Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
  • A61K31/47—Quinolines; Isoquinolines
  • A61K31/485—Morphinan derivatives, e.g. morphine, codeine
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/41—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with two or more ring hetero atoms, at least one of which being nitrogen, e.g. tetrazole
  • A61K31/4164—1,3-Diazoles
  • A61K31/4178—1,3-Diazoles not condensed 1,3-diazoles and containing further heterocyclic rings, e.g. pilocarpine, nitrofurantoin
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
  • A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
  • A61P25/30—Drugs for disorders of the nervous system for treating abuse or dependence
  • A61P25/36—Opioid-abuse

Definitions

• the present invention relates to compounds, compositions, and methods for the treatment and prevention of opioid neonatal abstinence syndrome.
• NAS infants are often born prematurely and display a range of symptoms: underweight, breathing and feeding difficulties, irritability, feeding intolerance, emesis, and seizures (Dryden, C, et al. (2009) BJOG 116:665-671; Patrick SW, et al. (2012) JAMA 307: 1934-1940).
• NAS presents a huge financial burden for society because of long intensive care retention times and likely effects on long-term cognitive, emotional and social development of affected children.
• the consensus strategy for newborns with NAS is oral methadone.
• NAS opioid neonatal abstinence syndrome
• a method for reducing or preventing opioid dependence in a fetus carried by a drug dependent or opioid tolerant pregnant subject receiving opioid therapy or maintenance to reduce or prevent neonatal abstinence syndrome (NAS)).
• the method involves administering to the pregnant subject a composition comprising an opioid antagonist in an amount effective to reduce or prevent fetal opioid dependence, wherein the opioid antagonist a) is orally available and reaches the circulation of the pregnant subject, b) is substantially excluded from the pregnant subject's brain by the blood brain barrier, and c) penetrates the placenta and enters the fetal brain.
• the opioid antagonist is administered systemically (for example, subcutaneously in a sustained release formulation, or transdermally) while being substantially excluded from the subject's brain by the blood brain barrier, and penetrating the placenta and entering the fetal brain.
• the opioid antagonist is a neutral antagonist and not an inverse agonist.
• the opioid antagonist comprises ⁇ -naltrexol.
• the opioid antagonist does not comprises naloxone or naltrexone.
• the composition comprises a sustained drug release formulation.
• the method further comprises administering to the subject a palliative therapy.
• the opioid antagonist therapy is continued after birth of the newborn (neonate or infant) in increasing amounts effective to facilitate weaning the neonate from continued opioid maintenance administered when neonatal abstinence is observed.
• a first composition comprising an opioid antagonist in an amount effective to treat the neonatal withdrawal or abstinence syndrome, wherein the opioid antagonist reaches the circulation of the pregnant subject but is substantially excluded from the pregnant subject's brain by the blood brain barrier, and wherein the opioid antagonist penetrates the placenta and enters the fetal brain;
• Figures 1 A and IB are graphs showing ⁇ -naltrexol levels in mice in embryonic (- ⁇ -) and adult (- ⁇ -) brain (Fig. 1 A) and liver (Fig. IB) as a function of survival time (min).
• Figure 1 A shows ⁇ -naltrexol levels in embryonic and adult brain at four different survival times after a single drug injection.
• Figure IB shows ⁇ -naltrexol levels in embryonic and adult liver at four different survival times after drug injection.
• the curve for adult plasma is superimposed for comparison to solid tissues.
• Asterisks in A indicate significant differences between adult and embryonic brain at individual survival times. * p ⁇ 0.05; ** p ⁇ 0.01. Number of samples (n) is indicated in Table 1.
• Figures 2A and 2B are bar graphs showing ⁇ -naltrexol levels (ng/g) in mice across tissue and development.
• Figure 2A shows levels of drug in plasma, brain and liver after a single injection at PD7, PD14, PD20, PD32, and PD50.
• Embryonic (ED17) and adult (>2 mo. old) data from Figure 1 were added for comparison purposes. 45 min. survival time for all data.
• For the PD7 liver sample note that the data bar was truncated to better illustrate the broad range of drug levels across all tissues.
• Figures 3 A to 3C show ⁇ -naltrexol prevents opioid-induced withdrawal behavior in mice.
• Figure 3 A shows ⁇ -naltrexol prevents a dependence behavior, ithdwrawal jumping, when delivered in combination with morphine. Total jumps were counted over a period of 15 minutes starting immediately after the injection of naloxone to induce withdrawal. Two concentration ramping procedure were used for the morphine injections with commensurate ramping of 6 ⁇ - naltrexol. Data are plotted using the lower of the two drug concentrations. Asterisks indicate a significant difference compared to morphine treated animals with no ⁇ -naltrexol; * p ⁇ 0.05; ** p ⁇ 0.01.
• Figure 3B shows jumps from Fig. 3 A separated into ten 1.5 min. time bins. Bidirectional arrows indicate the time bin for each ⁇ -naltrexol dose where an equal number of jumps occur prior to and after that time bin. Note that this timepoint increases with increasing 6P-naltrexol. Asterisk indicates a significant effect of the 1/3000, 1/1000, and 1/200 doses of 6 ⁇ - naltrexol compared to morphine-alone in the first three time bins.
• Figure 3C shows inhibition of weight gain by morphine is alleviated by 6P-naltrexol. The mass of each mouse was determined before and after the 6 day morphine dosing schedule and the percent weight change was determined.
• Asterisk indicates significant difference from animals that received morphine but no ("0") ⁇ -naltrexol (p ⁇ 0.05).
• the number in parentheses indicates the number of animals tested at each drug concentration.
• drug concentration is reported as a ratio of ⁇ -naltrexol to morphine in order to emphasize the combination treatment.
• Figure 4 is a bar graph showing naltrexone levels across tissues and development (45 minute survival time). Levels of drug in plasma, brain and liver after a single injection at PD7, PD14, PD20, and PD32. Embryonic (ED17) and adult (>2 mo. old) data from Table 4 were added for comparison purposes. 45 min. survival time for all data.
• PD7 liver sample note that the data bar was truncated to better illustrate the broad range of drug levels across all tissues.
• Asterisks indicate either differences across age, or plasma vs brain differences at a particular age. * p ⁇ 0.05; ** p ⁇ 0.01
• NAS opioid neonatal abstinence syndrome
• a method for reducing or preventing opioid dependence in a fetus carried by a drug dependent or opioid tolerant pregnant subject receiving opioid therapy or maintenance to reduce or prevent neonatal abstinence syndrome (NAS)).
• the method involves administering to the pregnant subject a composition comprising an opioid antagonist in an amount effective to reduce or prevent fetal opioid dependence, wherein the opioid antagonist a) is orally available and reaches the circulation of the pregnant subject, b) is substantially excluded from the pregnant subject's brain by the blood brain barrier, and c) penetrates the placenta and enters the fetal brain.
• the opioid antagonist is administered systemically (for example, subcutaneously in a sustained release formulation, or transdermally) while being substantially excluded from the subject's brain by the blood brain barrier, and penetrating the placenta and entering the fetal brain.
• the opioid antagonist therapy is continued after birth of the newborn in increasing amounts effective to facilitate weaning the neonate from continued opioid maintenance administered when neonatal abstinence is observed.
• a method for preventing neonatal withdrawal or abstinence syndrome comprising:
• a first composition comprising an opioid antagonist in an amount effective to reduce or prevent opioid dependence in the fetus, wherein the opioid antagonist reaches the circulation of the pregnant subject but is substantially excluded from the pregnant subject's brain by the blood brain barrier, and wherein the opioid antagonist penetrates the placenta and enters the fetal brain;
• Also disclosed herein is a method for treating withdrawal or abstinence syndrome in a drug dependent or opioid tolerant pregnant subject, comprising administering to the subject a composition comprising an opioid antagonist in an amount effective to treat the withdrawal or abstinence syndrome, wherein the opioid antagonist reaches the circulation of the pregnant subject but is substantially excluded from the subject's brain by the blood brain barrier, and wherein the opioid antagonist penetrates the placenta and enters the fetal brain.
• the amount of opioid antagonist postnatally administered to the infant is higher on a per weight basis than the dose administered prenatally to the pregnant subject.
• the infant's blood brain barrier has continued to mature and thus a higher dose may be needed to reach the newborn's brain.
• the opioid antagonist is a neutral antagonist and not an inverse agonist.
• the opioid antagonist does not comprises naloxone or naltrexone.
• the opioid antagonist comprises ⁇ -naltrexol.
• the composition comprises a sustained drug release formulation.
• the method further comprises administering to the subject a palliative therapy. In some cases, the method further comprises administering to the subject a 5-HT antagonist. In one embodiment, the 5-HT antagonist is ondansetron. In some embodiments, the opioid antagonist is delivered in two daily subdoses.
• the opioid antagonist is delivered in a daily dosage range from about O. lmg to about 100 mg. In some embodiments, the opioid antagonist is orally available.
• subject or "host” refers to any individual who is the target of administration or treatment.
• the subject can be a vertebrate, for example, a mammal.
• the subject can be a human or veterinary patient.
• patient refers to a subject under the treatment of a clinician, e.g., physician.
• terapéuticaally effective refers to the amount of the composition used is of sufficient quantity to ameliorate one or more causes or symptoms of a disease or disorder. Such amelioration only requires a reduction or alteration, not necessarily elimination.
• pharmaceutically acceptable refers to those compounds, materials, compositions, and/or dosage forms which are, within the scope of sound medical judgment, suitable for use in contact with the tissues of human beings and animals without excessive toxicity, irritation, allergic response, or other problems or complications commensurate with a reasonable benefit/risk ratio.
• pharmaceutically acceptable salts refers to those salts which are, within the scope of sound medical judgment, suitable for use in contact with hosts (e.g., human hosts) without undue toxicity, irritation, allergic response, and the like, commensurate with a reasonable benefit/risk ratio, and effective for their intended use, as well as the zwitterionic forms, where possible, of the compounds of the presently disclosed host matter.
• carrier means a compound, composition, substance, or structure that, when in combination with a compound or composition, aids or facilitates preparation, storage, administration, delivery, effectiveness, selectivity, or any other feature of the compound or composition for its intended use or purpose.
• a carrier can be selected to minimize any degradation of the active ingredient and to minimize any adverse side effects in the subject.
• treatment refers to the medical management of a patient with the intent to cure, ameliorate, stabilize, or prevent a disease, pathological condition, or disorder.
• This term includes active treatment, that is, treatment directed specifically toward the improvement of a disease, pathological condition, or disorder, and also includes causal treatment, that is, treatment directed toward removal of the cause of the associated disease, pathological condition, or disorder.
• this term includes palliative treatment, that is, treatment designed for the relief of symptoms rather than the curing of the disease, pathological condition, or disorder; preventative treatment, that is, treatment directed to minimizing or partially or completely inhibiting the development of the associated disease, pathological condition, or disorder; and supportive treatment, that is, treatment employed to supplement another specific therapy directed toward the improvement of the associated disease, pathological condition, or disorder.
• prevent refers to a treatment that forestalls or slows the onset of a disease or condition or reduced the severity of the disease or condition.
• a treatment can treat a disease in a subject having symptoms of the disease, it can also prevent that disease in a subject who has yet to suffer some or all of the symptoms.
• compositions disclosed can be used therapeutically in combination with a
• pharmaceutically acceptable carrier is employed herein to refer to those compounds, materials, compositions, and/or dosage forms which are, within the scope of sound medical judgment, suitable for use in contact with the tissues of human beings and animals without excessive toxicity, irritation, allergic response, or other problems or complications commensurate with a reasonable benefit/risk ratio.
• the compounds described herein, or their salt, isotopic analog, or prodrug can be administered to the host using any suitable approach which achieves the desired therapeutic result.
• the amount and timing of active compound administered will, of course, be dependent on the host being treated, the instructions of the supervising medical specialist, on the time course of the exposure, on the manner of administration, on the pharmacokinetic properties of the particular active compound, and on the judgment of the prescribing physician.
• the dosages given below are a guideline and the physician can titrate doses of the compound to achieve the treatment that the physician considers appropriate for the host.
• the physician can balance a variety of factors such as age and weight of the host, presence of preexisting disease, as well as presence of other diseases.
• Pharmaceutical formulations can be prepared for any desired route of
• parenteral administration including, but not limited to, systemic, topical, oral, intravenous, subcutaneous, transdermal, percutaneous (with optional penetration enhancers), buccal, sublingual, rectal, intraaortal, intranasal, parenteral, or aerosol administration. Some of these administration routes may avoid the first-pass effects in the liver.
• Formulations for parenteral administration include, but are not limited to, suspensions, solutions, emulsions in oily or aqueous vehicles, pastes, and implantable sustained-release or biodegradable formulations.
• a pharmaceutical composition can take the form of solutions, suspensions, tablets, pills, capsules, powders, and the like.
• Tablets containing various excipients such as sodium citrate, calcium carbonate and calcium phosphate may be employed along with various di sintegrants such as starch (e.g., potato or tapioca starch) and certain complex silicates, together with binding agents such as polyvinylpyrrolidone, sucrose, gelatin and acacia.
• binding agents such as polyvinylpyrrolidone, sucrose, gelatin and acacia.
• lubricating agents such as magnesium stearate, sodium lauryl sulfate, and talc are often very useful for tableting purposes.
• Solid compositions of a similar type may be employed as fillers in soft and hard-filled gelatin capsules.
• compositions in this connection also include lactose or milk sugar as well, as high molecular weight polyethylene glycols.
• lactose or milk sugar as well, as high molecular weight polyethylene glycols.
• the compounds of the presently disclosed host matter can be combined with various sweetening agents, flavoring agents, coloring agents, emulsifying agents and/or suspending agents, as well as such diluents as water, ethanol, propylene glycol, glycerin and various like combinations thereof.
• the disclosed opioid antagonist is administered to a subject (for example, a human subject) in a dose equivalent to parenteral administration of about 0.1 ng to about 100 g per kg of body weight, about 10 ng to about 50 g per kg of body weight, about 100 ng to about 1 g per kg of body weight, from about ⁇ ⁇ to about 100 mg per kg of body weight, from about 1 ⁇ g to about 50 mg per kg of body weight, from about 1 mg to about 500 mg per kg of body weight; and from about 1 mg to about 50 mg per kg of body weight.
• the amount of opioid antagonist administered to achieve a therapeutic effective dose is about 0.1 ng, 1 ng, 10 ng, 100 ng, 1 ⁇ g, 10 ⁇ g, 100 ⁇ g, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7 mg, 8 mg, 9 mg, 10 mg, 1 1 mg, 12 mg, 13 mg, 14 mg, 15 mg, 16 mg, 17 mg, 18 mg, 19 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 70 mg, 80 mg, 90 mg, 100 mg, 500 mg per kg of body weight or greater.
• the dosage range is from about 0.1 mg to about 100 mg when given orally. In one embodiment, the dosage range is from about 0.001 mg to about 1 mg per kg of body weight when given orally.
• the daily dosage can be administered in two (or more) daily subdoses.
• the disclosed opioid antagonist is administered in a controlled- release implant or depot.
• a slow release formulation if implanted, it may bypass the GI tract and liver, and thus a fifth of the dosage is needed per day (for example, if the bioavailability is about 20%).
• Pharmaceutical formulations can be designed for immediate release, sustained release, or delayed release of one or more opioid antagonists in a
• the formulation provides a sustained release.
• the compounds described herein can be formulated for parenteral administration.
• Parenteral formulations can be prepared as aqueous compositions using techniques is known in the art.
• such compositions can be prepared as injectable formulations, for example, solutions or suspensions; solid forms suitable for using to prepare solutions or suspensions upon the addition of a reconstitution medium prior to injection; emulsions, such as water-in-oil (w/o) emulsions, oil-in-water (o/w) emulsions, and microemulsions thereof, liposomes, or emulsomes.
• injectable formulations for example, solutions or suspensions
• solid forms suitable for using to prepare solutions or suspensions upon the addition of a reconstitution medium prior to injection emulsions, such as water-in-oil (w/o) emulsions, oil-in-water (o/w) emulsions, and microemulsions thereof, liposomes, or emulsomes.
• emulsions such as water-in-oil (w/o) emulsions
• the carrier can be a solvent or dispersion medium containing, for example, water, ethanol, one or more polyols (e.g., glycerol, propylene glycol, and liquid polyethylene glycol), oils, such as vegetable oils (e.g., peanut oil, corn oil, sesame oil, etc.), and combinations thereof.
• polyols e.g., glycerol, propylene glycol, and liquid polyethylene glycol
• oils such as vegetable oils (e.g., peanut oil, corn oil, sesame oil, etc.), and combinations thereof.
• the proper fluidity can be maintained, for example, by the use of a coating, such as lecithin, by the maintenance of the required particle size in the case of dispersion and/or by the use of surfactants.
• a coating such as lecithin
• surfactants for example, sugars or sodium chloride.
• pharmacologically acceptable salts thereof can be prepared in water or another solvent or dispersing medium suitably mixed with one or more pharmaceutically acceptable excipients including, but not limited to, surfactants, dispersants, emulsifiers, pH modifying agents, and combination thereof.
• Suitable surfactants may be anionic, cationic, amphoteric or nonionic surface active agents.
• Suitable anionic surfactants include, but are not limited to, those containing carboxylate, sulfonate and sulfate ions.
• Examples of anionic surfactants include sodium, potassium, ammonium of long chain alkyl sulfonates and alkyl aryl sulfonates such as sodium
• Cationic surfactants include, but are not limited to, quaternary ammonium compounds such as benzalkonium chloride, benzethonium chloride, cetrimonium bromide, stearyl dimethylbenzyl ammonium chloride, polyoxyethylene and coconut amine.
• nonionic surfactants include ethylene glycol monostearate, propylene glycol myristate, glyceryl monostearate, glyceryl stearate, polyglyceryl-4-oleate, sorbitan acylate, sucrose acylate, PEG-150 laurate, PEG-400 monolaurate, polyoxyethylene monolaurate, polysorbates, polyoxyethylene octylphenyl ether, PEG- 1000 cetyl ether, polyoxyethylene tridecyl ether, polypropylene glycol butyl ether, Poloxamer® 401, stearoyl
• amphoteric surfactants include sodium N-dodecyl- -alanine, sodium N-lauryl- ⁇ - iminodipropionate, myristoamphoacetate, lauryl betaine and lauryl sulfobetaine.
• the formulation can contain a preservative to prevent the growth of microorganisms. Suitable preservatives include, but are not limited to, parabens, chlorobutanol, phenol, sorbic acid, and thimerosal.
• the formulation may also contain an antioxidant to prevent degradation of the active agent(s).
• the formulation is typically buffered to a pH of 3-8 for parenteral administration upon reconstitution.
• Suitable buffers include, but are not limited to, phosphate buffers, acetate buffers, and citrate buffers.
• Water soluble polymers are often used in formulations for parenteral administration. Suitable water-soluble polymers include, but are not limited to, polyvinylpyrrolidone, dextran, carboxymethylcellulose, and polyethylene glycol.
• Sterile injectable solutions can be prepared by incorporating the active compounds in the required amount in the appropriate solvent or dispersion medium with one or more of the excipients listed above, as required, followed by filtered sterilization.
• dispersions are prepared by incorporating the various sterilized active ingredients into a sterile vehicle which contains the basic dispersion medium and the required other ingredients from those listed above.
• the preferred methods of preparation are vacuum-drying and freeze-drying techniques which yield a powder of the active ingredient plus any additional desired ingredient from a previously sterile-filtered solution thereof.
• the powders can be prepared in such a manner that the particles are porous in nature, which can increase dissolution of the particles. Methods for making porous particles are well known in the art.
• the compounds, and optionally one or more additional active agents can be incorporated into microparticles, nanoparticles, or combinations thereof that provide controlled release.
• the formulations contains two or more drugs
• the drugs can be formulated for the same type of controlled release (e.g., delayed, extended, immediate, or pulsatile) or the drugs can be independently formulated for different types of release (e.g., immediate and delayed, immediate and extended, delayed and extended, delayed and pulsatile, etc.).
• the compounds and/or one or more additional active agents can be incorporated into polymeric microparticles which provide controlled release of the drug(s).
• Suitable polymers include ethylcellulose and other natural or synthetic cellulose derivatives.
• Polymers which are slowly soluble and form a gel in an aqueous environment may also be suitable as materials for drug containing microparticles.
• Other polymers include, but are not limited to, polyanhydrides, poly(ester anhydrides), polyhydroxy acids, such as polylactide (PLA), polyglycolide (PGA), poly(lactide-co-glycolide) (PLGA), poly-3-hydroxybutyrate (PHB) and copolymers thereof, poly-4-hydroxybutyrate (P4HB) and copolymers thereof, polycaprolactone and copolymers thereof, and combinations thereof.
• PLA polylactide
• PGA polyglycolide
• PLGA poly(lactide-co-glycolide)
• PHB poly-4-hydroxybutyrate
• P4HB polycaprolactone and copolymers thereof, and combinations thereof.
• the drug(s) can be incorporated into microparticles prepared from materials which are insoluble in aqueous solution or slowly soluble in aqueous solution, but are capable of degrading within the GI tract by means including enzymatic degradation, surfactant action of bile acids, and/or mechanical erosion.
• slowly soluble in water refers to materials that are not dissolved in water within a period of 30 minutes. Preferred examples include fats, fatty substances, waxes, wax -like substances and mixtures thereof.
• Suitable fats and fatty substances include fatty alcohols (such as lauryl, myristyl stearyl, cetyl or cetostearyl alcohol), fatty acids and derivatives, including, but not limited to, fatty acid esters, fatty acid glycerides (mono-, di- and tri-glycerides), and hydrogenated fats.
• fatty alcohols such as lauryl, myristyl stearyl, cetyl or cetostearyl alcohol
• fatty acids and derivatives including, but not limited to, fatty acid esters, fatty acid glycerides (mono-, di- and tri-glycerides), and hydrogenated fats.
• Specific examples include, but are not limited to hydrogenated vegetable oil, hydrogenated cottonseed oil, hydrogenated castor oil, hydrogenated oils available under the trade name Sterotex®, stearic acid, cocoa butter, and stearyl alcohol.
• Suitable waxes and wax-like materials include natural or synthetic waxes, hydrocarbons
• waxes include beeswax, glycowax, castor wax, carnauba wax, paraffins and candelilla wax.
• a wax-like material is defined as any material which is normally solid at room temperature and has a melting point of from about 30 to 300°C.
• rate-controlling (wicking) agents may be formulated along with the fats or waxes listed above.
• rate-controlling materials include certain starch derivatives (e.g., waxy maltodextrin and drum dried corn starch), cellulose derivatives (e.g., hydroxypropylmethyl-cellulose, hydroxypropyl cellulose, methylcellulose, and carboxymethyl- cellulose), alginic acid, lactose and talc.
• a pharmaceutically acceptable surfactant for example, lecithin may be added to facilitate the degradation of such microparticles.
• Proteins which are water insoluble can also be used as materials for the formation of drug containing microparticles.
• proteins, polysaccharides and combinations thereof which are water soluble can be formulated with drug into microparticles and subsequently cross-linked to form an insoluble network.
• cyclodextrins can be complexed with individual drug molecules and subsequently cross-linked.
• Encapsulation or incorporation of drug into carrier materials to produce drug containing microparticles can be achieved through known pharmaceutical formulation techniques.
• the carrier material is typically heated above its melting temperature and the drug is added to form a mixture comprising drug particles suspended in the carrier material, drug dissolved in the carrier material, or a mixture thereof.
• Microparticles can be subsequently formulated through several methods including, but not limited to, the processes of congealing, extrusion, spray chilling or aqueous dispersion.
• wax is heated above its melting temperature, drug is added, and the molten wax-drug mixture is congealed under constant stirring as the mixture cools.
• the molten wax-drug mixture can be extruded and spheronized to form pellets or beads.
• a solvent evaporation technique to produce drug containing microparticles.
• drug and carrier material are co-dissolved in a mutual solvent and microparticles can subsequently be produced by several techniques including, but not limited to, forming an emulsion in water or other appropriate media, spray drying or by evaporating off the solvent from the bulk solution and milling the resulting material.
• drug in a particulate form is homogeneously dispersed in a water- insoluble or slowly water soluble material.
• the drug powder itself may be milled to generate fine particles prior to formulation. The process of jet milling, known in the pharmaceutical art, can be used for this purpose.
• drug in a particulate form is homogeneously dispersed in a wax or wax like substance by heating the wax or wax like substance above its melting point and adding the drug particles while stirring the mixture.
• a pharmaceutically acceptable surfactant may be added to the mixture to facilitate the dispersion of the drug particles.
• the particles can also be coated with one or more modified release coatings.
• Solid esters of fatty acids which are hydrolyzed by lipases, can be spray coated onto microparticles or drug particles.
• Zein is an example of a naturally water-insoluble protein. It can be coated onto drug containing microparticles or drug particles by spray coating or by wet granulation techniques.
• some substrates of digestive enzymes can be treated with cross-linking procedures, resulting in the formation of non-soluble networks.
• Many methods of cross-linking proteins initiated by both chemical and physical means, have been reported. One of the most common methods to obtain cross-linking is the use of chemical cross- linking agents.
• cross-linking agents examples include aldehydes (gluteraldehyde and formaldehyde), epoxy compounds, carbodiimides, and genipin.
• aldehydes gluteraldehyde and formaldehyde
• epoxy compounds carbodiimides
• genipin examples include aldehydes (gluteraldehyde and formaldehyde), epoxy compounds, carbodiimides, and genipin.
• oxidized and native sugars have been used to cross-link gelatin (Cortesi, R., et al., Biomaterials 19 (1998) 1641-1649).
• Cross-linking can also be accomplished using enzymatic means; for example, transglutaminase has been approved as a GRAS substance for cross-linking seafood products.
• cross-linking can be initiated by physical means such as thermal treatment, UV irradiation and gamma irradiation.
• a water soluble protein can be spray coated onto the
• microparticles and subsequently cross-linked by the one of the methods described above.
• drug containing microparticles can be microencapsulated within protein by coacervation-phase separation (for example, by the addition of salts) and subsequently cross- linked.
• suitable proteins for this purpose include gelatin, albumin, casein, and gluten.
• Polysaccharides can also be cross-linked to form a water-insoluble network. For many polysaccharides, this can be accomplished by reaction with calcium salts or multivalent cations which cross-link the main polymer chains. Pectin, alginate, dextran, amylose and guar gum are subject to cross-linking in the presence of multivalent cations. Complexes between oppositely charged polysaccharides can also be formed; pectin and chitosan, for example, can be complexed via electrostatic interactions.
• carrier includes but is not limited to diluents, binders, lubricants,
• Carrier also includes all components of the coating composition which may include plasticizers, pigments, colorants, stabilizing agents, and glidants.
• the delayed release dosage formulations may be prepared as described in references such as "Pharmaceutical dosage form tablets”, eds. Liberman et. al. (New York, Marcel Dekker, Inc., 1989), “Remington - The science and practice of pharmacy", 20th ed., Lippincott Williams & Wilkins, Baltimore, MD, 2000, and
• suitable coating materials include, but are not limited to, cellulose polymers such as cellulose acetate phthalate, hydroxypropyl cellulose, hydroxypropyl methylcellulose, hydroxypropyl methylcellulose phthalate and hydroxypropyl methylcellulose acetate succinate; polyvinyl acetate phthalate, acrylic acid polymers and copolymers, and methacrylic resins that are commercially available under the trade name Eudragit ® (Roth Pharma, Westerstadt,
• Optional pharmaceutically acceptable excipients present in the drug-containing tablets, beads, granules or particles include, but are not limited to, diluents, binders, lubricants, disintegrants, colorants, stabilizers, and surfactants.
• Diluents also termed “fillers,” are typically necessary to increase the bulk of a solid dosage form so that a practical size is provided for compression of tablets or formation of beads and granules.
• Suitable diluents include, but are not limited to, dicalcium phosphate dihydrate, calcium sulfate, lactose, sucrose, mannitol, sorbitol, cellulose, microcrystalline cellulose, kaolin, sodium chloride, dry starch, hydrolyzed starches, pre-gelatinized starch, silicone dioxide, titanium oxide, magnesium aluminum silicate and powder sugar.
• Binders are used to impart cohesive qualities to a solid dosage formulation, and thus ensure that a tablet or bead or granule remains intact after the formation of the dosage forms.
• Suitable binder materials include, but are not limited to, starch, pre-gelatinized starch, gelatin, sugars (including sucrose, glucose, dextrose, lactose and sorbitol), polyethylene glycol, waxes, natural and synthetic gums such as acacia, tragacanth, sodium alginate, cellulose, including hydroxypropylmethylcellulose, hydroxypropylcellulose, ethylcellulose, and veegum, and synthetic polymers such as acrylic acid and methacrylic acid copolymers, methacrylic acid copolymers, methyl methacrylate copolymers, aminoalkyl methacrylate copolymers, polyacrylic acid/polymethacrylic acid and polyvinylpyrrolidone.
• Some of the materials which are suitable as binders can also be used
• Lubricants are used to facilitate tablet manufacture.
• suitable lubricants include, but are not limited to, magnesium stearate, calcium stearate, stearic acid, glycerol behenate, polyethylene glycol, talc, and mineral oil.
• Disintegrants are used to facilitate dosage form disintegration or "breakup" after administration, and generally include, but are not limited to, starch, sodium starch glycolate, sodium carboxymethyl starch, sodium carboxymethylcellulose, hydroxypropyl cellulose, pre- gelatinized starch, clays, cellulose, alginine, gums or cross linked polymers, such as cross-linked PVP (Polyplasdone® XL from GAF Chemical Corp).
• PVP Polyplasdone® XL from GAF Chemical Corp.
• Stabilizers are used to inhibit or retard drug decomposition reactions which include, by way of example, oxidative reactions.
• Surfactants may be anionic, cationic, amphoteric or nonionic surface active agents.
• Suitable anionic surfactants include, but are not limited to, those containing carboxylate, sulfonate and sulfate ions.
• anionic surfactants include sodium, potassium, ammonium salts of long chain alkyl sulfonates and alkyl aryl sulfonates such as sodium dodecylbenzene sulfonate; dialkyl sodium sulfosuccinates, such as sodium dodecylbenzene sulfonate; dialkyl sodium sulfosuccinates, such as sodium bis-(2-ethylthioxyl)-sulfosuccinate; and alkyl sulfates such as sodium lauryl sulfate.
• Cationic surfactants include, but are not limited to, quaternary ammonium compounds such as benzalkonium chloride, benzethonium chloride, cetrimonium bromide, stearyl dimethylbenzyl ammonium chloride, polyoxyethylene and coconut amine.
• nonionic surfactants include ethylene glycol monostearate, propylene glycol myristate, glyceryl monostearate, glyceryl stearate, polyglyceryl-4-oleate, sorbitan acylate, sucrose acylate, PEG-150 laurate, PEG-400 monolaurate, polyoxyethylene monolaurate, polysorbates, polyoxyethylene octylphenyl ether, PEG- 1000 cetyl ether, polyoxyethylene tridecyl ether, polypropylene glycol butyl ether, Poloxamer ® 401, stearoyl
• amphoteric surfactants include sodium N-dodecyl-.beta.-alanine, sodium N-lauryl-.beta.- iminodipropionate, myristoamphoacetate, lauryl betaine and lauryl sulfobetaine.
• the tablets, beads, granules or particles may also contain minor amount of nontoxic auxiliary substances such as wetting or emulsifying agents, dyes, pH buffering agents, and preservatives.
• the delayed-release portion is designed to enable drug release after a defined period of time. In one embodiment, in the case of an orally delivered formulation, this would be in the upper part of the gastrointestinal (GI) tract. Delayed release in an oral formulation can be achieved using enteric coatings.
• the enteric coated formulation remains intact or substantially intact in the stomach but dissolves and releases the contents of the dosage form once it reaches the small intestine or large intestines.
• Other types of coatings can be used to provide delayed release following injection subcutaneously, intra-tissue or intramuscularly at a site near or at the area to be treated.
• the extended release formulations are generally prepared as diffusion or osmotic systems, for example, as described in "Remington - The science and practice of pharmacy” (20th ed., Lippincott Williams & Wilkins, Baltimore, MD, 2000).
• a diffusion system typically consists of two types of devices, a reservoir and a matrix, and is well known and described in the art.
• the matrix devices are generally prepared by compressing the drug with a slowly dissolving polymer carrier into a tablet form.
• the three major types of materials used in the preparation of matrix devices are insoluble plastics, hydrophilic polymers, and fatty compounds.
• Plastic matrices include, but are not limited to, methyl acrylate-m ethyl methacrylate, polyvinyl chloride, and polyethylene.
• Hydrophilic polymers include, but are not limited to, cellulosic polymers such as methyl and ethyl cellulose, hydroxyalkylcelluloses such as hydroxypropyl-cellulose, hydroxypropylmethylcellulose, sodium carboxymethylcellulose, and Carbopol® 934, polyethylene oxides and mixtures thereof.
• Fatty compounds include, but are not limited to, various waxes such as carnauba wax and glyceryl tristearate and wax -type substances including hydrogenated castor oil or hydrogenated vegetable oil, or mixtures thereof.
• Opioid antagonists can be administered adjunctively with other active compounds such as analgesics, anti-inflammatory drugs, antipyretics, antiepileptics, antihistamines, antimigraine drugs, antimuscarinics, anxioltyics, sedatives, hypnotics, antipsychotics, bronchodilators, anti- asthma drugs, cardiovascular drugs, corticosteroids, dopaminergics, electrolytes,
• active compounds such as analgesics, anti-inflammatory drugs, antipyretics, antiepileptics, antihistamines, antimigraine drugs, antimuscarinics, anxioltyics, sedatives, hypnotics, antipsychotics, bronchodilators, anti- asthma drugs, cardiovascular drugs, corticosteroids, dopaminergics, electrolytes,
• the opioid antagonists can be administered in combination with other active compounds including a 5HT antagonist.
• the 5-HT antagonist is ondansetron. Additional examples of 5-HT (or 5-HT 3 ) antagonists include, ergot alkaloids, granisetron, metoclopramide, trimethobenzamide, tropisetron, dolasetron, batanopride, zacopride, azasetron, ramosetron, lerisetron, cilansetron, itasetron, and indisetron.
• Example 1 Delivery of an opioid antagonist to the fetal brain in pregnant mice.
• mice of the C57BL/6NTac strain were produced in a breeding colony at Ohio State. Animals were housed in micro-isolator racks with positive air-flow and 24 hr access to food and water. They were kept on a 12: 12 light dark cycle. All procedures were approved by The Ohio State University Institutional Animal Care and Use Committee and are in compliance with guidelines established by the National Institutes of Health published in Guide for the Care and Use of Laboratory Animals.
• ⁇ -naltrexol and naltrexone were provided by the National Institute for Drug Addiction
• mice After injection and variable survival times adult and pregnant mice were euthanized by cervical dislocation, and brain, liver and plasma were collected, quickly frozen on dry-ice and stored at -70°C until processing. After euthanizing the dam, embryos were collected into a large (150 x 15 mm) petri dish and kept on ice while maternal tissues were processed. All embryonic tissues were then dissected and collected in a cold room at 4°C in order to facilitate and preserve tissue integrity during dissection, then stored at -70°C.
• Tissues from pregnant mice and embryos that had been dosed with ⁇ -naltrexol or naltrexone were resected, weighed, and quickly frozen on dry ice in individual microcentrifuge tubes. Samples were later thawed, processed and analyzed via liquid chromatography-tandem mass spectrometry (LC-MS/MS) to quantify levels of drug. Detailed methods for tissue processing and LC-MS/MS analysis are located in the supplemental information.
• the 6P-naltrexol dose is reported as a ratio relative to Morphine, or as a dose range.
• mice Immediately upon injection with naloxone mice were placed in a clear plastic container with a 6 inch square base and 10 inches tall, with a lid. Withdrawal jumping was videotaped and jumps were scored in a 15 minute interval.
• AUCs were integrated over the time span analyzed (i.e., from 0 to 240 min; Wolfsegger, MJ, et al. (2009) J Pharmacokinet Pharmacodyn 36:479-494). Confidence intervals for AUCs were obtained by bootstrapping, as recommended in Jaki & Wolfsegger (Jaki, T, et al. (2009) Pharmaceutical Statistics 8: 12-24). All statistical procedures were implemented in R (R Core Team, 2015), using the packages multcomp (Hothorn, T, et al.
• Blank mouse plasma, brain and liver tissues were obtained, weighed, and quickly frozen on dry ice in individual microcentrifuge tubes.
• the brain and liver samples were made into separate tissue homogenates with Omni-Inc GLH-01 homogenator with a final concentration of 0.5mg/ml tissue in 50% methanol. Each tissue was aliquoted into ⁇ 1.5ml microcentrifuge tubes for future use in standard curves or for use as QC's.
• Tissues from pregnant mice and embryos that had been dosed with ⁇ -naltrexol or naltrexone (pregnant female was dosed subcutaneously with 10.0 mg/kg) were resected, weighed, and quickly frozen on dry ice in individual microcentrifuge tubes. They were then thawed on ice and homogenized with Omni-Inc GLH-01 homogenator with a final concentration of 0.5mg/ml tissue in 50% methanol. Mouse embryo brains and mouse embryo livers each were pooled to obtain adequate quantities for analysis. Each sample was aliquoted into ⁇ 1.5ml microcentrifuge tubes.
• each standard concentration sample was then spiked with ⁇ internal standard (IS) nalbuphine at 2000ng/ml to obtain a final concentration of 200ng/ml.
• the samples for each curve were then extracted with the addition of 1ml of 4°C 100% methanol, vortex mixed vigorously for 30 seconds then centrifuged at 13,000 g's for 10 minutes. The liquid from each tube was then decanted to new 5ml glass test tube. Each tube was then placed in a nitrogen evaporator system until completely dry (-2.5 hours). 120 ⁇ 1 of lOmM ammonia formate and 0.1%) formic acid was used to resolubilize the contents of each tube. The tubes were vortex mixed and centrifuged at 13,000g for 10 minutes. 80 ⁇ supernatant was then placed into a liquid chromatography autosampler compatible tubes along with standard curve and quality control samples for analysis on a Thermo Accela UHPLC and Thermo Discovery TSQ Triple
• the samples for each curve were then extracted with the addition of 1ml of 4°C 100% methanol. They were then vortex mixed vigorously for 30 seconds and centrifuged at 13,000xg for 10 minutes. Supernatant from each tube was transferred to new 5ml glass test tubes and dried in a nitrogen evaporator system (-2.5 hours). 120 ⁇ 1 of lOmM ammonia formate and 0.1% formic acid was used to resolubilize the contents of each tube. The tubes were vortex mixed, aliquoted into new microcentrifuge tubes and centrifuged at 13,000g for 10 minutes. 80 ⁇ liquid was transferred into autosampler compatible tubes for analysis. 20 ⁇ of each sample were injected into LC-MS system.
• naltrexone an FDA approved opioid antagonist used to treat alcoholism
• ⁇ -naltrexol levels in mice are significantly higher in embryonic brain than adult brain at 20, 45, and 120 minutes postinjection, and drop to low residual levels at both ages after 4 hrs.
• embryonic brain levels are ⁇ 9- fold higher than in adult brain.
• levels in embryonic and adult liver are roughly comparable to one another, indicating that ⁇ -naltrexol enters the fetal circulation rapidly.
• 6P-naltrexol levels in adult and embryonic liver are not significantly different from embryonic brain levels (p > 0.05), supporting the finding that ⁇ -naltrexol diffuses unimpeded into fetal brain.
• the measured ⁇ -naltrexol levels were also examined using a non-compartmental pharmacokinetic model.
• the area under the curve (AUC) for embryonic brain was 6-fold greater than that of adult brain (302+60 x 10 3 ng/ml-min with 95%CI of 146-1060 for embryonic brain vs 49+2 x 10 3 with 95%CI of 44-54 for adult brain; significant based on 95% confidence intervals).
• AUC area under the curve
• the brain KP ratio based on AUC's was 0.58 and was significantly different from unity based on 95% CI's, again supporting adult brain exclusion of drug (83+6 x 10 3 ng/ml-min with 95%CI of 70-98 x 10 3 for plasma and 49+2 x 10 3 with 95%CI of 44-54 x 10 3 for adult brain).
• the greater KP ratio calculated based on AUC's integrated over 4 hrs compared to single time-points reflects the more rapid elimination of 6P-naltrexol from the circulation than from the brain in mice (see Figure 1); therefore, KP ratios measured under non-equilibrium conditions can vary with time as a function of rate of elimination and tissue distribution.
• the fetal braimmaternal plasma KP ratio was 2.7 at 45 min. after drug injection (p ⁇ 0.05 for difference from unity; see Figs. 1 & 2) and the ratio was 15.7 at 120 min after injection (p ⁇ 0.01 for difference from unity) (see Figs. 1 & 2).
• the fetal brain KP ratio is not significantly different from unity (p > 0.05), indicating rapid entry into fetal brain, and longer persistence than in maternal blood (Fig. 1).
• the fetal brain KP ratio based on non-compartmental AUC's is 3.6, which is significantly different from unity (83+6 x 10 3 ng/ml-min with 95%CI of 70-98 x 10 3 for maternal plasma and 302+60 x 10 3 with 95%CI of 146-1060 x 10 3 for fetal brain).
• the KP ratios based on AUC's is 4.3 for fetal liver and 2.6 for adult liver.
• drug levels in fetal brain, and fetal and adult liver are consistently higher than those in plasma. Owing to rapid elimination, ⁇ -naltrexol is largely depleted from all tissues between 2 and 4 hours after injection ( Figure 1 and Table 1).
• naltrexone (the parent compound) has free access to the brain (Table 4) confirming previous results (see Kastin, AJ, et al. (1991) Pharmacol Biochem Behav 40:771-774; Wang, D, et al. (2004) J Pharmacol Exp Ther 308:512-520).
• the contrast of low 6P-naltrexol and high naltrexone levels in adult brain highlights the relative exclusion of ⁇ -naltrexol by the intact BBB.
• ⁇ -naltrexol While ⁇ -naltrexol is relatively excluded from adult brain, it might accumulate slowly upon multiple dosing because of slow exit from the brain. Therefore, experiments were conducted to determine whether ⁇ -naltrexol accumulates in tissues over time after chronic delivery, and especially through retention in adult brain. After 4 injections of ⁇ -naltrexol over a 24 hr period (every 6 hrs), ⁇ -naltrexol levels were measured in fetal and maternal tissues 4 hrs after the last dose, and accumulation assessed in comparison to a single injection with a 4 hr survival. As shown in Table 2, a small increase of ⁇ -naltrexol occurred after cumulative injections with an average of ⁇ 1.5-fold for all tissues.
• the refractoriness of the newborn rodent to easily observable dependence behaviors is likely due, at least in part, to the developmental state of the brain: mouse and rat brains at birth are developmental ⁇ equivalent to an early second trimester human (Clancy B, et al. (2001) Neurosci. 105:7-17; Workman AD, et al. (2013) J Neurosci. 33 :7368- 7383).
• This rodent-human developmental difference also extends to the BBB: in humans the BBB is widely thought to be nearly fully developed at or shortly after birth, while in mice, although controversial, it likely does not develop until PD14 or later (Lossinsky AS, et al.
• mice A single injection of ⁇ -naltrexol was made in mice at PD7, PD14, PD20, PD32, and
• PD50 drug levels measured after 45 minutes (data for embryos and adults were added for comparison).
• ⁇ -naltrexol levels in mice in plasma, brain, and liver varied over a wide range during postnatal development as a result of drastically changing clearance rates.
• Plasma levels decreased progressively from 3660+350 ng/ml at PD7 to 170+30 ng/ml at PD32, then reversed to 930+220 ng/ml in adults.
• Levels in the brain and liver roughly followed the same general pattern, with values in liver far exceeding those in all other tissues, especially during early postnatal development (PD7 and PD14).
• Table 3 summarizes the braimplasma and livenplasma KP ratios for the indicated survival time points, showing that levels are lower in brain than plasma at PD20 and older (with ratios that range from 0.22 - 0.35). In contrast the levels in liver are higher than in plasma at all ages (with KP ratios that range from 1.3 - 4.2). Thus, the exclusion of ⁇ -naltrexol from brain starting at PD20 is unique to that tissue. Also, the braimplasma ratio for naltrexone is greater than unity at all ages ( Figure 4), consistent with its previously reported ability to cross the BBB (Kastin, AJ, et al. (1991)
• Age time (min) (ng/ml) (ng/g) Liver (ng/g) Brain:Plasma LivenPlasma
• This example identifies a new paradigm for preventing NAS in neonates born to mothers engaged in opioid maintenance therapy.
• An opioid antagonist that is largely excluded from the maternal brain (enabling ongoing opioid therapy), but which is able to penetrate the placenta and immature BBB in the fetus, can protect the fetus from opioid exposure and thereby prevent NAS.
• Previous studies had already indicated that the opioid antagonist, 6P-naltrexol, is largely excluded from the brain while acting as a potent antagonist in the periphery (Wang, D, et al. (2004) J Pharmacol Exp Ther 308:512-520; Yancey-Wrona JE, et al. (2009) Life Sci.
• ⁇ -naltrexol readily enters the fetal circulation and fetal brain, resulting in substantially higher levels in fetal compared to maternal brain.
• This ⁇ -naltrexol dose is ⁇ 500-fold lower than the morphine dose used for inducing dependence, and is 20- to 500-fold lower than the ID50 of ⁇ -naltrexol for the blockade of opiate antinociception in adults depending on the agonist used and the route (and timing) of administration (Yancey-Wrona JE, et al. (2009) Life Sci. 85:413-420; Wang D, et al. (2001) J Neurochem. 77: 1590-1600; Sirohi S, et al. (2009) J Pharmacol Exp Ther. 330:513-519).
• ⁇ -naltrexol The extreme potency of ⁇ -naltrexol is further highlighted by the observation that even at a dosage that is l/3000th that of morphine there is a 20% reduction in quantifiable withdrawal behavior. Efficacy of ⁇ -naltrexol is also quite high, with nearly complete suppression of juvenile withdrawal (94%) at the highest dose tested in the current example. Based on these results, ⁇ -naltrexol can be utilized in pregnant women undergoing opioid maintenance treatments to selectively block fetal dependence without interfering with the mother's pain and/or maintenance therapy.
• glucuroni dated drugs such as morphine
• the studied drugs generally display a long half-life in premature and full-term neonates, then the half-life decreases progressively over several months after birth, even below adult values, and then recovers to adult levels.
• This time course was attributed at least partly to the immaturity of hepatic and renal systems in the early postnatal period.
• the disclosed example shows a surprising stability of ⁇ -naltrexol from embryogenesis through the first two weeks after birth, after which levels drop precipitously as a result of increased clearance. This indicates that in addition to the known developmental delay in the brain of mice compared to humans at birth, there may also be a delay in developmental processes affecting drug metabolism and renal clearance in the postnatal period ( ⁇ -naltrexol is cleared both renally and by metabolism).
• ⁇ -naltrexol a neutral antagonist of the ⁇ - opioid receptor with low propensity to cause withdrawal compared to naloxone and naltrexone, 2) its relative exclusion from the adult CNS, and 3) its ability to enter the fetal circulation and brain show its utility and importance for preventive therapy for NAS.
• ⁇ -naltrexol is the main metabolite of naltrexone in humans (but not in mice), which is FDA approved for the treatment of alcoholism (Pettinati, H.M, et al. (2006) Journal of clinical psychopharmacology 26:610-625).
• 6P-naltrexol's known safety profile can facilitate its use in pregnant women.
• all technical and scientific terms used herein have the same meanings as commonly understood by one of skill in the art to which the disclosed invention belongs. Publications cited herein and the materials for which they are cited are specifically incorporated by reference.

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