Schedules of Controlled Substances: Removal of Naldemedine From Control. Final rule.

With the issuance of this final rule, the Drug Enforcement Administration removes the substance naldemedine (4R,4aS,7aR,12bS)-3-(cyclopropylmethyl)-4a,7,9-trihydroxy-N-(2-(3-phenyl-1,2,4-oxadiazol-5-yl)propan-2-yl)-2,3,4,4a,5,7a-hexahydro-1H-4,12-methanobenzofuro[3,2-e]isoquinoline-6-carboxamide) including its salts from the schedules of the Controlled Substances Act. Prior to the effective date of this rule, naldemedine was a schedule II controlled substance because it can be derived from opium alkaloids. This action removes the regulatory controls and administrative, civil, and criminal sanctions applicable to controlled substances, including those specific to schedule II controlled substances, on persons who handle (manufacture, distribute, reverse distribute, dispense, conduct research, import, export, or conduct chemical analysis) or propose to handle naldemedine.

Preclinical pharmacology and opioid combinations.

Although effective alone, opioids are often used in combination with other drugs for relief of moderate to severe pain. Guidelines for acute perioperative pain recommend the use of multimodal therapy for pain management, although combinations of opioids are not specifically recommended. Mu opioid drugs include morphine, heroin, fentanyl, methadone, and morphine 6ß-glucuronide (M6G). Their mechanism of action is complex, resulting in subtle pharmacological differences among them and with unpredictable differences in their potency, effectiveness, and tolerability among patients. Highly selective mu opioids do not bind to a single receptor. Rather, they interact with a large number of mu receptor subtypes with different activation profiles for the various drugs. Thus, mu-receptor-based drugs are not all the same and it may be possible to utilize these differences for enhanced pain control in a clinical setting. These differences among the drugs raise the question of whether combinations might result in better pain relief with fewer side effects. This concept has already been demonstrated between two mu opioids in preclinical studies and clinical trials on other combinations are ongoing. This article reviews the current state of knowledge about mu opioid receptor pharmacology, summarizes preclinical evidence for synergy from opioid combinations, and highlights the complex nature of the mu opioid receptor pharmacology.

Molecular insights into mu opioid pharmacology: From the clinic to the bench.

Most of the opioids used in clinical practice exert their effects through mu opioid receptors. Yet, subtle but important pharmacological differences have been observed among the mu opioids. Their potency, effectiveness, and adverse effects can vary unpredictably among patients. These clinical differences among the mu opioids strongly argue against a single receptor mediating their actions. The cloning of the mu opioid receptor has greatly enhanced our understanding of the complexity of this system and has provided possible mechanisms to explain these observations. A single mu opioid receptor gene has been identified, but we now know that it generates a multitude of different mu opioid receptor subtypes through a mechanism commonly used to enhance protein diversity, alternative splicing. Early studies identified a number of splice variants involving the tip of the C-terminus. This region of the receptor is far away from the binding pocket, explaining why these variants still exhibit the same selectivity for mu opioids. However, the differences in structure at the C-terminus influence the activation patterns of the mu opioids. In addition, a second series of variants has been isolated that involves alternative splicing at the N-terminus. Together, these sets of mu opioid receptor splice variants may help explain the clinical variability of the mu drugs among patients and provide insights into why it is so important to individualize therapy for every patient in pain.

Mu-opioid receptor ligands lack receptor subtype selectivity in the aequorin luminescence-based calcium assay.

The aim of the present study was to characterize the binding selectivity of the mu-opioid receptor ligands, endomorphin-1, endomorphin-2, and DAMGO, in the in vitro functional assay, based on the changes in intracellular calcium levels. For the experiments Chinese hamster ovary cells, stably expressing human mu-receptor, were used. The mu-agonist-induced calcium responses were significantly inhibited by naloxone, an opioid antagonist with high preference for the mu-opioid receptors. Naloxonazine, a mu1-non-peptide antagonist, inhibited the effect of all tested mu-agonists. However, there was no significant difference in the antagonist effect of naloxonazine on the calcium response induced by mu1- (endomorphin-2) and mu2-agonists (endomorphin-1, DAMGO). [D-Pro2]endomorphin-1 and [D-Pro2]endomorphin-2, putative peptide mu2- and mu1-antagonists, respectively, which had been shown in vivo to inhibit the antinociception induced by mu-agonists, produced no inhibitory effect in our in vitro experiments. Our results demonstrated that there is only one population of the mu-opioid receptors expressed in the Chinese hamster ovary cells. We suggest that the mu-opioid receptors form a homogenous population in the in vitro systems. However, the existence of mu-receptor subtypes in vivo is still pharmacologically possible.

Involvement of mu1-opioid receptor on oxycodone-induced antinociception in diabetic mice.

The effect of naloxonazine, a selective mu(1)-opioid receptor antagonist, on oxycodone-induced antinociception was examined in streptozotocin-induced diabetic mice. Oxycodone (5 mg/kg, s.c.) induced significant antinociception in both non-diabetic and diabetic mice. This antinociceptive effect of oxycodone was completely antagonized by pretreatment with naloxonazine (35 mg/kg, s.c.) in both non-diabetic and diabetic mice. The selective kappa-opioid receptor antagonist nor-binaltorphimine (20 mg/kg, s.c.) also antagonized oxycodone-induced antinociception in diabetic mice, but only had a partial effect in non-diabetic mice. These results suggest that although primarily interacts with mu(1)-opioid receptor, kappa-opioid receptors are also strongly involved in oxycodone-induced antinociception.

The mu-opioid receptor subtype is required for the anorectic effect of an opioid receptor antagonist.

A diaryl ether derivative, (6-(4-{[(3-methylbutyl)amino]methyl}phenoxy)nicotinamide, was prepared and investigated for its biochemical properties at cloned opioid receptors and its pharmacological effects on animal feeding. The compound displaced [(3)H]DAMGO binding of human mu-opioid receptor, [(3)H]U-69593 of human kappa-opioid receptor, and [(3)H]DPDPE of human delta-opioid receptor with IC(50) values of 0.5+/-0.2 nM, 1.4+/-0.2 nM, and 71+/-15 nM, respectively. The compound also potently inhibited [(3)H]DAMGO binding of cloned mouse and rat mu-opioid receptors (IC(50) approximately 1 nM), and acted as a competitive antagonist in a cAMP functional assay using cultured cells expressing human or mouse mu-opioid receptors. Following a single oral administration in diet-induced obese mice (at 10 or 50 mg/kg) or rats (at 1, 3, or 10 mg/kg), the compound caused a dose-dependent suppression of acute food intake and body weight gain in both species. Importantly, the anorectic efficacy of the compound was mostly diminished in mice deficient in the mu-opioid receptor. Our results suggest an important role for the mu-opioid receptor subtype in animal feeding regulation and support the development of mu-selective antagonists as potential agents for treating human obesity.

Differences in tolerance to anti-hyperalgesic effects between chronic treatment with morphine and fentanyl under a state of pain.

The present study was undertaken to investigate the possible change in anti-hyperalgesic effect following repeated treatment with morphine or fentanyl using the dose to improve the thermal hyperalgesia under an inflammatory pain-like state. The anti-hyperalgesic effect induced by fentanyl in complete Freund's adjuvant (CFA)-pretreated mice rapidly disappeared during the consecutive administration of fentanyl, whereas morphine preserved its potency of anti-hyperalgesic effect. In addition, repeated treatment with fentanyl, but not morphine, resulted in the increase in levels of phosphorylated-mciro-opioid receptor (MOR) associated with the enhanced inactivation of protein phosphatase 2A and the reduction in Rab4-dependent MOR resensitization. Next, we investigated the specific involvement of the opioid receptor types and MOR subtypes in analgesic properties of morphine and fentanyl in the mouse spinal cord. In the competitive displacement binding assay with [1H]DAMGO, no significant difference in the binding affinity to MOR between morphine and fentanyl was noted in membranes obtained from the mouse spinal cord. Furthermore, there was no significant difference between morphine and fentanyl in either antinociceptive effect or G-protein activation in mice partially lacking MOR-1B, which shows a greater resistance to agonist-induced desensitization than for other MOR subtypes. These findings point out the possibility that the chronic treatment with fentanyl may cause the different modulation from chronic treatment with morphine on either the internalization or resensitization of MORs in the spinal cord under a pain-like state. The present data provide the first evidence for the mechanism underlying the development of tolerance to fentanyl-induced anti-hyperalgesic effect under chronic pain.

Mu opiate receptor subtypes.

The . opiate receptor gene (MOR) has at least 14 exons that can generate 15 different splice variants. Recently, two new human MOR splice variants (hMOR-1O and hMOR-1X) have been identified and characterized. The two variants containing human MOR exons 1, 2, and 3 and a fourth alternative exon O, or exon X, are expressed in human brain tissue, and are selective for mu opioid binding in transfected cells. It is unclear; however, what the biologic role of these two novel human splice variants is in vivo. The mu3 opiate receptor subtype found in various human tissues where it is coupled to constitutive nitric oxide synthase derived nitric oxide release is characterized by its opiate alkaloid selectivity and its insensitivity to opioid peptides. The mu3 clone exhibits 100% identity to the mu1 receptor subtype in the center and conserved region, but with a truncated 5'-end (position 503 of mu1 mRNA) (missing several hundred nucleotides). In addition, the 3'-end of the new clone contains the 3'-end of the mu1 receptor, followed by a new fragment of 263 bases, and then by a 202 bp fragment of the 3'-end of the mu1 gene untranslated region. When mu3 is expressed in a heterologous system, the protein produced from this cDNA exhibits all of the expected biochemical characteristics of the mu3 receptor. The isolation of this novel splice variant adds support to the presence of morphinergic signaling in animals.

Characterization of opioid receptors that modulate nociceptive neurotransmission in the trigeminocervical complex.

1. Opioid agonists have been used for many years to treat all forms of headache, including migraine. We sought to characterize opioid receptors involved in craniovascular nociceptive pathways by in vivo microiontophoresis of micro -receptor agonists and antagonists onto neurons in the trigeminocervical complex of the cat. 2. Cats were anaesthetized with alpha-chloralose 60 mg kg(-1), i.p. and 20 mg kg(-1), i.v. supplements after induction and surgical preparation using halothane. Units were identified in the trigeminocervical complex responding to supramaximal electrical stimulation of the superior sagittal sinus, and extracellular recordings of activity made. 3. Seven- or nine-barrelled glass micropipettes incorporating tungsten recording electrodes in their centre barrels were used for microiontophoresis of test substances onto cell bodies. 4. Superior sagittal sinus (SSS)-linked cells whose firing was evoked by microiontophoretic application of L-glutamate (n=8 cells) were reversibly inhibited by microiontophoresis of H(2)N-Tyr-D-Ala-Gly-N-Me-Phe-Gly-ol (DAMGO) (n=12), a selective micro -receptor agonist, in a dose dependent manner, but not by control ejection of sodium or chloride ions from a barrel containing saline. 5. The inhibition by DAMGO of SSS-linked neurons activated with L-glutamate could be antagonized by microiontophoresis of selective micro -receptor antagonists D-Phe-Cys-Tyr-D-Trp-Orn-Thr-Pen-Thr-NH(2) (CTOP) or D-Phe-Cys-Tyr-D-Trp-Arg-Thr-Pen-Thr-NH(2) (CTAP), or both, in all cells tested (n=4 and 6, respectively). 6. Local iontophoresis of DAMGO during stimulation of the superior sagittal sinus resulted in a reduction in SSS-evoked activity. This effect was substantially reversed 10 min after cessation of iontophoresis. The effect of DAMGO was markedly inhibited by co-iontophoresis of CTAP. 7. Thus, we found that micro -receptors modulate nociceptive input to the trigeminocervical complex. Characterizing the sub-types of opioid receptors that influence trigeminovascular nociceptive transmission is an important component to understanding the pharmacology of this synapse, which is pivotal in primary neurovascular headache.

Insights into mu opioid pharmacology the role of mu opioid receptor subtypes.

Although mu opioids share many pharmacological characteristics, they also reveal many differences. Many approaches over the years have suggested the existence of multiple mu opioid receptors. The unique selectivities of naloxonazine, for example, provided a way of distinguishing mu1from mu2actions. Studies of morphine-6beta-gluruconide suggested that its actions involved yet another mu opioid receptor subtype. The cloning of a mu opioid receptor, MOR-1, provided a way of exploring this possibility at the molecular level. Recent studies have now identified a number of splice variants of this gene that appear to be important in the production of mu opioid analgesia.

Contribution of spinal mu1-opioid receptors to morphine-induced antinociception.

To determine the role of mu-opioid receptor subtypes, mu1 and mu2, in antinociception induced by intrathecal (i.t.) or intracerebroventricular (i.c.v.) injection of morphine, we assessed the effect of naloxonazine, a selective antagonist at mu1-opioid receptors. The antinociceptive effects of morphine were measured using four different nociceptive tests. The selective mu1 antagonist, naloxonazine (35 mg/kg, s.c.), 24 h before testing antagonized the antinociceptive effect of morphine on responses to chemical and thermal stimuli to a greater extent than that on responses to mechanical stimuli, as judged from ED50 values. The present results suggest that the antinociceptive activity of both i.t. and i.c.v. morphine on responses to chemical and thermal stimuli may be mediated through the mu1-opioid receptor subtype (naloxonazine-sensitive sites). These findings may be interpreted as indicative of the existence of mu1-receptor subtypes capable of mediating antinociception not only in supraspinal sites but also in spinal sites.

DAMGO, a mu-opioid receptor selective ligand, distinguishes between mu-and kappa-opioid receptors at a different region from that for the distinction between mu- and delta-opioid receptors.

The structural basis of opioid receptors (OPRs) for the subtype-selective binding of DAMGO, a mu-opioid receptor selective ligand, was investigated using chimeric mu/kappa-OPRs. Replacement of the region from the middle of the fifth transmembrane domain to the C-terminal of mu-OPR with the corresponding region of mu-OPR remarkably decreased the binding affinity to DAMGO, while the reciprocal chimera revealed the high affinity to DAMGO. These results indicate that DAMGO distinguishes between mu- and mu-OPRs at the region around the third extracellular loop, different from the case of the distinction between mu-and delta-OPRs in which the region around the first extracellular loop is important. Furthermore, displacement studies revealed that the region around the third extracellular loop is involved in the discrimination between mu- and kappa-OPRs not only by peptidic mu- selective ligands but also by non-peptidic ligands, such as morphine and naloxone.

Morphine receptors in immunocytes and neurons.

Receptor interactions of morphine are reviewed, with particular attention given to a recently discovered opiate receptor, designated mu 3, with unique selectivity for morphine and certain other opiate alkaloids. Morphine, other opiate alkaloids and related analogs are known to bind to the classical delta, mu and kappa opioid receptor subtypes. Each of these subtypes also binds one or more of the endogenous opioid peptides with high affinity. Immunocytes have recently been found to contain a unique receptor for morphine, capable of binding morphine and certain other opiate alkaloids, but with essentially no or exceedingly low affinity for the naturally occurring endogenous opioid peptides or peptide analogs. This putative mu 3 (morphine/opiate alkaloid) receptor is present in invertebrate immunocytes as well as in human peripheral blood monocytes (macrophages). More recently this same receptor has been found in certain established macrophage cell lines and in human peripheral blood granulocytes. Finally, the same or closely related opiate alkaloid-selective (mu 3) receptor has been found to be present in a neuroblastoma and in a hybrid neural cell line. Studies indicate that in the immunocytes the receptor mediates inhibitory effects of morphine on cellular chemotaxis. While the functional coupling of this receptor in neurons is not known, it is postulated that the receptor may mediate effects of opiates on neuronal differentiation and cell division as well as neuronal transmission. Both for the immune system and the nervous system, the mu 3 receptor may constitute a major site of action for putative endogenous morphine or morphine-like substances. This receptor system also provides an additional pharmacological site of action for exogenously administered opiate alkaloid drugs. The mu 3 receptor is proposed to be an important neuro-immune link. This system is likely to play a significant role in a variety of responses involving the immune system, including the response of the organism to stress, infection and malignant transformation.

Opioid mu receptor subtypes (possibly mu 1 and mu 2) revealed by morphine-induced antinociception vs endothelin-1 in recombinant inbred CXBK mice.

Morphine was administered intracerebroventricularly to normal or recombinant inbred CXBK (mu-opioid receptor deficient) mice and antinociception was determined against two different stimuli. Morphine-induced antinociception against acetylcholine was strain-dependent, whereas against endothelin-1 it was not. The antinociception was mediated via opioid mu receptors (blocked by beta-FNA, but not naltrindole, ICI 174,864 or nor-BNI) through separate pathways, one naloxonazine-sensitive and the other naloxonazine-insensitive. Taken together, these results appear to demonstrate supraspinal morphine-induced antinociception through distinct subtypes of the mu opioid receptor, supporting the possibility of novel subtype-selective therapeutic agents with greater separation between analgesia and side-effects or physical dependence. Furthermore, the methodology described herein provides model systems for the in vivo screening of such agents.

Independent expression of two pharmacologically distinct supraspinal mu analgesic systems in genetically different mouse strains.

Morphine coadministered at the level of the brainstem and the spinal cord in rodents elicits a profound synergism with a combined analgesic potency almost 10-fold greater than that seen with morphine in either region alone. In the present study, we demonstrate that supraspinal mu2 receptors mediate this synergy, whereas morphine given only within the brainstem elicits analgesia through mu1 receptors. In the mu1-deficient CXBK strain of mice, morphine given intracerebroventricularly (i.c.v.) alone at doses up to 10 micrograms fails to produce greater than 20% analgesia in marked contrast to CD-1 mice (ED50 0.51 micrograms i.c.v.). At the spinal level, both the CXBK and CD-1 strains are equally sensitive to morphine (ED50 0.91 and 0.94 micrograms intrathecally, respectively), a mu2 action. Morphine administered i.c.v. potentiates a fixed low dose of intrathecal morphine as effectively in the CXBK mice as the CD-1 mice. Additional studies using selective mu antagonists differentiated these two analgesic responses pharmacologically. The mu1-selective drug naloxonazine (35 mg/kg s.c.) antagonizes the analgesic actions of morphine given only supraspinally without diminishing the potency of i.c.v. morphine in the synergy model. beta-Funaltrexamine, which blocks both mu1 and mu2 receptors, given i.c.v. antagonizes the analgesia after supraspinal morphine alone (ID50 2.5 micrograms i.c.v.) or its potentiation of intrathecal morphine (ID50 2.4 micrograms i.c.v.) equally well, confirming the involvement of mu receptors in both actions. In contrast, naloxonazine reverses the analgesia after supraspinal morphine alone (ID50 2.8 micrograms i.c.v.) almost 6-fold more potently than the synergy between i.c.v. and intrathecal morphine (ID50 18.3 micrograms i.c.v.). Together our results indicate the presence of two genetically and pharmacologically distinct populations of supraspinal mu receptors capable of mediating analgesia.

Involvement of mu1 and mu2 opioid receptor subtypes in tail-pinch feeding in rats.

Tail-pinch feeding (TPF) in rats is decreased following general (naltrexone, NTX) and mu (Cys2-Tyr3-Orn5-Pen7-amide, CTOP) opioid antagonists, but not following kappa (nor-binaltorphamine. Nor-BNI) or delta (naltrindole, NTI) opioid antagonists. Because multiple mu (mu1 and mu2) and delta (delta 1 and delta 2) opioid receptor subtypes have been characterized, the present study evaluated whether TPF was differentially altered following ICV administration of general (NTX), mu (beta-funaltrexamine, B-FNA), mu1 (naloxonazine, NAZ), kappa (Nor-BNI), delta 1 ([D-Ala2, Leu5, Cys6]-enkephalin, DALCE) and delta 2 (NTI) opioid antagonists. Like the reversible mu antagonist CTOP, the irreversible mu antagonist B-FNA significantly and dose-dependently (1-20 micrograms) reduced TPF by up to 28%. In contrast, whereas NAZ (50 micrograms) reduced TPF by 32%, this effect was highly variable and failed to achieve significance. Neither NTX (5-10 mg/kg, SC), Nor-BNI (20 micrograms), DALCE (40 micrograms) nor NTI (20 micrograms) significantly altered TPF, suggesting that kappa, delta 1 and delta 2 opioid receptor subtypes were not involved. Because no antagonist altered the duration of food contact during tail pinch, it appears that the opioid effect modulates ingestive rather than activational mechanisms. The reliable inhibition of TPF by B-FNA (mu1 and mu2), together with the variable effect of naloxonazine (mu1), appears to implicate both mu binding sites in this response.

Analgesic potency of TRIMU-5: a mixed mu 2 opioid receptor agonist/mu 1 opioid receptor antagonist.

TRIMU-5 (Tyr-D-Ala-Gly-NH-(CH2)2CH(CH3)2) is a potent enkephalin analog with analgesic actions. Detailed studies show high affinity for both mu 1 and mu 2 sites, with poor affinity for delta, kappa 1 and kappa 3 receptors. Of all the mu ligands examined in binding assays, TRIMU-5 was the most mu-selective. In mice, TRIMU-5 administered either intracerebroventricularly (i.c.v.) or intrathecally elicited analgesia which was readily reversed by the mu-selective antagonist beta-funaltrexamine (beta-FNA). However, the analgesia observed following i.c.v. injections differed from traditional mu ligands: (1) the dose of drug required for analgesic activity i.c.v. was 100-fold greater than those following intrathecal administration; (2) although sensitive to beta-FNA, the analgesia was not antagonized by naloxonazine; and (3) the analgesia was reversed by an opioid antagonist given intrathecally (i.t.) but not i.c.v. Thus, TRIMU-5 analgesia appeared to be mediated spinally through mu 2 receptors. TRIMU-5 did have supraspinal actions, inhibiting gastrointestinal transit, another mu 2 action. In binding studies TRIMU-5 had high affinity for mu 1 sites, but pharmacological studies revealed antagonist actions at this receptor. In mice, the analgesia produced by morphine given i.c.v. was antagonized by coinjection of a low TRIMU-5 dose which was inactive alone. Similarly, TRIMU-5 coadministered with morphine into the periaqueductal gray of rats reversed the analgesia seen with morphine alone. Thus, TRIMU-5 is a highly selective mixed mu 2 opioid receptor agonist/mu 1 opioid receptor antagonist.