Opioids are scheduled by the propensity for misuse and abuse with a high rate of dependency and risk of fatal overdose. Opioids can be divided into different classes, including, natural, synthetic, and semi-synthetic. Opiates are naturally occurring and come directly from the opium poppy plant; whereas the semi synthetics opioids are chemical modifications of the poppy plant. Synthetic opioids attach to the opioid receptor but contain no part of the poppy plant. The increased variety and frequency in opioid prescriptions contributed to an opioid epidemic in the United States which is still on going. According to the CDC, the opioid epidemic has occurred in three waves. The first wave of the epidemic began in the 1990’s with the increase in opioid prescription pain medication overdoses. The second wave began around 2010 when heroin overdoses became more prevalent. This was followed by a sharp uptick in fentanyl deaths beginning around the year 2013, indicating the start of the third wave. The opioid epidemic has had a huge cost to society, not just due to deaths but also because of lost productivity, medical expenses and judicial system costs (Florence, Zhou, Luo, & Xu, 2016). To best design and implement strategies to combat this issue, an understanding of the population effected is needed. Since many public health policies are implemented at the regional level, knowing the characteristics and demographics of the epidemic at the local level is important. This study evaluates trends in drug related death cases in the Florida District 6 Medical Examiner Office (MEO) from the calendar years 2011 through 2016. Specifically, it focuses on opioids and the role of fentanyl in overdose related mortality. Additional attention is given to fentanyl and fentanyl analog related deaths. Fentanyl analogs present challenges from an analytical toxicology perspective. Fentanyl analogs can be difficult to detect. Two sets of data from each calendar year were obtained from the MEO. This data was collated, standardized and then statistically analyzed. It was determined that there was not a significant difference in month of the year or the day of the week that drug related fatalities occurred. The time of day was statistically significant with more drug related mortalities occurring during the hours of 8:00am and 4:00pm. When assessing mortality rates, Pinellas and Pasco county demonstrated differences. Pasco county has higher overall mortality for opioid related deaths. Pinellas county has almost twice the number of the opioid, fentanyl, related overdose fatalities. Racial demographics, divided into White, Black, and Asian populations, demonstrated that the White population is disproportionally affected by fentanyl drug related mortality. Binary logistic regression showed that fentanyl and heroin tend to co-occur, and that ethanol, hydrocodone, methadone, morphine, and oxycodone do not usually co-occur with fentanyl in drug related fatalities. These data help elucidate trends in the opioid epidemic at a regional level. There are differences between Pinellas and Pasco county; with the former having more fentanyl related drug deaths and the latter having more opioid related drug deaths over the six years analyzed. An interesting result is derived from the binary logistic regression. It is shown here that fentanyl and heroin tend to co-occur together. It is also shown that ethanol, hydrocodone, morphine, oxycodone, and methadone do not co-occur with fentanyl related overdose cases. Notably, methadone has the strongest negative association with fentanyl related overdoses.

A case is presented of a fatal drug interaction caused by ingestion of oxycodone (Oxycontin®) and clonazepam (Klonapin®). Oxycodone is an opium alkaloid used in long-term pain management therapy. Clonazepam is a benzodiazepine used for the treatment of seizures and panic disorders. The Drug Abuse Warning Network (DAWN) has reported an increase of 108% in the last two years of emergency department episodes related to Oxycontin®. Six billion prescriptions were written for Oxycontin® in the year 2000, an 18-fold increase from four years previous (1). Oxycontin has recently gained enormous notoriety at the local and national levels; however, there are very few previously documented cases of lethal drug interactions between oxycodone and clonazepam. Synergistic effects between these two drugs are postulated to arise from different agonistic mechanisms producing similar physiological changes. It is also theorized that clonazepam may inhibit the metabolism of oxycodone. A 38-year-old white female was found dead in Jefferson County, Tennessee in March of 2001. The deceased had physical evidence of previous drug abuse and positive serological findings of hepatitis B and C. Prescription pill bottles filled under the name of the deceased, as well as another name, were found with the body. Serum, urine and gastric contents from the deceased were screened for numerous drugs and metabolites using a combination of thin layer chromatography and immunoassay techniques (EMIT and FPIA). Analysis of biological specimens from the deceased revealed the presence of: benzodiazepines, opiates (oxycodone), and trazodone metabolites in the serum; cannabinoids, benzodiazepines, opiates (oxycodone), trazodone, trazodone metabolites, nicotine, and nicotine metabolite in the urine; and benzodiazepines, opiates (oxycodone), nicotine, and nicotine metabolite in the gastric contents. Quantitative analyses for clonazepam was performed by high performance liquid chromatography (HPLC) and revealed a plasma concentration of 1.41 μg/mL. Plasma oxycodone and urine 11-nor-carboxy-delta-9-tetrahydrocannabinol concentrations were determined by gas chromatography/mass spectrometry and revealed concentrations of 0.60 μg/mL and 27.9 ng/mL, respectively. The deceased had pathologies consistent with severe central nervous system (CNS) and respiratory depression produced by high concentrations of clonazepam and oxycodone including collapsed lungs, aspirated mucus, and heart failure. The pathologies were sufficient to cause death, which was officially attributed to a drug overdose; however, the manner of death was unknown.

Opiate addiction is now a major public health problem. Pregnant women continue to use opiates during gestation; up to 5.4% of pregnant women report using illicit drugs during pregnancy. Previous studies have shown that perinatal insults and exposure to opiates such as morphine in utero can affect the development of the hypothalamic-pituitary-adrenal (HPA)-axis of the offspring and are associated with higher risk of developing neurobehavioral problems. Oxycodone, a semisynthetic putative kappa opioid receptor and partial mu opioid receptor agonist is now one of the most frequently abused pain killers during pregnancy, however limited data are available regarding whether and how perinatal oxycodone exposure (POE) alters the development and functions of the HPA-axis, the related stress axis and neurobehavioral outcomes of the offspring. Data from these experiments have provided novel evidence that POE indeed is associated with sex-specific changes in the HPA-axis in response to stress that persist beyond the neonatal period. 1) POE is associated with an increased adrenocorticotropic hormone (ACTH) response to corticotropin-releasing hormone (CRH), but not the corticosterone (CORT) response to CRH stimulation in late adolescent male offspring. 2) POE is associated with increased CORT, but not ACTH response to restraint stress test in adult female offspring. These changes in the HPA-axis response to stress may be partially explained by 1) an increase in the subpopulation of CRH neurons that also contain estrogen receptor-beta immunoreactivity following POE which then can exaggerate the stimulation of the HPA-axis, and 2) a decrease in mineralocorticoid receptor-mRNA expression in the hippocampus which may be associated with impaired negative feedback control of the HPA-axis by the limbic system. POE is also associated with cardiovascular changes in response to stress during a classical conditioning paradigm; adolescent male POE rats have a larger blood pressure increase than the control group. Although POE male rats can properly discriminate the stress versus non-stress cues in the conditioning paradigm, they do not retain this memory when retested during adulthood. When tested for learning and memory in a water maze, however, we did not find any differences between control rats and rats exposed to high dose oxycodone in utero. In addition, we demonstrated that exposure to the lower dose of oxycodone in utero is associated with hyperactivity in adult rats when tested in an open field. Our results make a significant contribution to the literature because they extend our knowledge about the effects of oxycodone on the developing brain and the resulting outcomes in animal models that are actually relevant to a current major public health problem in humans and will provide a platform for us to further study the underlying mechanisms and interventions that may mitigate these effects.

Opioids, such as oxycodone, morphine, and fentanyl, are commonly used medications in the treatment of moderate to severe pain. In spite of their efficacious analgesic properties, their increased prescribing rates by physicians and inherent abuse-related effects have led to the ongoing opioid epidemic. Their clinical utility is limited by the risk of adverse dose-dependent side effects, such as constipation and respiratory depression, and the development of tolerance and dependence. Opioid-sparing adjunctive therapies are sought to address these issues by reducing the dose of opioid needed to achieve analgesia through alternative non-opioidergic mechanisms and as a result, reduce the incidence of the previously mentioned side effects. Serotonin type-2C receptor agonists have demonstrated antinociceptive efficacy in preclinical models of chronic pain. Lorcaserin is a selective 5-HT2C receptor agonist and was reported to attenuate the abuse-related effects of oxycodone. The antinociceptive properties of 5-HT2C receptor agonists and their potential to alter the abuse-related effects of commonly abused drugs suggest that lorcaserin may be a potential opioid-sparing therapeutic. The goal of these studies was to evaluate the utility of lorcaserin, in combination with opioids, in a preclinical model of acute pain. Based on previous studies demonstrating the antinociceptive activity of 5-HT2C agonists, the hypotheses for these studies were that lorcaserin would increase the acute antinociceptive effects of opioids and would attenuate the development of tolerance associated with chronic opioid consumption. The results demonstrate that the acute antinociceptive effects and the time-course of activity of opioids were enhanced by doses of lorcaserin. These effects were mediated through activation of the 5-HT2C receptor and were not blocked by administration of naloxone. Additionally, the acute effects of lorcaserin to increase opioid potency and time course was not mediated through changes in opioid distribution in the blood or central tissues. Opioid tolerance was evaluated in vivo, and tolerance was developed using two methods of treatment: an acute (single dose administration) model of tolerance and a multiple-injection model. Testing the effect of lorcaserin in these models was important because current research suggests that the mechanisms that underlie both models of tolerance are distinct from one another. The results demonstrate that lorcaserin significantly blocked the development of acute tolerance in the whole animal and on a single cell level in dorsal root ganglion cell cultures. In the multiple-day tolerance model, lorcaserin partially attenuated the development of opioid antinociceptive tolerance. Chronic administration of an opioid is associated with desensitization of the MOR, and the effect of lorcaserin on opioid tolerance may be mediated through changes in MOR functional activity. Upon further investigation using agonist-stimulated [35S]GTPyS, the results showed that lorcaserin altered basal binding of [35S]GTPyS but not agonist-stimulated binding in mice that received chronic opioid treatment. These data suggest that the effect of lorcaserin on opioid tolerance, in the multiple-injection model, is not mediated through changes in MOR functional activity. Collectively, the tolerance studies suggest that the effect of 5-HT2C receptor activation by lorcaserin has differential effects on the stages of opioid tolerances and further supports the notion that the mechanisms that underlie the stages of opioid tolerance are distinct. Given the efficacy of lorcaserin to increase the acute antinociceptive effects of opioids and its ability to impair the development of opioid tolerance, collectively, these data suggest that lorcaserin may be a useful opioid-sparing adjunctive therapy.

<p>The pharmacokinetics and pharmacodynamics of oxycodone and morphine was investigated and related to the transport across the blood-brain barrier (BBB) in rats. The influence of a P-glycoprotein (P-gp) inhibitor on the plasma pharmacokinetics and pharmacodynamics of oxycodone was evaluated. Microdialysis experiments were conducted to evaluate the unbound pharmacokinetics, including the rate and extent of transport across the BBB, of oxycodone and morphine. Mathematical models were used to assess the pharmacokinetics and also the relationship between pharmacokinetics and pharmacodynamics of the drugs.</p><p>Oxycodone clearance, volume of distribution at steady-state, half-life, total brain tissue concentrations and tail-flick latency were all unaffected when a P-gp inhibitor was co-administered with oxycodone as compared to a control group. The lack of differences between the groups indicates that oxycodone BBB transport is not affected by P-gp inhibition. Investigating the unbound concentrations of oxycodone in brain and blood using microdialysis revealed an exciting finding. At steady-state, the unbound concentration in brain was 3 times higher than in blood (i.e. a K_p,uu of 3), indicating that active influx is involved in the BBB transport of oxycodone. In contrast, the K_p,uu of morphine was estimated to 0.56, which is an indication that active efflux mechanisms are involved in the BBB transport of morphine. This means that based on the same unbound concentration in blood, an approximately 6-fold higher unbound concentration of oxycodone compared to morphine will be reached in the brain. Using pharmacokinetic-pharmacodynamic modelling, the unbound brain concentrations of oxycodone and morphine were correlated to the tail-flick latency in vivo. The relative potency of the drugs was found to be concentration dependent with an infliction point of 55 nM.</p><p>In summary, this thesis emphasise the importance of taking the local brain pharmacokinetics into consideration when investigating the pharmacokinetics and the pharmacokinetic-pharmacodynamic relationships of centrally acting drugs.</p>

The pharmacokinetics and pharmacodynamics of oxycodone and morphine was investigated and related to the transport across the blood-brain barrier (BBB) in rats. The influence of a P-glycoprotein (P-gp) inhibitor on the plasma pharmacokinetics and pharmacodynamics of oxycodone was evaluated. Microdialysis experiments were conducted to evaluate the unbound pharmacokinetics, including the rate and extent of transport across the BBB, of oxycodone and morphine. Mathematical models were used to assess the pharmacokinetics and also the relationship between pharmacokinetics and pharmacodynamics of the drugs. Oxycodone clearance, volume of distribution at steady-state, half-life, total brain tissue concentrations and tail-flick latency were all unaffected when a P-gp inhibitor was co-administered with oxycodone as compared to a control group. The lack of differences between the groups indicates that oxycodone BBB transport is not affected by P-gp inhibition. Investigating the unbound concentrations of oxycodone in brain and blood using microdialysis revealed an exciting finding. At steady-state, the unbound concentration in brain was 3 times higher than in blood (i.e. a Kp,uu of 3), indicating that active influx is involved in the BBB transport of oxycodone. In contrast, the Kp,uu of morphine was estimated to 0.56, which is an indication that active efflux mechanisms are involved in the BBB transport of morphine. This means that based on the same unbound concentration in blood, an approximately 6-fold higher unbound concentration of oxycodone compared to morphine will be reached in the brain. Using pharmacokinetic-pharmacodynamic modelling, the unbound brain concentrations of oxycodone and morphine were correlated to the tail-flick latency in vivo. The relative potency of the drugs was found to be concentration dependent with an infliction point of 55 nM. In summary, this thesis emphasise the importance of taking the local brain pharmacokinetics into consideration when investigating the pharmacokinetics and the pharmacokinetic-pharmacodynamic relationships of centrally acting drugs.

Diss. (sammanfattning) Uppsala : Uppsala universitet, 2007. / Härtill 4 uppsatser.

La variabilité interindividuelle dans la réponse aux médicaments constitue une problématique importante pouvant causer des effets indésirables ou l’échec d’un traitement. Ces variabilités peuvent être causées par une diminution de l’activité de l’enzyme responsable du métabolisme de certains médicaments, fréquemment les cytochromes P450, un système enzymatique majeur dans le métabolisme de ces derniers. Ces enzymes sont sujets à des mutations génétiques appelées polymorphismes, qui altèrent l’activité métabolique. Il est donc important d’évaluer le rôle de ces enzymes dans le métabolisme des médicaments afin d’identifier leur responsabilité dans la variabilité interindividuelle de la réponse au traitement. Parmi l’important système enzymatique que représentent les cytochromes P450, l’isoenzyme CYP2D6 est particulièrement étudiée, ses variations métaboliques revêtant une haute importance clinique. L’un des substrats du CYP2D6 est l’oxycodone, un analgésique narcotique largement prescrit en clinique. Une grande variabilité est observée dans la réponse analgésique à l’oxycodone, variabilité pouvant être causée par un polymorphisme génétique. Il est connu que des variations génétiques dans le CYP2D6 compromettent la réponse analgésique à la codéine en rendant moins importante la formation de son métabolite actif, la morphine. Par analogie, plusieurs études supportent l’hypothèse selon laquelle le métabolite oxymorphone, formée par l’isoenzyme CYP2D6, serait responsable de l’analgésie de l’oxycodone. Une déficience génétique de l’enzyme compromettrait la réponse analgésique au médicament. Les travaux effectués dans le cadre de ce mémoire ont démontré que l’inhibition du CYP2D6 chez des sujets volontaires réduit de moitié la production d’oxymorphone, confirmant l’importante implication de l’enzyme dans le métabolisme de l’oxycodone. Ces résultats démontrent une forte ressemblance avec le métabolisme de la codéine, suggérant que l’oxymorphone pourrait être responsable de l’analgésie. Cependant, les travaux effectués n’ont pu établir de relation entre la concentration plasmatique d’oxymorphone et le niveau d’analgésie ressenti par les sujets. La continuation des études sur le mécanisme d’action de l’oxycodone dans la réponse analgésique est essentielle afin d’établir la source des variabilités interindividuelles expérimentées par les patients et ainsi d’éviter des effets secondaires ou lacunes dans le traitement. / Intersubject variability in drug response is an important issue provoking side effects or treatment failure. Such variability may be caused by the decreased activity of the enzyme metabolising the drug, frequently cytochromes P450, a major enzyme system in drug metabolism. These enzymes are prone to genetic mutations called polymorphisms, which alter their metabolic activity. It is therefore important to assess the role of these enzymes to identify their responsibility in the intersubject variability of the drug. Among the important enzyme system that represents the cytochrome P450, CYP2D6 is particularly studied for its genetic polymorphisms, which are of clinical importance. One of CYP2D6 substrates is oxycodone, a narcotic analgesic widely prescribed in clinical practice. A large variability is observed in the analgesic response to oxycodone, which could be caused by genetic polymorphism. It is known that these variations affect the analgesic response to codeine, which form the active metabolite morphine by CYP2D6 to be effective. Several studies support the hypothesis that oxymorphone, a metabolite formed by CYP2D6, has the analgesia properties, in a similar mechanism to codeine. A genetic deficiency in the enzyme would compromise the analgesic response to the drug. Results obtained from our laboratory indicate that inhibition of CYP2D6 halved oxymorphone production, confirming the significant involvement of the enzyme in the metabolism of oxycodone. These results demonstrate a strong resemblance to codeine metabolism, suggesting that oxymorphone may be responsible for analgesia. We could not find a relationship between plasma concentration of oxymorphone and analgesia level experienced by subjects. Studies on oxycodone mecanism of action in the analgesic response should continue to establish the source of intersubject variability experienced by patients and thus avoid side effects or gaps in treatment.

The Medical Examiner of Virginia (ME) dataset and the Virginia Department of Forensic Science Driving Under the Influence of Drugs (DUI) datasets were used to determine whether people have the potential to develop tolerances to diphenhydramine, cocaine, oxycodone, hydrocodone, methadone, and morphine. These datasets included the years 2000-2004 and were used to compare the concentrations of these six drugs between people who died from a drug-related cause of death (of the drug of interest) and people who were pulled over for driving under the influence. Three drug pattern groups were created to divide each of the six drug-specific datasets in order to compare concentrations between individuals with the drug alone, the drug and ethanol, or a poly pharmacy of drugs (multiple drugs). An ANOVA model was used to determine if there was an interaction effect between the source dataset (ME or DUI) and the drug pattern groups. For diphenhydramine and cocaine, an interaction was statistically significant, but for the other drugs, it was not significant. The other four drug-specific datasets showed that the DUI and ME were statistically significantly different from each other, and all of those datasets except for methadone showed that there was a statistically significant difference between at least two drug pattern groups. Showing that all of these datasets showed differences between the ME and DUI datasets did not provide sufficient evidence to suggest the development of tolerances to each of the six drugs. One exception was with methadone because there were 14 individuals that had what is defined as a "clinical 'lethal' blood concentration". These individuals provide some evidence for the possibility of developing tolerances.The main outcomes of this study include suggesting changes to make to the ME datasets and the DUI datasets with regard to the way data is kept and collected. Several problems with the fields of these datasets arose before beginning the analysis and had to be corrected. Some of the changes suggested are currently being considered at the Virginia Office of the Chief Medical Examiner as they are beginning to restructure their database.

Epidemiological data indicate that patients who experience a traumatic brain injury (TBI) have an elevated risk of developing a substance use disorder (SUD), but the underlying neurobiological connections remain unclear. To further understand the relationship between TBI and SUD, we investigated the effects of TBI on the abuse-related effects of oxycodone in preclinical models. Our evaluation utilized a lateral fluid percussion injury of moderate severity in adult male Sprague-Dawley rats. In the first aim, we tested the hypothesis that moderate TBI increases the risk for relapse to an opioid use disorder as measured by reinstatement of lever-pressing behavior following extinction in an intravenous oxycodone self-administration procedure. In the second aim, we tested the hypothesis that moderate TBI increases physiological dependence to oxycodone as measured by decreases in food-reinforced lever-pressing behavior and increases in other withdrawal behaviors in both precipitated withdrawal and spontaneous withdrawal. In tests for self-administration, brain-injured subjects, relative to non-injured subjects, showed no significant differences in the number of oxycodone-reinforced sessions required to meet stable maintenance criteria for lever-pressing behavior. Likewise, brain-injured subjects showed no significant differences in the number of non-reinforced sessions to meet extinction criteria for lever-pressing behavior relative to non-injured subjects. In tests for reinstatement, non-injured subjects reinstated responding under oxycodone-associated cue- and oxycodone prime-induced conditions, however, brain-injured subjects did not reinstate lever-pressing behavior under any conditions. In tests for physical dependence, brain-injured subjects showed no significant differences from non-injured subjects with regards to their mean withdrawal scores or food-reinforced lever-pressing behavior. Overall, these data suggest that brain-injured patients no significant pre-morbid history of opioid abuse are at a lesser risk of relapse to opioid use disorders. Moreover, the characteristic withdrawal syndrome in opioid-dependent patients may not contribute to continued opioid abuse to a greater degree in brain-injured patients than compared to non-injured patients.