BACKGROUND AND PURPOSE: Opioids and benzodiazepines are frequently combined in medical as well as in non-medical contexts. At high doses, such combinations often result in serious health complications attributed to pharmacodynamics interactions. Here, we investigate the contribution of the metabolic interactions between oxycodone, diazepam and diclazepam (a designer benzodiazepine) in abuse/overdose conditions through ex vivo, in vivo and in silico approaches. EXPERIMENTAL APPROACH: A preparation of pooled human liver microsomes was used to study oxycodone metabolism in the presence or absence of diazepam or diclazepam. In mice, diazepam or diclazepam was concomitantly administered with oxycodone to mimic acute intoxication. Diclazepam was introduced on Day 10 in mice continuously infused with oxycodone for 15 days to mimic chronic intoxication. In silico modelling was used to study the molecular interactions of the three drugs with CYP3A4 and 2D6. KEY RESULTS: In mice, in acute conditions, both diazepam and diclazepam inhibited the metabolism of oxycodone. In chronic conditions and at pharmacologically equivalent doses, diclazepam drastically enhanced the production of oxymorphone. In silico, the affinity of benzodiazepines was higher than oxycodone for CYP3A4, inhibiting oxycodone metabolism through CYP3A4. Oxycodone metabolism is likely to be diverted towards CYP2D6. CONCLUSION AND IMPLICATIONS: Acute doses of diazepam or diclazepam result in the accumulation of oxycodone, whereas chronic administration induces the accumulation of oxymorphone, the toxic metabolite. This suggests that overdoses of opioids in the presence of benzodiazepines are partly due to metabolic interactions, which in turn explain the patterns of toxicity dependent on usage. LINKED ARTICLES: This article is part of a themed issue on Advances in Opioid Pharmacology at the Time of the Opioid Epidemic. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v180.7/issuetoc.

Department of Pharmacology Toxicology and Pharmacovigilance CHU Limoges Limoges France

Department of Physical Chemistry Faculty of Science Palacký University Olomouc Olomouc Czechia

INSERM IPPRITT U1248 Limoges France

Regional Center of Advanced Technologies and Materials Czech Advanced Technology and Research Institute Palacký University Olomouc Olomouc Czechia

University of Limoges IPPRITT Limoges France

See more in PubMed

Abouchedid, R., Gilks, T., Dargan, P. I., Archer, J. R. H., & Wood, D. M. (2018). Assessment of the availability, cost, and motivations for use over time of the new psychoactive substances-benzodiazepines diclazepam, flubromazepam, and pyrazolam-in the UK. Journal of Medical Toxicology: Official Journal of the American College of Medical Toxicology, 14, 134-143. https://doi.org/10.1007/s13181-018-0659-3

Alexander, S. P., Christopoulos, A., Davenport, A. P., Kelly, E., Mathie, A., Peters, J. A., Veale, E. L., Armstrong, J. F., Faccenda, E., Harding, S. D., Pawson, A. J., Southan, C., Davies, J. A., Abbracchio, M. P., CGTP Collaborators, Alexander, W., Al-Hosaini, K., Bäck, M., Barnes, N. M., … Ye, R. D. (2021). THE CONCISE GUIDE TO PHARMACOLOGY 2021/22: G protein-coupled receptors. British Journal of Pharmacology, 178(S1), S27-S156. https://doi.org/10.1111/bph.15538

Alexander, S. P., Fabbro, D., Kelly, E., Mathie, A., Peters, J. A., Veale, E. L., Armstrong, J. F., Faccenda, E., Harding, S. D., Pawson, A. J., Southan, C., Davies, J. A., Boison, D., Burns, K. E., Dessauer, C., Gertsch, J., Helsby, N. A., Izzo, A. A., Koesling, D., … Wong, S. S. (2021). THE CONCISE GUIDE TO PHARMACOLOGY 2021/22: Enzymes. British Journal of Pharmacology, 178(S1), S313-S411. https://doi.org/10.1111/bph.15542

Bosetti, C., Santucci, C., Radrezza, S., Erthal, J., Berterame, S., & Corli, O. (2019). Trends in the consumption of opioids for the treatment of severe pain in Europe, 1990-2016. European Journal of Pain, 23, 697-707. https://doi.org/10.1002/ejp.1337

Brodney, M. A., Beck, E. M., Butler, C. R., Barreiro, G., Johnson, E. F., Riddell, D., Parris, K., Nolan, C. E., Fan, Y., Atchison, K., Gonzales, C., Robshaw, A. E., Doran, S. D., Bundesmann, M. W., Buzon, L., Dutra, J., Henegar, K., LaChapelle, E., Hou, X., … O'Neill, B. T. (2015). Utilizing structures of CYPoxymoirp and BACE1 complexes to reduce risk of drug-drug interactions with a novel series of centrally efficacious BACE1 inhibitors. Journal of Medicinal Chemistry, 58, 3223-3252. https://doi.org/10.1021/acs.jmedchem.5b00191

Case, D. A., Ben-Shalom, I. Y., Brozell, S. R., Cerutti, D. S., Cheatham, T. E. III, Cruzeiro, V. W. D., Darden, T. A., Duke, R. E., Ghoreishi, D., Gilson, M. K., Gohlke, H., Goetz, A. W., Greene, D., Harris, R., Homeyer, N., Huang, Y., Izadi, S., Kovalenko, A., Kurtzman, T., … Kollman, P. A. (2018). Amber 18. Univ. Calif. San Franc.

Chen, L. H., Hedegaard, H., & Warner, M. (2014). Drug-poisoning deaths involving opioid analgesics: United States, 1999-2011. NCHS Data Brief, (166), 1-8.

Cheng, H. G., & Coplan, P. M. (2018). Incidence of nonmedical use of OxyContin and other prescription opioid pain relievers before and after the introduction of OxyContin with abuse deterrent properties. Postgraduate Medicine, 130, 568-574. https://doi.org/10.1080/00325481.2018.1495541

Chevillard, L., Declèves, X., Baud, F. J., Risède, P., & Mégarbane, B. (2013). Respiratory effects of diazepam/methadone combination in rats: A study based on concentration/effect relationships. Drug and Alcohol Dependence, 131, 298-307. https://doi.org/10.1016/j.drugalcdep.2012.12.020

Cohier, C., Chevillard, L., Risède, P., Roussel, O., & Mégarbane, B. (2014). Respiratory effects of buprenorphine/naloxone alone and in combination with diazepam in naive and tolerant rats. Toxicology Letters, 228, 75-84. https://doi.org/10.1016/j.toxlet.2014.04.009

Cone, E. J., Darwin, W. D., Buchwald, W. F., & Gorodetzky, C. W. (1983). Oxymorphone metabolism and urinary excretion in human, rat, guinea pig, rabbit, and dog. Drug Metabolism and Disposition: The Biological Fate of Chemicals, 11, 446-450.

Curtis, M. J., Alexander, S., Cirino, G., Docherty, J. R., George, C. H., Giembycz, M. A., Hoyer, D., Insel, P. A., Izzo, A. A., Ji, Y., MacEwan, D. J., Sobey, C. G., Stanford, S. C., Teixeira, M. M., Wonnacott, S., & Ahluwalia, A. (2018). Experimental design and analysis and their reporting II: Updated and simplified guidance for authors and peer reviewers. British Journal of Pharmacology, 175, 987-993. https://doi.org/10.1111/bph.14153

Dickson, C. J., Madej, B. D., Skjevik, A. A., Betz, R. M., Teigen, K., Gould, I. R., & Walker, R. C. (2014). Lipid14: The amber lipid force field. Journal of Chemical Theory and Computation, 10, 865-879. https://doi.org/10.1021/ct4010307

Dulaurent, S., El Balkhi, S., Poncelet, L., Gaulier, J.-M., Marquet, P., & Saint-Marcoux, F. (2016). QuEChERS sample preparation prior to LC-MS/MS determination of opiates, amphetamines, and cocaine metabolites in whole blood. Analytical and Bioanalytical Chemistry, 408, 1467-1474. https://doi.org/10.1007/s00216-015-9248-3

El Balkhi, S., Monchaud, C., Herault, F., Géniaux, H., & Saint-Marcoux, F. (2020). Designer benzodiazepines' pharmacological effects and potencies: How to find the information. Journal of Psychopharmacology (Oxford, England), 34, 1029. https://doi.org/10.1177/0269881119901096

Frisch, M. J., Trucks, G. W., Schlegel, H. B., Scuseria, G. E., Robb, M. A., Cheeseman, J. R., Scalmani, G., Barone, V., Mennucci, B., Petersson, G. A., Nakatsuji, H., Caricato, M., Li, X., Hratchian, H. P., Izmaylov, A. F., Bloino, J., Zheng, G., Sonnenberg, J. L., Hada, M., … Fox, D. J. (2009). Gaussian 09, Revision A.02 (Gaussian, Inc., Wallingford CT).

Gonek, M., Akbarali, H. I., Henderson, G., & Dewey, W. L. (2017). Reversal of oxycodone and hydrocodone tolerance by diazepam. Brain Research, 1674, 84-90. https://doi.org/10.1016/j.brainres.2017.08.017

Götz, A. W., Williamson, M. J., Xu, D., Poole, D., Le Grand, S., & Walker, R. C. (2012). Routine microsecond molecular dynamics simulations with AMBER on GPUs. 1. Generalized born. Journal of Chemical Theory and Computation, 8, 1542-1555. https://doi.org/10.1021/ct200909j

Hastings, J. S., Howison, M., & Inman, S. E. (2020). Predicting high-risk opioid prescriptions before they are given. Proceedings of the National Academy of Sciences of the United States of America, 117, 1917-1923. https://doi.org/10.1073/pnas.1905355117

Hill, R., Dewey, W. L., Kelly, E., & Henderson, G. (2018). Oxycodone-induced tolerance to respiratory depression: Reversal by ethanol, pregabalin and protein kinase C inhibition. British Journal of Pharmacology, 175, 2492-2503. https://doi.org/10.1111/bph.14219

Hill, R., Lyndon, A., Withey, S., Roberts, J., Kershaw, Y., MacLachlan, J., Lingford-Hughes, A., Kelly, E., Bailey, C., Hickman, M., & Henderson, G. (2016). Ethanol reversal of tolerance to the respiratory depressant effects of morphine. Neuropsychopharmacology: Official Publication of the American College of Neuropsychopharmacology, 41, 762-773. https://doi.org/10.1038/npp.2015.201

Ji, B., Liu, S., Xue, Y., He, X., Man, V. H., Xie, X.-Q., & Wang, J. (2019). Prediction of drug-drug interactions between opioids and overdosed benzodiazepines using physiologically based pharmacokinetic (PBPK) modeling and simulation. Drugs in R&D, 19, 297-305. https://doi.org/10.1007/s40268-019-00282-3

Jones, J. D., Mogali, S., & Comer, S. D. (2012). Polydrug abuse: A review of opioid and benzodiazepine combination use. Drug and Alcohol Dependence, 125, 8-18. https://doi.org/10.1016/j.drugalcdep.2012.07.004

Jones, M. R., Viswanath, O., Peck, J., Kaye, A. D., Gill, J. S., & Simopoulos, T. T. (2018). A brief history of the opioid epidemic and strategies for pain medicine. Pain and Therapy, 7, 13-21. https://doi.org/10.1007/s40122-018-0097-6

Jorgensen, W. L., Chandrasekhar, J., Madura, J. D., Impey, R. W., & Klein, M. L. (1983). Comparison of simple potential functions for simulating liquid water. The Journal of Chemical Physics, 79, 926-935. https://doi.org/10.1063/1.445869

Kilicarslan, T., & Sellers, E. M. (2000). Lack of interaction of buprenorphine with flunitrazepam metabolism. The American Journal of Psychiatry, 157, 1164-1166. https://doi.org/10.1176/appi.ajp.157.7.1164

Klimas, R., Witticke, D., El Fallah, S., & Mikus, G. (2013). Contribution of oxycodone and its metabolites to the overall analgesic effect after oxycodone administration. Expert Opinion on Drug Metabolism & Toxicology, 9, 517-528. https://doi.org/10.1517/17425255.2013.779669

Kolodny, A., Courtwright, D. T., Hwang, C. S., Kreiner, P., Eadie, J. L., Clark, T. W., & Alexander, G. C. (2015). The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction. Annual Review of Public Health, 36, 559-574. https://doi.org/10.1146/annurev-publhealth-031914-122957

Lalovic, B., Kharasch, E., Hoffer, C., Risler, L., Liu-Chen, L.-Y., & Shen, D. D. (2006). Pharmacokinetics and pharmacodynamics of oral oxycodone in healthy human subjects: Role of circulating active metabolites. Clinical Pharmacology and Therapeutics, 79, 461-479. https://doi.org/10.1016/j.clpt.2006.01.009

Lalovic, B., Phillips, B., Risler, L. L., Howald, W., & Shen, D. D. (2004). Quantitative contribution of CYP2D6 and CYP3A to oxycodone metabolism in human liver and intestinal microsomes. Drug Metabolism and Disposition: The Biological Fate of Chemicals, 32, 447-454. https://doi.org/10.1124/dmd.32.4.447

Le Grand, S., Götz, A. W., & Walker, R. C. (2013). SPFP: Speed without compromise-A mixed precision model for GPU accelerated molecular dynamics simulations. Computer Physics Communications, 184, 374-380. https://doi.org/10.1016/j.cpc.2012.09.022

Lilley, E., Stanford, S. C., Kendall, D. E., Alexander, S. P. H., Cirino, G., Docherty, J. R., George, C. H., Insel, P. A., Izzo, A. A., Ji, Y., Panettieri, R. A., Sobey, C. G., Stefanska, B., Stephens, G., Teixeira, M., & Ahluwalia, A. (2020). ARRIVE 2.0 and the British Journal of Pharmacology: Updated guidance for 2020. British Journal of Pharmacology, 177, 3611-3616. https://doi.org/10.1111/bph.15178

Lintzeris, N., & Nielsen, S. (2010). Benzodiazepines, methadone and buprenorphine: Interactions and clinical management. The American Journal on Addictions, 19, 59-72. https://doi.org/10.1111/j.1521-0391.2009.00007.x

Loncharich, R. J., Brooks, B. R., & Pastor, R. W. (1992). Langevin dynamics of peptides: The frictional dependence of isomerization rates of N-acetylalanyl-N′-methylamide. Biopolymers, 32, 523-535. https://doi.org/10.1002/bip.360320508

Luk, S., Atayee, R. S., Ma, J. D., & Best, B. M. (2014). Urinary diazepam metabolite distribution in a chronic pain population. Journal of Analytical Toxicology, 38, 135-142. https://doi.org/10.1093/jat/bku001

Maier, J. A., Martinez, C., Kasavajhala, K., Wickstrom, L., Hauser, K. E., & Simmerling, C. (2015). ff14SB: Improving the accuracy of protein side chain and backbone parameters from ff99SB. Journal of Chemical Theory and Computation, 11, 3696-3713. https://doi.org/10.1021/acs.jctc.5b00255

Martignoni, M., Groothuis, G. M. M., & de Kanter, R. (2006). Species differences between mouse, rat, dog, monkey and human CYP-mediated drug metabolism, inhibition and induction. Expert Opinion on Drug Metabolism & Toxicology, 2, 875-894. https://doi.org/10.1517/17425255.2.6.875

Megarbane, B., Pirnay, S., Borron, S. W., Trout, H., Monier, C., Risède, P., Boschi, G., & Baud, F. J. (2005). Flunitrazepam does not alter cerebral distribution of buprenorphine in the rat. Toxicology Letters, 157, 211-219. https://doi.org/10.1016/j.toxlet.2005.02.002

Miyamoto, S., & Kollman, P. A. (1992). SETTLE: An analytical version of the SHAKE and RATTLE algorithm for rigid water models. Journal of Computational Chemistry, 13, 952-962. https://doi.org/10.1002/jcc.540130805

Morris, G. M., Huey, R., Lindstrom, W., Sanner, M. F., Belew, R. K., Goodsell, D. S., & Olson, A. J. (2009). AutoDock4 and AutoDockTools4: Automated docking with selective receptor flexibility. Journal of Computational Chemistry, 30, 2785-2791. https://doi.org/10.1002/jcc.21256

Percie du Sert, N., Hurst, V., Ahluwalia, A., Alam, S., Avey, M. T., Baker, M., Browne, W. J., Clark, A., Cuthill, I. C., Dirnagl, U., Emerson, M., Garner, P., Holgate, S. T., Howells, D. W., Karp, N. A., Lazic, S. E., Lidster, K., MacCallum, C. J., Macleod, M., … Würbel, H. (2020). The ARRIVE guidelines 2.0: Updated guidelines for reporting animal research. PLoS Biology, 18(7), e3000410. https://doi.org/10.1371/journal.pbio.3000410

Salomon-Ferrer, R., Götz, A. W., Poole, D., Le Grand, S., & Walker, R. C. (2013). Routine microsecond molecular dynamics simulations with AMBER on GPUs. 2. Explicit solvent particle mesh Ewald. Journal of Chemical Theory and Computation, 9, 3878-3888. https://doi.org/10.1021/ct400314y

Samer, C. F., Daali, Y., Wagner, M., Hopfgartner, G., Eap, C. B., Rebsamen, M. C., Rossier, M. F., Hochstrasser, D., Dayer, P., & Desmeules, J. A. (2010). The effects of CYP2D6 and CYP3A activities on the pharmacokinetics of immediate release oxycodone. British Journal of Pharmacology, 160, 907-918. https://doi.org/10.1111/j.1476-5381.2010.00673.x

Seth, P., Scholl, L., Rudd, R. A., & Bacon, S. (2018). Overdose deaths involving opioids, cocaine, and psychostimulants-United States, 2015-2016. Morbidity and Mortality Weekly Report, 67(12), 349.

Sevrioukova, I. F., & Poulos, T. L. (2017). Structural basis for regiospecific midazolam oxidation by human cytochrome P450 3A4. Proceedings of the National Academy of Sciences of the United States of America, 114, 486-491. https://doi.org/10.1073/pnas.1616198114

Šrejber, M., Navrátilová, V., Paloncýová, M., Bazgier, V., Berka, K., Anzenbacher, P., & Otyepka, M. (2018). Membrane-attached mammalian cytochromes P450: An overview of the membrane's effects on structure, drug binding, and interactions with redox partners. Journal of Inorganic Biochemistry, 183, 117-136. https://doi.org/10.1016/j.jinorgbio.2018.03.002

Sun, E. C., Dixit, A., Humphreys, K., Darnall, B. D., Baker, L. C., & Mackey, S. (2017). Association between concurrent use of prescription opioids and benzodiazepines and overdose: Retrospective analysis. BMJ, 356, j760. https://doi.org/10.1136/bmj.j760

Trott, O., & Olson, A. J. (2010). AutoDock Vina: Improving the speed and accuracy of docking with a new scoring function, efficient optimization, and multithreading. Journal of Computational Chemistry, 31, 455-461. https://doi.org/10.1002/jcc.21334

Wang, J., Wolf, R. M., Caldwell, J. W., Kollman, P. A., & Case, D. A. (2004). Development and testing of a general amber force field. Journal of Computational Chemistry, 25, 1157-1174. https://doi.org/10.1002/jcc.20035

White, J. M., & Irvine, R. J. (1999). Mechanisms of fatal opioid overdose. Addiction, 94, 961-972. https://doi.org/10.1046/j.1360-0443.1999.9479612.x

Xu, L., Chockalingam, A., Stewart, S., Shea, K., Matta, M. K., Narayanasamy, S., Pilli, N. R., Volpe, D. A., Weaver, J., Zhu, H., Davis, M. C., Strauss, D. G., & Rouse, R. (2020). Developing an animal model to detect drug-drug interactions impacting drug-induced respiratory depression. Toxicology Reports, 7, 188-197. https://doi.org/10.1016/j.toxrep.2020.01.008