Medical School, Ann Arbor, United States; 2Edward F Domino Research Center, University of Michigan, Ann Arbor, United States; 3Department of Pharmaceutical Chemistry, School of Pharmacy, University of California San Francisco, San Francisco, United States; 4Department of Pharmacology, University of California San Diego School of Medicine, La Jolla, United States Abstract The intrinsic efficacy of orthosteric ligands acting at G-protein-coupled receptors (GPCRs) reflects their ability to stabilize active receptor states (R*) and is a major determinant of their physiological effects. Here, we present a direct way to quantify the efficacy of ligands by measuring the binding of a R*-specific biosensor to purified receptor employing interferometry. As an example, we use the mu-opioid receptor (m-OR), a prototypic class A GPCR, and its active state sensor, nanobody-39 (Nb39). We demonstrate that ligands vary in their ability to recruit Nb39 to m- OR and describe methadone, loperamide, and PZM21 as ligands that support unique R* conformation(s) of m-OR. We further show that positive allosteric modulators of m-OR promote formation of R* in addition to enhancing promotion by orthosteric agonists. Finally, we demonstrate that the technique can be utilized with heterotrimeric G protein. The method is cell- free, signal transduction-independent and is generally applicable to GPCRs. DOI: https://doi.org/10.7554/eLife.32499.001 *For correspondence: [email protected] Competing interests: The authors declare that no Introduction competing interests exist. -
1 Impact of Opioid Agonists on Mental Health in Substitution
Impact of opioid agonists on mental health in substitution treatment for opioid use disorder: A systematic review and Bayesian network meta-analysis of randomized clinical trials Supplementary Table 1_ Specific search strategy for each database The following general combination of search terms, Boolean operators, and search fields were used where “*” means that any extension of that word would be considered: Title field [opium OR opiate* OR opioid OR heroin OR medication assisted OR substitution treatment OR maintenance treatment OR methadone OR levomethadone OR buprenorphine OR suboxone OR (morphine AND slow) OR diamorphine OR diacetylmorphine OR dihydrocodeine OR hydromorphone OR opium tincture OR tincture of opium OR methadol OR methadyl OR levomethadyl] AND Title/Abstract field [trial* OR random* OR placebo] AND All fields [depress* OR anxiety OR mental] Wherever this exact combination was not possible, a more inclusive version of the search strategy was considered. Database Search Strategy Ovid for EBM Reviews - Cochrane Central Register of (opium or opiate$ or opioid or heroin or medication Controlled Trials August 2018; Embase 1974 to assisted or substitution treatment or maintenance September 07, 2018; MEDLINE(R) and Epub Ahead treatment or methadone or levomethadone or of Print, In-Process & Other Non-Indexed Citations buprenorphine or suboxone or (morphine and slow) or and Daily 1946 to September 07, 2018 diamorphine or diacetylmorphine or dihydrocodeine or hydromorphone or opium tincture or tincture of opium or methadol or methadyl -
Hydromorphone and Morphine Are Not the Same Drug!
HYDROmorphone and Morphine are not the same drug! HYDROmorphone and morphine are deemed high risk/high alert medications. An Independent Double Check (IDC) must be done to avoid errors when administering all high risk drugs. Please refer to Clinical Practice Standard 1-20-6-3-260. HYDROmorphone and morphine need to knows: HYDROmorphone is 5 times more potent than morphine! (e.g., 1 mg of HYDROmorphone PO is equivalent to 5 mg of morphine PO) When administered via the subcutaneous route, these drugs are twice as strong! Therefore when converting between oral and subcutaneous routes half the dose. (10 mg of oral morphine = 5 mg of subcutaneous morphine) HYDROmorphone and morphine: The name game. Both drugs are used in the management of moderate to severe pain. HYDROmorphone and morphine come in different brand names and formulations. HYDROmorphone = Dilaudid (Injectable), Jurnista (SR), HYDROmorph Contin (SR) Morphine = Morphine Sulphate (Injectable), MS-IR, M.O.S. (Liquid/Tablet/SR), M-Eslon (SR), Statex (Liquid/Tablet/Supp.), Doloral (Liquid), MS Contin (SR), Kadian (SR) (SR=Slow Release CAP) *As per NH, use the generic names (NOT THE BRAND NAME), of these drugs in your documentation. Common side effects: 3 ‘B’s of opioid prescribing: Common: Nausea, Vomiting, Constipation, Sedation, Syncope, Xerostomia (Dry Mouth), If your client is on an opioid: Delirium, Restlessness, Urinary Retention. Do they have a Breakthrough? Less Common: Respiratory Depression, Do they have something for Barfing? Opioid-Induced Neurotoxicity, Myoclonus, Do they have something for their Bowels? Pruritis (itching). Opioid induced neurotoxicity: What does it look like? Opioid induced neurotoxicity is the result of a build up of toxic opioid metabolites in the blood stream. -
Better Agonist for the Opioid Receptors Syed Lal Badshah1* , Asad Ullah1, Salim S
Badshah et al. Chemistry Central Journal (2018) 12:13 https://doi.org/10.1186/s13065-018-0383-8 COMMENTARY Open Access Better agonist for the opioid receptors Syed Lal Badshah1* , Asad Ullah1, Salim S. Al‑showiman2 and Yahia Nasser Mabkhot2* Abstract This commentary highlights the recent work published in journal Nature on the structural based discovery of novel analgesic compounds for opioid receptors with minimal efects. Manglik et al. selectively targeted the Gi based μOR pathway instead of the β-arrestin pathway of the opioids. The computational screening of millions of compounds showed a list of several competent ligands. From these ligands they synthesized the compounds with the best docking score, which were further optimized by adding side residues for better interaction with the μOR. A promis‑ ing compound, PZM21, was a selective agonist of μOR. It has better analgesic properties with minimal side efects of respiratory depression and constipation. This work is a step towards better drug designing and synthesizing in terms of efcacy, specifcity with least side efects of targeted GPCR proteins present in the human proteome. Keywords: Opioid receptors, Analgesics, Agonists, Molecular docking, Selectivity Introduction for GPCRs includes lipids, fatty acids, neurotransmitters, Morphine is the natural alkaloid present in opium and it photons, cytokines, hormones and metal ions [8, 9]. Tey is obtained from poppy plant. Opium has been used as an transduce the signal across the plasma membrane by analgesic and as a recreational drug since ancient times. binding with these ligands that causes certain conforma- Other common analgesics used include natural alkaloids tional changes into the seven trans-membrane alpha heli- like codeine, oxycodone, etc. -
List of Narcotic Substances Circulation of Which Is Restricted in Uzbekistan
List of narcotic substances circulation of which is restricted in Uzbekistan 1. 2C-B(4-bromo-2,5-dimethoxyphenethylamine) 2. 3-methylfentanyl 3. 3-methylthiofentanyl 4. 3-Monoacetylmorphine 5. 4-methylaminorex 6. 6- Monoacetylmorphine 7. Acetorphine 8. Acetyl Dihydrocodeine 9. Acetyl-alfametilfentanil 10. Acetylated opium 11. Acetylcodeine 12. Acetylmethadol 13. Alfametadol 14. Alfatsetilmetadol 15. all fungi that contain Psilocine and Psilocybine 16. Allylprodine 17. Alpha Methylfentanyl 18. Alpha Metiltiofentanil 19. Alphaprodine 20. Anileridin 21. Benzethidine 22. Benzylmorphine 23. Betacetylmethadol 24. Betahydroxyfentanyl 25. Betameprodine 26. Betamethadol 27. Betaprodine 28. Bezitramide 29. Cannabis oil (hashish oil) 30. Cannabis, marihuana 31. Cathine ((+)-norpseudoephedrine) 32. Cathinone (l-alpha-aminopropiofenon) 33. Clonitazene 34. Cocaine 35. Codoxime 36. d- Methadone 37. DB [L-(3,4 - methylenedioxyphenyl) -2 butanamine] 38. Desmethylprodine; MPPP (1-methyl-4-phenyl-4-propionoxypiperidine) 39. Desomorphine 40. DET (N,N-diethyltryptamine) 41. Dexamphetamine 42. Diampromide 43. Diethyl phosphate 44. Diethylthiambutene 45. Dihydromorphine 46. Dimenoxadol 47. Dimepheptanol 48. Dimethylthiambutene 49. Dioxaphetyl butyrate 50. Diphenoxine 51. Dipipanone 52. DMA (2,5-dimethoxyamphetamine) 53. DMGP (dimetilgeptilpiran) 54. DMT (dimethyltryptamine) 55. DOB (d, L-2,5-dimethoxy-4-bromo-amphetamine) 56. DOC (d, L-2,5-dimethoxy-4-chloro-amphetamine) 57. DOET (2,5-dimethoxy-4-ethylamphetamine) 58. Drotebanol 59. Ecgonine 60. Ephedrone 61. Ethylmethylthiambutene 62. Eticyclidine 63. Etonitazene 64. Etorphine 65. Etoxeridine 66. Etryptamine 67. Furethidine 68. Hashish (Anasha, cannabis resin) 69. Heroin (Diacetylmorphine) 70. Hydrocodone 71. Hydrocodone phosphate 72. Hydromorphinol 73. Hydromorphone 74. Isomethadone 75. Ketobemidone 76. Khat 77. L- Methadone 78. Levomethorphan 79. Levomoramide 80. Levophenacylmorphan 81. Levorphanol 82. Lysergic acid and its preparations, that include d-Lysergide (LSD, LSD-25) 83. -
Effects of Medication-Assisted Treatment (MAT) on Functional Outcomes Among Patients with Opioid Use Disorder (OUD)
NATIONAL DEFENSE RESEARCH INSTITUTE Effects of Medication- Assisted Treatment (MAT) for Opioid Use Disorder on Functional Outcomes A Systematic Review Margaret A. Maglione, Laura Raaen, Christine Chen, Gulrez Shah Azhar, Nima Shahidinia, Mimi Shen, Ervant J. Maksabedian Hernandez, Roberta M. Shanman, Susanne Hempel Prepared for the Office of the Secretary of Defense Approved for public release; distribution unlimited For more information on this publication, visit www.rand.org/t/RR2108 Published by the RAND Corporation, Santa Monica, Calif. © Copyright 2018 RAND Corporation R® is a registered trademark. Limited Print and Electronic Distribution Rights This document and trademark(s) contained herein are protected by law. This representation of RAND intellectual property is provided for noncommercial use only. Unauthorized posting of this publication online is prohibited. Permission is given to duplicate this document for personal use only, as long as it is unaltered and complete. Permission is required from RAND to reproduce, or reuse in another form, any of its research documents for commercial use. For information on reprint and linking permissions, please visit www.rand.org/pubs/permissions. The RAND Corporation is a research organization that develops solutions to public policy challenges to help make communities throughout the world safer and more secure, healthier and more prosperous. RAND is nonprofit, nonpartisan, and committed to the public interest. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. Support RAND Make a tax-deductible charitable contribution at www.rand.org/giving/contribute www.rand.org Preface Over the past two decades, the U.S. Department of Defense (DoD) has invested unparalleled resources into developing effective treatments for military-related psychological health conditions.