Suvorexant for Opioid Use Disorder
Recruiting in Palo Alto (17 mi)
+4 other locations
Overseen byAndrew S Huhn, PhD
Age: 18+
Sex: Any
Travel: May Be Covered
Time Reimbursement: Varies
Trial Phase: Phase 2
Recruiting
Sponsor: Johns Hopkins University
Must be taking: Methadone, Buprenorphine, XR-NTX
Must not be taking: Benzodiazepines, Suvorexant, Stimulants, others
Disqualifiers: Serious mental illness, Stimulant use, Pregnancy, others
Prior Safety Data
Approved in 3 Jurisdictions
Trial Summary
What is the purpose of this trial?
This study is designed to elucidate the role of the orexin neurotransmitter system in sleep disturbance and circadian rhythms of stress that might in turn influence relapse behaviors in persons on medication-assisted treatments (MAT) who are in early recovery from opioid use disorder (OUD). Briefly, the study will enroll recently abstinent OUD patients (N=200) maintained on either extended-release naltrexone (XR-NTX), buprenorphine, or methadone. Within each MAT group, participants will be randomized to either suvorexant or placebo. The study is expected to have a 20% treatment attrition rate which will result in N=160 completers in the entire study. Patients will be recruited from and treated at Ashley Addiction Treatment, Addiction Treatment Services at Johns Hopkins Bayview Medical Center, Man Alive, or community providers.
Will I have to stop taking my current medications?
You may need to stop taking certain medications to participate in this trial. Specifically, you cannot use benzodiazepines or other schedule IV medications for insomnia, Cytochrome P450 3A inhibitors, or glucocorticoid medications. If you are on these, you might need to stop them before joining the study.
What data supports the effectiveness of the drug Suvorexant for treating opioid use disorder?
Is suvorexant safe for humans?
Suvorexant, also known as Belsomra, has been studied for its safety in humans, primarily for treating insomnia. It is generally considered safe at doses of 5-20 mg, though higher doses may cause next-morning drowsiness, unusual dreams, and other nighttime behaviors. Studies suggest it has a low potential for abuse and does not significantly interact with other drugs at clinical doses.12367
How is the drug Suvorexant unique in treating opioid use disorder?
Suvorexant is unique because it is a dual orexin receptor antagonist originally approved for treating insomnia, and it works by blocking orexin receptors involved in wakefulness. This novel mechanism may help reduce drug-seeking behavior and relapse in opioid use disorder, offering a different approach compared to traditional treatments.12456
Eligibility Criteria
This trial is for adults aged 21-65 with opioid use disorder who are in early recovery and experiencing sleep disturbances. They must be on medication-assisted treatments like methadone, buprenorphine, or XR-NTX, have abstained from illicit opioids for two weeks, and agree to weekly visits and daily monitoring. Exclusions include unstable serious mental illnesses, other severe substance disorders, certain medication allergies or uses, pregnancy/breastfeeding, specific sleep disorders like narcolepsy or severe apnea.Inclusion Criteria
Have no clinically significant chronic medical disorders or conditions that are judged by the investigators to prevent participation.
Use of birth control throughout study
I am between 21 and 65 years old.
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Exclusion Criteria
I am not taking steroids or medications that affect my hormone control system.
I have been diagnosed with narcolepsy, sleep paralysis, or restless leg syndrome.
You have shown signs of wanting to harm yourself in the past month, as evaluated by a specific questionnaire.
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Trial Timeline
Screening
Participants are screened for eligibility to participate in the trial
2-4 weeks
Treatment
Participants receive either suvorexant or placebo while maintained on medication-assisted treatments (MAT) for opioid use disorder
8 weeks
Weekly visits for assessments
Follow-up
Participants are monitored for safety and effectiveness after treatment
4 weeks
Treatment Details
Interventions
- Placebos (Behavioural Intervention)
- Suvorexant (Orexin Antagonist)
Trial OverviewThe study tests whether suvorexant can improve sleep and reduce stress-related relapse behaviors in patients recovering from opioid addiction compared to a placebo. Participants maintained on different medications (methadone/buprenorphine/XR-NTX) will randomly receive either suvorexant or a placebo while their sleep patterns and stress levels are monitored.
Participant Groups
2Treatment groups
Active Control
Placebo Group
Group I: SuvorexantActive Control1 Intervention
Sleep medication (20mg suvorexant; 2 10mg capsules; patients can self-titrate to 1 10mg capsule)
Group II: PlaceboPlacebo Group1 Intervention
Placebo sleep medication (2 placebo oral capsules)
Suvorexant is already approved in United States, Australia, Japan for the following indications:
🇺🇸 Approved in United States as Belsomra for:
- Insomnia characterized by difficulties with sleep onset and/or sleep maintenance
🇦🇺 Approved in Australia as Belsomra for:
- Insomnia characterized by difficulties with sleep onset and/or sleep maintenance
🇯🇵 Approved in Japan as Belsomra for:
- Insomnia characterized by difficulties with sleep onset and/or sleep maintenance
Find a Clinic Near You
Research Locations NearbySelect from list below to view details:
Behavioral Pharmacology Research Unit at the Johns Hopkins Bayview Medical CenterBaltimore, MD
Man Alive Inc., Lane Treatment CenterBaltimore, MD
Ashley Addiction TreatmentBel Air, MD
Ashley Addiction TreatmentElkton, MD
More Trial Locations
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Who Is Running the Clinical Trial?
Johns Hopkins UniversityLead Sponsor
National Heart, Lung, and Blood Institute (NHLBI)Collaborator
References
Preclinical assessment of the abuse potential of the orexin receptor antagonist, suvorexant. [2018]Suvorexant (Belsomra®) is a dual orexin receptor antagonist approved for the treatment of insomnia. Because of its pharmacology within the central nervous system, intended therapeutic indication, and first-in-class status, an assessment of suvorexant abuse liability potential was required prior to marketing approval. The nonclinical abuse liability potential studies for suvorexant included: 1) rat drug-dependence model to assess physical dependence following abrupt cessation; 2) rat drug-discrimination model to examine the potential similarity of the interoceptive or subjective effects of suvorexant to those elicited by zolpidem and morphine; 3) self-administration model to assess the relative reinforcing efficacy of suvorexant in rhesus monkeys conditioned to self-administer methohexital. No significant signs of spontaneous drug withdrawal or 'discontinuation syndrome' were observed in rats following abrupt discontinuation of suvorexant. Suvorexant did not elicit complete cross-generalization to either a zolpidem or morphine training/reference stimuli in rats, and suvorexant was devoid of behavioral evidence of positive reinforcing efficacy in monkeys. These nonclinical findings suggested that suvorexant will have low abuse potential in humans. In the final regulatory risk assessment, suvorexant was placed into Schedule IV, likely due to its first-in-class status, its sedative properties, and the outcome of the clinical abuse potential assessment.
Tissue Distribution of Suvorexant in Three Forensic Autopsy Cases. [2018]Suvorexant (Belsomra®) is a relatively new insomnia medication that has been available in USA and Japan since 2014. It is a dual orexin receptor antagonist that promotes sleep by inhibiting the binding of orexin neurons to the OX1R and OX2R receptors. In this report, we describe the detection and quantitation of suvorexant from the postmortem specimens of three separate autopsy cases handled by our department. Suvorexant was identified by fast gas chromatography/mass spectrometry during routine screening, and quantitated by a fully validated liquid chromatography-tandem mass spectroscopy method. Quantitation was achieved by positive electrospray ionization in the selected reaction monitoring mode. Monitored transitions were m/z 451 > 186 for quantitation and m/z 451 > 104 for qualification. To our knowledge, this is the first instance of suvorexant being quantitated from actual autopsy cases. It is likely that this compound will be encountered more often by the forensic toxicology community going forward.
Suvorexant ameliorated sleep disturbance, opioid withdrawal, and craving during a buprenorphine taper. [2022]Increased orexin/hypocretin signaling is implicated in opioid withdrawal, sleep disturbances, and drug-seeking behaviors. This study examined whether a dual-orexin receptor antagonist would improve sleep and withdrawal outcomes when compared with placebo during a buprenorphine/naloxone taper. Thirty-eight participants with opioid use disorder were recruited to a clinical research unit and maintained on 8/2 to 16/4 mg of buprenorphine/naloxone treatment for 3 days before being randomized to 20 mg of suvorexant (n = 14), 40 mg of suvorexant (n = 12), or placebo (n = 12); 26 individuals completed the study. After randomization, participants underwent a 4-day buprenorphine/naloxone taper and 4-day post-taper observation period. Total sleep time (TST) was collected nightly with a wireless electroencephalography device and wrist-worn actigraphy; opioid withdrawal symptoms were assessed via the Subjective Opiate Withdrawal Scale (SOWS); and abuse potential was assessed on a 0- to 100-point visual analog scale of "High" every morning. A priori outcomes included two-group (collapsing suvorexant doses versus placebo) and three-group comparisons of area-under-the-curve (AUC) scores for TST, SOWS, and High. In two-group comparisons, participants receiving suvorexant displayed increased TST during the buprenorphine/naloxone taper and decreased SOWS during the post-taper period. In three-group comparisons, participants receiving 20 mg of suvorexant versus placebo displayed increased AUC for TST during the buprenorphine/naloxone taper, but there was no difference in SOWS among groups. There was no evidence of abuse potential in two- or three-group analyses. The results suggest that suvorexant might be a promising treatment for sleep and opioid withdrawal in individuals undergoing a buprenorphine/naloxone taper.
Suvorexant, an FDA-approved dual orexin receptor antagonist, reduces oxycodone self-administration and conditioned reinstatement in male and female rats. [2023]Background: The Department of Health and Human Services reports that prescription pain reliever (e.g., oxycodone) misuse was initiated by 4,400 Americans each day in 2019. Amid the opioid crisis, effective strategies to prevent and treat prescription opioid use disorder (OUD) are pressing. In preclinical models, the orexin system is recruited by drugs of abuse, and blockade of orexin receptors (OX receptors) prevents drug-seeking behavior. The present study sought to determine whether repurposing suvorexant (SUV), a dual OX receptor antagonist marketed for the treatment of insomnia, can treat two features of prescription OUD: exaggerated consumption and relapse. Methods: Male and female Wistar rats were trained to self-administer oxycodone (0.15 mg/kg, i. v., 8 h/day) in the presence of a contextual/discriminative stimulus (SD) and the ability of SUV (0-20 mg/kg, p. o.) to decrease oxycodone self-administration was tested. After self-administration testing, the rats underwent extinction training, after which we tested the ability of SUV (0 and 20 mg/kg, p. o.) to prevent reinstatement of oxycodone seeking elicited by the SD. Results: The rats acquired oxycodone self-administration and intake was correlated with the signs of physical opioid withdrawal. Additionally, females self-administered approximately twice as much oxycodone as males. Although SUV had no overall effect on oxycodone self-administration, scrutiny of the 8-h time-course revealed that 20 mg/kg SUV decreased oxycodone self-administration during the first hour in males and females. The oxycodone SD elicited strong reinstatement of oxycodone-seeking behavior that was significantly more robust in females. Suvorexant blocked oxycodone seeking in males and reduced it in females. Conclusions: These results support the targeting of OX receptors for the treatment for prescription OUD and repurposing SUV as pharmacotherapy for OUD.
Identification of Suvorexant in Urine Using Liquid Chromatography-Quadrupole/Time-of-Flight Mass Spectrometry (LC-Q/TOF-MS). [2017]Suvorexant (Belsomra®) is a new hypnotic drug with a novel mechanism of action. In prescribed doses of 10 mg before bedtime, the drug produces rapid onset of sleep by inhibiting the orexin neurons of the arousal system, promoting decreased wakefulness. Suvorexant is a potent and highly selective dual orexin receptor antagonist. Sedative hypnotics are of forensic importance due to their widespread use, potential for additive effects with other central nervous system depressants, impairing effects and potential for misuse. In this report we describe a highly sensitive assay for the identification and quantification of suvorexant in urine. Suvorexant was isolated using liquid/liquid extraction (LLE) and identified using liquid chromatography-quadrupole/time-of-flight mass spectrometry. Suvorexant was quantified using a quadratic calibration model between 5 and 250 ng/mL (R2 = 1.000, n = 6). Processed sample stability was demonstrated for up to 24 h. The limit of detection was 0.5 ng/mL and the limit of quantification (LOQ) was 5 ng/mL. The accuracy, bias and precision of the assay at the LOQ were 99% (81-117%), -1% and 12% (n = 18). Intraassay (n = 5) and interassay (n = 15) precision (% CV) at 10, 50 and 200 ng/mL were ≤8%, and bias ranged from -2% to 4% (98-104% accuracy). No qualitative interferences were detected from matrix, internal standard or 50 common drugs. Matrix effects evaluated at low and high concentrations were -16% and -9%, respectively, and produced CVs of 11% and 5% (n = 20). Suvorexant is a new drug of forensic importance. In this report we describe how a simple acidic/neutral LLE can be used to isolate this lipophilic drug with high recoveries and sound analytical performance.
In vitro and in vivo characterisation of the metabolism and disposition of suvorexant in humans. [2017]1. Suvorexant (MK-4305, Belsomra®) is a first-in-class dual orexin receptor antagonist approved in the USA and Japan for the treatment of insomnia. The current studies describe suvorexant's absorption, disposition and potential for CYP-mediated drug interactions in humans. 2. Following single oral administration of [(14)C]suvorexant to healthy human subjects, 90% of the radioactivity was recovered (66% in faeces, 23% in urine), primarily as oxidative metabolites. 3. In plasma, suvorexant and M9 were predominant, accounting for 30 and 37% of the total radioactivity, respectively. Metabolite M17 became more prominent (approaching 10%) following multiple daily doses of unlabelled suvorexant. M9 and M17 are not expected to contribute to the pharmacological activity of suvorexant due to reduced orexin receptor binding affinity and limited brain penetration. 4. CYP3A was determined to be the predominant enzyme mediating suvorexant oxidation. In vitro, suvorexant demonstrated reversible inhibition of CYP3A4 and 2C19 (IC50 ∼ 4-5 μM), and weak time-dependent inhibition of CYP3A4 (KI = 12 μM, kinact = 0.14 min(-1)). Suvorexant was also a weak inducer of CYP3A4, 1A2 and 2B6. Given the low plasma concentrations at clinical doses, suvorexant was not anticipated to cause significant drug interactions via inhibition and/or induction of major CYPs in vivo.
Suvorexant for the treatment of insomnia. [2015]Suvorexant (Belsorma(®)) is the first orexin receptor antagonist approved by the US FDA (August 2014) for insomnia treatment. Following comprehensive Phase II/III studies, with up to 12 months of treatment in adult and elderly patients, there is little doubt that suvorexant induces and maintains sleep. However, the FDA and sponsor disagreed about effective versus safe doses (November 2012). The FDA considered that 5-15 mg were efficient and probably safe, whereas the sponsors had proposed 15-40 mg. The final approved doses are 5, 10, 15 and 20 mg. The major issues are next-morning somnolence and safety as seen in driving tests, with possible signs of muscle weakness, weird dreams, sleep walking, other nighttime behaviors and suicidal ideation. Despite its limitations, suvorexant's market entry offers a truly novel treatment for insomnia, paving the way for follow-up compounds and opening therapeutic avenues in other disorders for orexin receptor modulating compounds.