WO2018064672A1 - Treatment with intranasal naloxone - Google Patents

Abstract

Methods of achieving high levels of naltrexone occupancy of the μ-opioid receptors in the brain of a subject, or in a region thereof, within specific time points, are disclosed herein, comprising the intranasal administration of a formulation of naloxone or a salt or hydrate thereof.

Description

TREATMENT WITH INTRANASAL NALOXONE

[001] This application claims the benefit of United States Provisional Applications No. 62/402,648, filed September 30, 2016, and 62/403,477, filed 10/3/2016, the disclosures of which are hereby incorporated by reference as if written herein in their entireties. This application also incorporates by reference United States Provisional Application No.

61/953,379, filed March 14, 2014, United States Application No. 14/659,472, filed March 16, 2015, and United States Application No. 14/942,344, filed Nov. 16, 2015, as if written herein in their entireties.

[002] Provided are drug products adapted for nasal delivery comprising an opioid receptor antagonist, pharmaceutical formulations comprising an opioid receptor antagonist, and methods of use thereof.

[003] Opioid receptors are G protein-coupled receptors (GPCRs) that are activated both by endogenous opioid peptides and by clinically important analgesic opioid drugs such as morphine, oxycodone, hydrocodone, and codeine, as well as by illicit opioid drugs. There are three principal types of opioid receptors: the δ-opioid receptor, the κ-opioid receptor, and the μ-opioid receptor. Opioids effect a wide variety of physiologic changes, some transient and some more persistent, by binding to and activating opioid receptors (in the case of opioid agonists). These include effects on regions of the brain where opioid receptors reside or exert downstream effects, such as in the regions controlling respiration and reward.

[004] For example, stimulation of opioid receptors by opioid agonists, depresses respiration. Opioid receptors are abundant in respiratory control centers that include, primarily, the brainstem (including medulla oblongata, pons, and midbrain), as well as higher centers such as the insula, thalamus, and anterior cingulate cortex. Brainstem structures including medullary respiratory centers are critical in sensing and responding to chemical components of the blood via chemoreceptors, and generating and maintaining respiratory rhythm. See, e.g., Pattinson, Br J Anaesth (2008) 100 (6):747-758. Opioid agonists produce inhibition at the chemoreceptors via μ-opioid receptors and in the medulla via μ- and δ-opioid receptors. Accordingly, a sufficiently high dose of an opioid agonist can cause fatal respiratory depression, especially when combined with benzodiazepines, alcohol, and other substances which facilitate the inhibitory effect of the neurotransmitter γ-aminobutyric acid (GABA) at the GABAA receptor, and/or decrease the excitatory effect of the neurotransmitter glutamate at N-methyl-D-aspartate (NMD A) receptors.

[005] Opioid receptors also play a key role in modulating mood, motivation, and desire, behaviors associated with addiction, via its role in the brain's reward circuitry. The reward circuitry includes structures such as the ventral tegmental area, nucleus accumbens and other parts of the ventral striatum, dorsal striatum, substantia nigra, prefrontal cortex, anterior cingulate cortex, insular cortex, hippocampus, hypothalamus, thalamus, subthalamic nucleus, globus pallidus, ventral pallidum, parabrachial nucleus, and amygdala. The mesolimbic dopamine pathway, which connects the ventral tegmental area (VTA) to the nucleus accumbens (NAcc), is an important component of the reward system that is involved in the immediate perception of the motivational component of reward and reinforcement. Opioid peptides and receptors are widely distributed in reward pathways and circuitry, and the opioid system is intimately involved in reinforcement processes. Mu and, to a lesser extent, delta agonists produce positive reinforcement, whereas mu and delta antagonists can suppress the positive reinforcing properties of opioids, natural rewards (such as highly palatable foods) which trigger the release of endogenous opioid-like peptides (e.g., endorphins), and certain nonopioid drugs (e.g. alcohol) that trigger the release of opioid-like peptides.

[006] Naloxone is an opioid receptor antagonist that is approved for use intranasally and by injection for the reversal of opioid overdose. The onset of action of naloxone used in treating opioid overdose should be as fast as possible in order to reverse respiratory depression and restore vital processes. Naloxone can also induce withdrawal and dysphoria in opioid- intoxicated or -dependent subjects, and produces conditioned aversive effects in animals; it has therefore been investigated for the treatment of reward-based disorders (though, notably, it has not been particularly successful in clinical investigations into the treatment of addictions). A fast onset of action might therefore also potentially be useful in the treatment of reward-based disorders, because it would permit the user to interrupt the reward cycle at various stages in the cycle, depending on time of administration: priming, reinforcement, etc. Due to a high first pass metabolism, oral dosage forms comprising naloxone display a low bioavailability and are thus generally viewed as unsuitable for such purposes. The administration of naloxone via injection into the blood stream or into the muscle requires trained medical personnel. Intranasal dosing, however, allows the untrained user to administer naloxone.

[007] Naloxone has a relatively short half-life compared to some longer-acting opioid drugs and formulations. Accordingly, after a typical therapeutic dose of naloxone is administered to an opioid overdose patient there is often the need to re-administer naloxone, in some cases even several times, and it is important to seek immediate medical attention. Similarly, naloxone's short half life presents an opportunity to intervene at strategic time points in the reward cycle without the burden of a long-acting drug which may occupy opioid receptors for long periods of time and interfere with the natural reward system.

[008] Thus, there remains a need for providing an extremely fast-acting opioid antagonist to a patient, which achieves high occupancy of mu opioid receptors in the brain or a region thereof in a short period of time, and which clears quickly from the patient's system.

[009] Accordingly, provided herein are methods of treatment of reward-based disorders comprising intranasally administering a dose of naloxone or a salt or hydrate thereof that i) achieves μ-opioid receptor (MOR) occupancy by naloxone of > about 50% in the brain, or a region thereof, in less than about 15 minutes; and

ii) is cleared form the brain to a level that yields MOR occupancy by naloxone of < about 15% within six hours.

[010] Also provided are methods of achieving at least about 70% μ-opioid receptor (MOR) occupancy by naloxone in the brain of a subject, or in a region thereof, within one hour, comprising administering to a subject in need thereof a pharmaceutical formulation for intranasal administration comprising about 2 to about 12 mg of naloxone or a salt or hydrate thereof.

[011] Also provided are methods of achieving at least about 50% μ-opioid receptor (MOR) occupancy by naloxone in the brain of a subject in less than about 15 minutes by intranasally administering at least about 4 mg of naloxone or a salt or hydrate thereof.

[012] Also provided are methods of achieving at least about 50% μ-opioid receptor (MOR) occupancy by naloxone in the brain of a subject in less than about 30 minutes by intranasally administering at least about 2 mg of naloxone or a salt or hydrate thereof.

[013] Also provided are methods of achieving at least about 90% occupancy by naloxone of the μ-opioid receptors in the medulla oblongata of a subject in one hour by intranasally administering about 2 to about 12 mg of naloxone or a salt or hydrate thereof.

[014] Also provided are methods of achieving 50% μ-opioid receptor (MOR) occupancy by naloxone in the medulla oblongata of a subject in less than about 10 minutes by intranasally administering at least about 4 mg of naloxone or a salt or hydrate thereof.

[015] Also provided herein are pharmaceutical formulations, and devices adapted for nasal delivery of pharmaceutical formulations to a patient, comprising a therapeutically effective amount of an opioid antagonist selected from naloxone and pharmaceutically acceptable salts and hydrates thereof. In certain embodiments, the therapeutically effective amount of naloxone is equivalent to about 2 mg to about 12 mg, or a molar equivalent of naloxone hydrochloride.

[016] Also provided are methods of treating opioid overdose or a symptom thereof, comprising nasally administering to a patient in need thereof a therapeutically effective amount of an opioid antagonist selected from naloxone and pharmaceutically acceptable salts thereof. In certain embodiments, the therapeutically effective amount of naloxone is equivalent to about 2 mg to about 12 mg, or a molar equivalent of naloxone hydrochloride.

BRIEF DESCRIPTION OF THE DRAWINGS

[017] Figure 1 shows the mean (±SD) naloxone plasma concentration following administration of 0.4 mg intramuscular (IM), 2 mg intranasal (IN), and 4 mg IN in 14 human subjects.

[018] Figure 2 shows the mean (±SD) naloxone plasma concentration with logarithmic transformation following administration of 0.4 mg intramuscular (IM), 2 mg intranasal (IN), and 4 mg IN in 14 human subjects.

[019] Figure 3 shows the mean naloxone plasma concentration following single intranasal administrations (Fig. 3 A) and intramuscular injections (Fig. 3B) of naloxone to healthy subjects (N = 28) over a twelve-hour period.

[020] Figure 4 shows the mean naloxone plasma concentration following single intranasal administrations (Fig. 4A) and intramuscular injections (Fig. 4B) of naloxone to healthy subjects (N = 28) over a four-hour period.

[021] Figure 5 shows the mean naloxone plasma concentration following intramuscular injection of 0.4 mg naloxone (Fig. 5A, top) and one spray of 20 mg/mL naloxone (Fig. 5B, bottom) to healthy male (N = 16) and female (N = 12) subjects over a twelve-hour period.

[022] Figure 6 shows the mean naloxone plasma concentration following two sprays of 20 mg/mL (Fig. 6A, top) and one spray of 40 mg/mL (Fig. 6B, bottom) to healthy male (N = 16) and female (N = 12) subjects over a twelve-hour period.

[023] Figure 7 shows the mean naloxone plasma concentration following two sprays of 40 mg/mL to healthy male (N = 16) and female (N = 12) subjects over a twelve-hour period.

DETAILED DESCRIPTION OF THE INVENTION [024] For clarity and consistency, the following definitions will be used throughout this patent document.

[025] The term "abusable substance," as used herein, includes those substances that are known to be used in amounts or using methods that are harmful to the user or others. The United States National Institutes of Health maintains a list of commonly abused substances, available at www.drugabuse.gov/drugs-abuse/commonly-abused-drugs-charts. Abusable substances include opioid agonists (both prescription as well as illicit narcotics), alcohol, and other substances which activate the reward circuitry via exogenous or endogenous opioids upon consumption.

[026] The term "active ingredient" or "pharmaceutically active compound" is defined in the context of a "pharmaceutical formulation" and is intended to mean a component of a pharmaceutical formulation that provides the primary pharmacological effect, as opposed to an "inactive ingredient" which would generally be recognized as providing no

pharmaceutical benefit.

[027] The term "actuation," as used herein, refers to operation of the device such that the pharmaceutical formulation is delivered therefrom.

[028] The term "agonist," as used herein, refers to as used herein refers to a moiety that interacts with and activates a receptor, and thereby initiates a physiological or

pharmacological response characteristic of that receptor. The term "antagonist," as used herein, refers to a moiety that competitively binds to a receptor at the same site as an agonist (for example, the endogenous ligand), but which does not activate the intracellular response initiated by the active form of the receptor and can thereby inhibit the intracellular responses by an agonist or partial agonist. An antagonist does not diminish the baseline intracellular response in the absence of an agonist or partial agonist. The term "inverse agonist" refers to a moiety that binds to the endogenous form of the receptor or to the constitutively activated form of the receptor and which inhibits the baseline intracellular response initiated by the active form of the receptor below the normal base level of activity which is observed in the absence of an agonist or partial agonist.

[029] The term "antimicrobial preservative," as used herein, refers to a pharmaceutically acceptable excipient with antimicrobial properties which is added to a pharmaceutical formulation to maintain microbiological stability.

[030] The term "AUC," as used herein, refers to the area under the drug plasma

concentration-time curve. The term "AUCo-t," as used herein, refers to the area under the drug plasma concentration-time curve from t = 0 to the last measurable concentration. The term "AUCo as used herein, refers to the area under the drug plasma concentration-time curve extrapolated to∞. The term "AUCo-t D," as used herein, refers to the AUCo-t normalized to 0.4 mg IM naloxone. The term "AUCO-∞/D," as used herein, refers to the AUCo-∞ normalized to 0.4 mg IM naloxone

[031] The term "binding potential (BP)," as used herein, means the ratio of Bmax (receptor density) to KD (radioligand equilibrium dissociation) or, equivalently, the product of Bmax and affinity. BPND refers to the ratio at equilibrium of specifically bound radioligand to that of nondisplaceable radioligand in tissue. BPND is the typical measurement from reference tissue methods, as it compares the concentration of radioligand in receptor-rich to receptor-free regions.

[032] The term "bioavailability (F)," as used herein, refers to the fraction of a dose of drug that is absorbed from its site of administration and reaches, in an unchanged form, the systemic circulation. The term "absolute bioavailability" is used when the fraction of absorbed drug is related to its IV bioavailability. It may be calculated using the following formula:

AUC "'_^ext_™ravas,^cular ^ Dose ir

F ^:

AUC intravenous Dose extravascular

The term relative bioavailability (F_rei) is used to compare two different extravascular routes of drug administration and it may be calculated using the following formula:

[033] The term "clearance (CL)," as used herein, refers to the rate at which a drug is eliminated divided by its plasma concentration, giving a volume of plasma from which drug is completely removed per unit of time. CL is equal to the elimination rate constant (λ) multiplied by the volume of distribution (Vd), wherein "Vd" is the fluid volume that would be required to contain the amount of drug present in the body at the same concentration as in the plasma. The term "apparent clearance (CL/F)," as used herein, refers to clearance that does not take into account the bioavailability of the drug. It is the ratio of the dose over the AUC.

[034] The term "Cmax," as used herein, refers to the maximum observed plasma

concentration. The term "Cmax/Dose," as used herein, refers to Cmax normalized to 0.4 mg IM naloxone.

[035] The term "coefficient of variation (CV)," as used herein, refers to the ratio of the sample standard deviation to the sample mean. It is often expressed as a percentage. [036] The term "confidence interval," as used herein, refers to a range of values which will include the true average value of a parameter a specified percentage of the time.

[037] The term "device," as used herein, refers to an apparatus capable of delivering a drug to patient in need thereof.

[038] The term "delivery time," as used herein, refers to the amount of time that elapses between a determination made by a healthcare professional, or an untrained individual that an individual is in need of nasal delivery of an opioid antagonist and completion of the delivery.

[039] The term "disease" as used herein is intended to be generally synonymous, and is used interchangeably with, the terms "disorder," "syndrome," and "condition" (as in medical condition), in that all reflect an abnormal condition of the human or animal body or of one or more of its parts that impairs normal functioning, is typically manifested by distinguishing signs and symptoms, and causes the human or animal to have a reduced duration or quality of life. The term "disease" also includes mental diseases, such as those defined in the

Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

[040] The term "elimination rate constant (λ)," as used herein, refers to the fractional rate of drug removal from the body. This rate is constant in first-order kinetics and is independent of drug concentration in the body, λ is the slope of the plasma concentration-time line (on a logarithmic y scale). The term "λ_ζ," as used herein, refers to the terminal phase elimination rate constant, wherein the "terminal phase" of the drug plasma concentration-time curve is a straight line when plotted on a semilogarithmic graph. The terminal phase is often called the "elimination phase" because the primary mechanism for decreasing drug concentration during the terminal phase is drug elimination from the body. The distinguishing characteristic of the terminal elimination phase is that the relative proportion of drug in the plasma and peripheral volumes of distribution remains constant. During this "terminal phase" drug returns from the rapid and slow distribution volumes to the plasma, and is permanently removed from the plasma by metabolism or renal excretion.

[041] The term "equivalent," as used herein refers to a weight of an opioid antagonist selected from naloxone and pharmaceutically acceptable salts thereof that is equimolar to a specified weight of naloxone hydrochloride. For example, 8 mg of anhydrous naloxone hydrochloride (molecular weight, 363.84) is equivalent to about 7.2 mg of naloxone freebase (molecular weight, 327.37), and to about 8.8 mg of naloxone hydrochloride dihydrate (molecular weight 399.87).

[042] The term "filled," as used herein, refers to an association between a device and a pharmaceutical formulation, for example, when a pharmaceutical formulation described herein comprising a therapeutically effective amount of an opioid antagonist is present within a reservoir that forms a part of a device described herein.

[043] The term "hydrate," as used herein, refers to an opioid antagonist described herein or a salt thereof that further includes a stoichiometric or non-stoichiometric amount of water bound by non-covalent intermolecular forces.

[044] The term "in need of treatment" and the term "in need thereof when referring to treatment are used interchangeably and refer to a judgment made by a caregiver (e.g.

physician, nurse, nurse practitioner, that a patient will benefit from treatment.

[045] As used herein, two embodiments are "mutually exclusive" when one is defined to be something which is different than the other. For example, an embodiment wherein the amount of naloxone hydrochloride is specified to be 4 mg is mutually exclusive with an embodiment wherein the amount of naloxone hydrochloride is specified to be 2 mg.

However, an embodiment wherein the amount of naloxone hydrochloride is specified to be 4 mg is not mutually exclusive with an embodiment in which less than about 10% of the pharmaceutical formulation leaves the nasal cavity via drainage into the nasopharynx or externally.

[046] The term "naloxone," as used herein, refers to a compound of the following structure:

or a pharmaceutically acceptable salt, hydrate, or solvate thereof. The CAS registry number for naloxone is 465-65-6. Other names for naloxone include: 17-allyl-4,5a-epoxy-3,14- dihydroxymorphinan-6-one; (-)-17-allyl-4,5a-epoxy-3,14-dihydroxymorphinan-6-one; 4,5a- epoxy-3,14-dihydroxy-17-(2-propenyl)morphinan-6-one; and (-)-12-allyl-7,7a,8,9- tetrahydro-3,7a-dihydroxy-4aH-8,9c-indnoethanophenanthro[4,5- )ca furan-5(6H)-one. Naloxone hydrochloride may be anhydrous (CAS Reg. No. 357-08-4) and also forms a dihydrate (CAS No. 51481-60-8). It has been sold under various brand names including Narcan®, Nalone®, Nalossone®, Naloxona®, Naloxonum®, Narcanti®, and Narcon®.

[047] The term "nostril," as used herein, is synonymous with "naris." [048] The term "opioid antagonist" includes naloxone and pharmaceutically acceptable salts thereof. In some embodiments, the opioid antagonist is naloxone hydrochloride. In some embodiments, the opioid antagonist is naloxone hydrochloride dihydrate.

[049] The term "opioid overdose," as used herein, refers to an acute medical condition induced by excessive use of one or more opioids. Symptoms of opioid overdose include including respiratory depression (including postoperative opioid respiratory depression, acute lung injury, and aspiration pneumonia), central nervous system depression (which may include sedation, altered level consciousness, miotic (constricted) pupils), and cardiovascular depression (which may include hypoxemia and hypotension). Visible signs of opioid overdose or suspected opioid overdose include: unresponsiveness and/or loss of

consciousness (won't respond to stimuli such as shouting, shaking, or rubbing knuckles on sternum); slow, erratic, or stopped breathing; slow, erratic, or stopped pulse; deep snoring or choking/gurgling sounds; blue or purple fingernails or lips; pale and/or clammy face; slack or limp muscle tone; contracted pupils; and vomiting. Because opioid overdose may be difficult to diagnose and/or quantify, particularly by a lay person, as used herein, treatment of opioid overdose is meant to include treatment of suspected opioid overdose in opioid-intoxicated patients. Opioids that may induce overdose include, codeine, morphine, methadone, fentanyl, oxycodone, hydrocodone, hydromorphone, oxymorphone, meperidine, propoxyphene, opium, heroin, tramadol, tapentadol, and certain narcotic-antagonist analgesics, such as, nalbuphine, pentazocine and butorphanol. In some embodiments, the opioid agonist is in an abuse- deterrent formulation. In some embodiments, the opioid agonist is selected from Acurox® Oxycodone DETERx®, Egalet hydrocodone, Egalet morphine, Egalet oxycodone, Exalgo®, Opana®, and Remoxy®.

[050] The term "patient," or equivalently, "subject," as used herein, refers to any subject (preferably human) afflicted with a condition likely to benefit from a treatment, e.g., with a therapeutically effective amount of intranasal naloxone.

[051] The terms "absorption enhancer," "permeation enhancer," and "penetration enhancer," as disclosed herein, are intended to be equivalent, both referring to an agent which aids in absorption of a compound, such as through the nasal mucosa.

[052] The term "pharmaceutical composition," or equivalently, "pharmaceutical formulation," as used herein, refers to a formulation comprising at least one active ingredient; including but not limited to, salts, solvates and hydrates of naloxone, whereby the formulation is amenable to use for a specified, efficacious outcome in a mammal (for example, without limitation, a human).

[053] The term "pre-primed," as used herein, refers to a device, such as a nasal spray which is capable of delivering a pharmaceutical formulation to a patient in need thereof with the first actuation of the spray pump, i.e. , without the need to prime the pump prior to dosing, such as by actuating the pump one or more times until a spray appears.

[054] The term "pharmaceutically acceptable," as used herein, refers to a component of a pharmaceutical formulation that it compatible with the other ingredients of the formulation and not overly deleterious to the recipient thereof.

[055] The term "prone," as used herein, refers to a patient who is lying face down.

[056] The term "receptor binding or occupancy" refers to a characterization of the kinetics between a radioactive drug and receptors or other binding sites throughout the body, and characterization of the radioactive drug binding affinity to these receptors.

[057] The term "recovery position," as used herein, means a position of the human body in which a patient lies on his/her side, with a leg or knee out in front (e.g., to prevent rolling onto his/her stomach) and at least one hand supporting the head (e.g., to elevate the face to facilitate breathing and prevent inhalation of vomit).

[058] The term "reward-based disorder," as used herein, means a medical condition characterized by compulsive engagement in rewarding stimuli, despite adverse consequences to physical and/or mental health. Reward-based disorders include addictions. The terms "addictive behavior" and "addictive stimulus," as used herein, refer to a behavior or a stimulus, respectively, that is both rewarding and reinforcing. The term "reinforcing stimuli," as used herein refers to stimuli that increase the probability of repeating behaviors paired with them (i.e., they increase the likelihood that a person will seek repeated exposure to them). The term, "rewarding stimuli," as used herein, refers to stimuli that the brain interprets as intrinsically positive or desirable, or as something to be approached. Stimulus-driven behavioral responses (i.e., stimulus control) that are associated with a particular rewarding stimulus tend to dominate one's behavior in an addiction over the countervailing cognitive control. Reward-based disorders include substance use disorders, pathological gambling, and eating disorders such as binge eating and bulimia nervosa, as well as neuropsychiatric disorders in which the patient performs self-injurious and/or inappropriate behaviors which result in the release of endogenous opioids.

[059] The term "reward circuitry" as used herein means those brain structures and connections involved in the experience of reward, which are known in the art and not recapitulated in detail here. Briefly, however, reward circuitry includes the cortico-basal ganglia-thalamo-cortical loop, which involves structures such as the basal ganglia, itself including the striatum (ventral/rostral, limbic/temporal/executive) and nucleus accumbens (itself the major portion of the limbic/ventral striatum), and the ventral tegmental area; the thalamus and hypothalamus; and the cortex, including the prefrontal cortex.

[060] The term "self-injurious and/or inappropriate behavior," as used herein, means a reward-based disorder which results in the release of one or more endogenous opioids.

Examples of such self-injurious and/or inappropriate behaviors include self- cutting, skin picking, burning, and the like, as well as eating disorders, pathological gambling, etc. The term excludes behaviors done in furtherance of suicide, and those performed due to other disorders and conditions, such as autism or schizophrenia. Self-injurious and/or

inappropriate behaviors are treatable by the methods disclosed herein employing the administration of intranasal naloxone.

[061] The term "solvate," as used herein, refers to naloxone or a salt, thereof, that further includes a stoichiometric or non-stoichiometric amount of a solvent bound by non-covalent intermolecular forces. Preferred solvents are volatile, non-toxic, and/or acceptable for administration to humans in trace amounts.

[062] The term "sterile filling," as used herein, refers methods of manufacturing the devices and pharmaceutical formulations described herein, such that the use of preservatives is not required. Sterile drug products may be produced using aseptic processing or terminal sterilization. Terminal sterilization usually involves filling and sealing product containers under high-quality environmental conditions. In an aseptic process, the drug product, container, and closure are first subjected to sterilization methods separately, as appropriate, and then brought together.

[063] The term "storage-stable," as used herein, refers to a pharmaceutical formulation in which at least about 95% to 99.5% of the active ingredient remains in an undegraded state after storage of the pharmaceutical formulation at specified temperature and humidity for a specified time, for example, for 12 months at 25 °C and 60% relative humidity.

[064] The term "substantially free of antimicrobial preservatives" is understood by one of ordinary skill in the art to described a pharmaceutical formulation that may comprise less than 1% w/w antimicrobial preservatives.

[065] The term "supine," as used herein, refers to a patient who is lying face up.

[066] The term "therapeutically effective amount," as used herein, refers to the amount of active compound or pharmaceutical agent that elicits the biological or medicinal response in a tissue, system, or individual that is being sought by a researcher, healthcare provider or individual.

[067] The term "ti/2" or "half-life," as used herein, refers to the amount of time required for half of a drug to be eliminated from the body or the time required for a drug concentration in the blood (and routinely measured in plasma) to decline by half.

[068] The term "Tmax," as used herein, refers to the time from administration of the pharmaceutical formulations described herein to maximum drug plasma concentration in blood (and routinely measured in plasma).

[069] The term "tomography," as used herein, refers to a process of imaging by sections. The images may be looked at individually, as a series of two-dimensional slices or together, as a computer-generated three-dimensional representation.

[070] The term "tonicity agent," as used herein, refers to a compound which modifies the osmolality of a formulation, for example, to render it isotonic. Tonicity agents include, dextrose, lactose, sodium chloride, calcium chloride, magnesium chloride, sorbitol, sucrose, mannitol, trehalose, raffinose, polyethylene glycol, hydroxy ethyl starch, glycine and the like.

[071] The term "untrained individual" refers to an individual administering to patient naloxone using a device described herein, wherein the individual is not a healthcare professional and has received no training in the use of the device, such as through an overdose education and nasal naloxone distribution (OEND) program.

Opioid Antagonists

[072] Provided are drug products adapted for nasal delivery of naloxone. Naloxone specifically reverses the effects of opioid agonists but has no opioid agonist activity.

Naloxone is commercially available as a hydrochloride salt. Naloxone hydrochloride (17- allyl-4,5a-epoxy-3,14-dihydroxymorphinan-6-one hydrochloride), a narcotic antagonist, is a synthetic congener of oxymorphone. In structure it differs from oxymorphone in that the methyl group on the nitrogen atom is replaced by an allyl group. Naloxone hydrochloride is an essentially pu re narcotic antagonist, i.e., it does not possess "agonistic" or morphine-like properties; naloxone does not produce respiratory depression, psychotomimetic effects or pupillary constriction. Naloxone has not been shown to produce tolerance or to cause physical or psychological dependence. In the presence of a physical dependence on narcotics naloxone will precipitate withdrawal symptoms.

[073] The preponderance of evidence suggests that naloxone antagonizes the opioid effects by competing for the same receptor sites. When naloxone hydrochloride is administered intravenously the onset of action is generally apparent within two minutes; the onset of action is less rapid when it is administered subcutaneously or intramuscularly. The duration of action is dependent upon the dose and route of administration of naloxone hydrochloride. Intramuscular administration produces a more prolonged effect than intravenous

administration. The requirement for repeat doses of naloxone will also be dependent upon the amount, type and route of administration of the narcotic being antagonized. Following parenteral administration, naloxone hydrochloride is rapidly distributed in the body. It is metabolized in the liver, primarily by glucuronide conjugation, and excreted in urine. In one study the plasma half-life in adults following intramuscular injection was reported as 1.3 hours.. In a neonatal study the mean plasma half-life was observed to be 3.1 ± 0.5 hours.

[074] Provided are pharmaceutical formulations, devices adapted for nasal delivery of a pharmaceutical formulation to a patient, and methods of treatment in a patient, each comprising a therapeutically effective amount of an opioid antagonist selected from naloxone and pharmaceutically acceptable salts thereof, wherein the device is pre-primed, and wherein the therapeutically effective amount, is equivalent to about 2 mg to about 12 mg of naloxone hydrochloride. Also provided are devices adapted for nasal delivery of a pharmaceutical formulation to a patient, comprising a therapeutically effective amount of an opioid antagonist selected from naloxone and pharmaceutically acceptable salts thereof, wherein the device is pre-primed, and wherein the therapeutically effective amount, is equivalent to about 2 mg to about 12 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 2 mg to about 24 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 2 mg to about 12 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 3 mg to about 18 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 2 mg to about 12 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 4 mg to about 12 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 4 mg to about 10 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 2 mg to about 8 mg of naloxone hydrochloride. In some embodiments, the

therapeutically effective amount is equivalent to about 5 mg to about 11 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 6 mg to about 10 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 4 mg to about 8 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 7 mg to about 9 mg of naloxone hydrochloride. In some embodiments, the

therapeutically effective amount is equivalent to about 2 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 3.4 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 4 mg of naloxone hydrochloride. In some embodiments, the

therapeutically effective amount is equivalent to about 5 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 6 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 7 mg of naloxone hydrochloride. In some embodiments, the

therapeutically effective amount is equivalent to about 8 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 9 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 10 mg of naloxone hydrochloride. In some embodiments, the

therapeutically effective amount is equivalent to about 11 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 12 mg of naloxone hydrochloride. In some embodiments, the naloxone is the only pharmaceutically active compound in pharmaceutical formulation. In some embodiments, the therapeutically effective amount is equivalent to about 2, about 4, or about 8 mg of naloxone hydrochloride. In some embodiments, the opioid antagonist is anhydrous naloxone hydrochloride.

[075] In some embodiments, the opioid antagonist is naloxone hydrochloride dihydrate; in these embodiments, the amount may be a molar equivalent of an amount of naloxone disclosed herein. For example, in some embodiments, the therapeutically effective amount is about 2.2 mg to about 13.2 mg of naloxone hydrochloride dihydrate. In some embodiments, the therapeutically effective amount is about 4.4 mg to about 11 mg of naloxone

hydrochloride dihydrate. In some embodiments, the therapeutically effective amount is an amount chosen from about 2.2 mg naloxone hydrochloride dihydrate, about 4.4 mg of naloxone hydrochloride dihydrate, and about 8.8 mg naloxone hydrochloride dihydrate. In some embodiments, the therapeutically effective amount is about 2.2 mg of naloxone hydrochloride dihydrate. In some embodiments, the therapeutically effective amount is about 4.4 mg of naloxone hydrochloride dihydrate. In some embodiments, the therapeutically effective amount is about 8.8 mg of naloxone hydrochloride dihydrate. Nasal Drug Delivery Devices and Kits

[076] Provided herein are nasal drug delivery devices comprising a pharmaceutical formulation described herein. Nasal delivery is considered an attractive route for needle-free, systemic drug delivery, especially when rapid absorption and effect are desired. In addition, nasal delivery may help address issues related to poor bioavailability, slow absorption, drug degradation, and adverse events (AEs) in the gastrointestinal tract and avoids the first-pass metabolism in the liver.

[077] Liquid nasal formulations are mainly aqueous solutions, but suspensions and emulsions can also be delivered. In traditional spray pump systems, antimicrobial preservatives are typically required to maintain microbiological stability in liquid formulations.

[078] Some EMS programs have developed a system using existing technologies of an approved drug and an existing medical device to administer naloxone intranasally, albeit in a non-FDA approved manner. This has been accomplished by using the injectable formulation (1 mg/mL) and administering 1 mL per nostril via a marketed nasal atomizer/nebulizer device. The system combines an FDA-approved naloxone injection product (with a Luer fitted tip, no needles) with a marketed, medical device called the Mucosal Atomization Device (MAD™ Nasal, Wolfe Tory Medical, Inc.). This initiative is consistent with the U.S. Needlestick Safety and Prevention Act (Public Law 106-430). The EMS programs recognize limitations of this system, one limitation being that it is not assembled and ready-to-use. Although this administration mode appears to be effective in reversing narcosis, the formulation is not concentrated for retention in the nasal cavity. The 1 mL delivery volume per nostril is larger than that generally utilized for intranasal drug administration. Therefore, there is loss of drug from the nasal cavity, due either to drainage into the nasopharynx or externally from the nasal cavity. The devices described herein are improved ready-to-use products specifically optimized, concentrated, and formulated for nasal delivery.

[079] Metered spray pumps have dominated the nasal drug delivery market since they were introduced. The pumps typically deliver 100 (25-200 μί) per spray, and they offer high reproducibility of the emitted dose and plume geometry in in vitro tests. The particle size and plume geometry can vary within certain limits and depend on the properties of the pump, the formulation, the orifice of the actuator, and the force applied. Traditional spray pumps replace the emitted liquid with air, and preservatives are therefore required to prevent contamination. However, driven by the studies suggesting possible negative effects of preservatives, pump manufacturers have developed different spray systems that avoid the need for preservatives. These systems use a collapsible bag, a movable piston, or a compressed gas to compensate for the emitted liquid volume (www.aptar.com and www.rexam.- com). The solutions with a collapsible bag and a movable piston compensating for the emitted liquid volume offer the additional advantage that they can be emitted upside down, without the risk of sucking air into the dip tube and compromising the subsequent spray. This may be useful for some products where the patients are bedridden and where a head down application is recommended. Another method used for avoiding preservatives is that the air that replaces the emitted liquid is filtered through an aseptic air filter. In addition, some systems have a ball valve at the tip to prevent contamination of the liquid inside the applicator tip (www.aptar.com). More recently, pumps have been designed with side- actuation and introduced for delivery of fluticasone furoate for the indication of seasonal and perennial allergic rhinitis. The pump was designed with a shorter tip to avoid contact with the sensitive mucosal surfaces. New designs to reduce the need for priming and re-priming, and pumps incorporating pressure point features to improve the dose reproducibility and dose counters and lock-out mechanisms for enhanced dose control and safety are available (www.rexam.com and www.aptar.com).

[080] Metered-dose spray pumps require priming and some degree of overfill to maintain dose conformity for the labeled number of doses. They are well suited for drugs to be administered daily over a prolonged duration, but due to the priming procedure and limited control of dosing, they are less suited for drugs with a narrow therapeutic window. For expensive drugs and vaccines intended for single administration or sporadic use and where tight control of the dose and formulation is of particular importance, single-dose or bi-dose spray devices are preferred (www.aptar.com). A simple variant of a single-dose spray device (MAD™) is offered by LMA (LMA, Salt Lake City, UT, USA; www.lmana. com). A nosepiece with a spray tip is fitted to a standard syringe. The liquid drug to be delivered is first drawn into the syringe and then the spray tip is fitted onto the syringe. This device has been used in academic studies to deliver, for example, a topical steroid in patients with chronic rhinosinusitis and in a vaccine study. A pre-filled device based on the same principle for one or two doses (Accuspray™, Becton Dickinson Technologies, Research Triangle Park, NC, USA; www.bdpharma.com) is used to deliver the influenza vaccine FluMist

(www.flumist.com), approved for both adults and children in the US market. A similar device for two doses was marketed by a Swiss company for delivery of another influenza vaccine a decade ago. The single- and bi-dose devices mentioned above consist of a reservoir, a piston, and a swirl chamber (see, e.g., the UDS UnitDose and BDS BiDose devices from Aptar, formerly Pfeiffer). The spray is formed when the liquid is forced out through the swirl chamber. These devices are held between the second and the third fingers with the thumb on the actuator. A pressure point mechanism incorporated in some devices secures

reproducibility of the actuation force and emitted plume characteristics. Currently, marketed nasal migraine drugs like Imitrex (www.gsk.com) and Zomig (www.az.com; Pfeiffer/Aptar single-dose device) and the marketed influenza vaccine Flu-Mist (www.flumist.com; Becton Dickinson single-dose spray device) are delivered with this type of device.

[081] With sterile filling, the use of preservatives is not required, but overfill is required resulting in a waste fraction similar to the metered-dose, multi-dose sprays. To emit 100 μί, a volume of 125 is filled in the device (Pfeiffer/ Aptar single-dose device) used for the intranasal migraine medications Imitrex (sumatriptan) and Zomig (zolmitriptan) and about half of that for a bi-dose design. Sterile drug products may be produced using aseptic processing or terminal sterilization. Terminal sterilization usually involves filling and sealing product containers under high-quality environmental conditions. Products are filled and sealed in this type of environment to minimize the microbial and particulate content of the in- process product and to help ensure that the subsequent sterilization process is successful. In most cases, the product, container, and closure have low bioburden, but they are not sterile. The product in its final container is then subjected to a sterilization process such as heat or irradiation. In an aseptic process, the drug product, container, and closure are first subjected to sterilization methods separately, as appropriate, and then brought together. Because there is no process to sterilize the product in its final container, it is critical that containers be filled and sealed in an extremely high-quality environment. Aseptic processing involves more variables than terminal sterilization. Before aseptic assembly into a final product, the individual parts of the final product are generally subjected to various sterilization processes. For example, glass containers are subjected to dry heat; rubber closures are subjected to moist heat; and liquid dosage forms are subjected to filtration. Each of these manufacturing processes requires validation and control.

[082] Accordingly, provided herein are devices adapted for nasal delivery of a

pharmaceutical formulation to a patient, comprising a therapeutically effective amount of an opioid antagonist selected from naloxone and pharmaceutically acceptable salts thereof, wherein the device is pre-primed, and wherein the therapeutically effective amount, is equivalent to about 2 mg to about 12 mg of naloxone hydrochloride.

[083] In some embodiments, the opioid antagonist is naloxone hydrochloride. In some embodiments, the opioid antagonist is naloxone hydrochloride dihydrate. [084] In some embodiments, the patient is an opioid overdose patient or a suspected opioid overdose patient.

[085] In some embodiments, the patient is in a lying, supine, or recovery position. In some embodiments, the patient is in a lying position. In some embodiments, the patient is in a supine position. In some embodiments, the patient is in a recovery position.

[086] In some embodiments, the therapeutically effective amount of an opioid antagonist is delivered by an untrained individual.

[087] In some embodiments, the opioid antagonist is the only pharmaceutically active compound in the pharmaceutical formulation.

[088] In some embodiments, the pharmaceutical formulation comprises a solution of naloxone hydrochloride, or a hydrate thereof.

[089] In some embodiments, the volume of the pharmaceutical formulation in the reservoir is not more than about 140 μί.

[090] In some embodiments, about 100 of the pharmaceutical formulation in the reservoir is delivered to the patient in one actuation.

[091] In some embodiments, the device is filled with the pharmaceutical formulation using sterile filling.

[092] In some embodiments, the pharmaceutical formulation is storage-stable in the device for about twelve months at about 25 °C and about 60% relative humidity.

[093] In some embodiments, the device is a single-dose device, wherein the pharmaceutical formulation is present in one reservoir, and wherein the therapeutically effective amount of the opioid antagonist is delivered essentially by one actuation of the device into one nostril of the patient.

[094] In some embodiments, about 100 of the pharmaceutical formulation is delivered by the actuation.

[095] In some embodiments, the device is actuatable with one hand.

[096] In some embodiments, the delivery time is less than about 25 seconds. In some embodiments, the delivery time is less than about 20 seconds.

[097] In some embodiments, the 90% confidence interval for dose delivered per actuation is ± about 2%. In some embodiments, the 95% confidence interval for dose delivered per actuation is ± about 2.5%.

[098] In some embodiments, upon nasal delivery of the pharmaceutical formulation to the patient, less than about 20% of the pharmaceutical formulation leaves the nasal cavity via drainage into the nasopharynx or externally. In some embodiments, upon nasal delivery of the pharmaceutical formulation to the patient, less than about 10% of the pharmaceutical formulation leaves the nasal cavity via drainage into the nasopharynx or externally. In some embodiments, upon nasal delivery of the pharmaceutical formulation to the patient, less than about 5% of the pharmaceutical formulation leaves the nasal cavity via drainage into the nasopharynx or externally.

[099] In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of less than 30 minutes. In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of less than 25 minutes. In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of less than 20 minutes. In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of about 20 minutes. In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of less than 19 minutes. In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of about 18.5 minutes.

[0100] In some embodiments, delivery of the therapeutically effective amount to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 90%. In some embodiments, delivery of the therapeutically effective amount to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 95%. In some embodiments, delivery of the therapeutically effective amount to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 99%.

[0101] In some embodiments, the patient is free from respiratory depression for at least about 1 hour following treatment comprising essentially of delivery of the therapeutically effective amount of the opioid antagonist. In some embodiments, the patient is free from respiratory depression for at least about 2 hours following treatment comprising essentially of delivery of the therapeutically effective amount of the opioid antagonist. In some embodiments, the patient is free from respiratory depression for at least about 4 hours following treatment comprising essentially of delivery of the therapeutically effective amount of the opioid antagonist. In some embodiments, the patient is free from respiratory depression for at least about 6 hours following treatment comprising essentially of delivery of the therapeutically effective amount of the opioid antagonist. [0102] In some embodiments, the device is a bi-dose device, wherein a first volume of the pharmaceutical formulation is present in a first reservoir and a second volume of the pharmaceutical formulation is present in a second reservoir, and wherein the therapeutically effective amount is delivered essentially by a first actuation of the device into a first nostril of the patient and a second actuation of the device into a second nostril of the patient.

[0103] In some embodiments, the first volume and the second volume combined is equal to not more than about 380 μί.

[0104] In some embodiments, about 100 of the first volume of the pharmaceutical formulation is delivered by the first actuation.

[0105] In some embodiments, about 100 of the second volume of the pharmaceutical formulation is delivered by the second actuation.

[0106] In some embodiments, the device is actuatable with one hand.

[0107] In some embodiments, the delivery time is less than about 25 seconds. In some embodiments, the delivery time is less than about 20 seconds.

[0108] In some embodiments, the 90% confidence interval for dose delivered per actuation is ± about 2%. In some embodiments, the 95% confidence interval for dose delivered per actuation is ± about 2.5%.

[0109] In some embodiments, upon nasal delivery of the pharmaceutical formulation to the patient, less than about 20% of the pharmaceutical formulation leaves the nasal cavity via drainage into the nasopharynx or externally. In some embodiments, upon nasal delivery of the pharmaceutical formulation to the patient, less than about 10% of the pharmaceutical formulation leaves the nasal cavity via drainage into the nasopharynx or externally. In some embodiments, upon nasal delivery of the pharmaceutical formulation to the patient, less than about 5% of the pharmaceutical formulation leaves the nasal cavity via drainage into the nasopharynx or externally.

[0110] In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of less than 30 minutes. In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of less than 25 minutes. In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of about 20 minutes. In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of less than 19 minutes. In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of about 18.5 minutes. [0111] In some embodiments, delivery of the therapeutically effective amount to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 90%. In some embodiments, delivery of the therapeutically effective amount to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 95%. In some embodiments, delivery of the therapeutically effective amount to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 99%.

[0112] In some embodiments, the patient is free from respiratory depression for at least about 1 hour following treatment comprising essentially of delivery of the therapeutically effective amount of the opioid antagonist. In some embodiments, the patient is free from respiratory depression for at least about 2 hours following treatment comprising essentially of delivery of the therapeutically effective amount of the opioid antagonist. In some embodiments, the patient is free from respiratory depression for at least about 4 hours following treatment comprising essentially of delivery of the therapeutically effective amount of the opioid antagonist. In some embodiments, the patient is free from respiratory depression for at least about 6 hours following treatment comprising essentially of delivery of the therapeutically effective amount of the opioid antagonist.

[0113] Also provided herein is i) a single-use, pre-primed device or ii) a bi-dose, pre-primed device, adapted for nasal delivery of a pharmaceutical formulation to a patient by one actuation of the device into one nostril of the patient, having a single reservoir comprising not more than about 140 of a pharmaceutical formulation which is an aqueous solution comprising:

about 2 mg or about 4 mg naloxone hydrochloride or a hydrate thereof; between about 0.2 mg and about 1.2 mg of an isotonicity agent;

between about 0.005 mg and about 0.015 mg of a compound which is a preservative, cationic surfactant, and/or permeation enhancer;

between about 0.1 mg and about 0.5 mg of a stabilizing agent;

an amount of an acid sufficient to achieve a pH of 3.5-5.5.

[0114] In some embodiments, the device comprises about 4 mg naloxone hydrochloride or a hydrate thereof. In some embodiments, the device comprises about 2 mg naloxone hydrochloride or a hydrate thereof.

[0115] In some embodiments,

the isotonicity agent is NaCl; the compound which is a preservative, cationic surfactant, and/or permeation enhancer is benzalkonium chloride;

the stabilizing agent is disodium edetate; and

the acid is hydrochloric acid.

[0116] In some embodiments, the device comprises:

about 2 mg or about 4 mg naloxone hydrochloride;

about 0.74 mg NaCl;

about 0.01 mg benzalkonium chloride;

about 0.2 mg disodium edetate; and

an amount of hydrochloric acid sufficient to achieve a pH of 3.5-5.5.

[0117] In some embodiments, upon nasal delivery of the pharmaceutical formulation to the patient, less than about 10% of the pharmaceutical formulation leaves the nasal cavity via drainage into the nasopharynx or extemally.

[0118] In some embodiments, the plasma concentration versus time curve of the naloxone hydrochloride in the patient has a Tmax of between about 20 and about 30 minutes.

[0119] In some embodiments, the device is actuatable with one hand.

[0120] In some embodiments, the delivery time is less than about 25 seconds. In some embodiments, the delivery time is less than about 20 seconds.

[0121] In some embodiments, the 90% confidence interval for dose delivered per actuation is ± about 2%. In some embodiments, the 95% confidence interval for dose delivered per actuation is ± about 2.5%.

[0122] In some embodiments, upon nasal delivery of the pharmaceutical formulation to the patient, less than about 20% of the pharmaceutical formulation leaves the nasal cavity via drainage into the nasopharynx or externally. In some embodiments, upon nasal delivery of the pharmaceutical formulation to the patient, less than about 10% of the pharmaceutical formulation leaves the nasal cavity via drainage into the nasopharynx or extemally. In some embodiments, upon nasal delivery of the pharmaceutical formulation to the patient, less than about 5% of the pharmaceutical formulation leaves the nasal cavity via drainage into the nasopharynx or externally.

[0123] In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of less than 30 minutes. In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of less than 25 minutes. In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of about 20 minutes. In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of less than 19 minutes. In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of about 18.5 minutes.

[0124] In some embodiments, delivery of the therapeutically effective amount to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 90%. In some embodiments, delivery of the therapeutically effective amount to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 95%. In some embodiments, delivery of the therapeutically effective amount to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 99%.

[0125] In some embodiments, the patient is free from respiratory depression for at least about 1 hour following treatment comprising essentially of delivery of the therapeutically effective amount of the opioid antagonist. In some embodiments, the patient is free from respiratory depression for at least about 2 hours following treatment comprising essentially of delivery of the therapeutically effective amount of the opioid antagonist. In some embodiments, the patient is free from respiratory depression for at least about 4 hours following treatment comprising essentially of delivery of the therapeutically effective amount of the opioid antagonist. In some embodiments, the patient is free from respiratory depression for at least about 6 hours following treatment comprising essentially of delivery of the therapeutically effective amount of the opioid antagonist.

[0126] In some embodiments, the device is filled with the pharmaceutical formulation using sterile filling.

[0127] In some embodiments, the pharmaceutical formulation is storage-stable for about twelve months at about 25 °C and about 60% relative humidity.

[0128] In some embodiments, the opioid antagonist is the only pharmaceutically active compound in the pharmaceutical formulation.

[0129] Also provided are devices as recited in any of the preceding embodiments for use in the treatment of an opioid overdose symptom selected from: respiratory depression, postoperative opioid respiratory depression, altered level consciousness, miotic pupils, cardiovascular depression, hypoxemia, acute lung injury, aspiration pneumonia, sedation, and hypotension.

[0130] Also provided are devices as recited in any of the preceding embodiments for use in the reversal of respiratory depression induced by opioids. [0131] In some embodiments, the respiratory depression is caused by the illicit use of opioids or by an accidental misuse of opioids during medical opioid therapy.

[0132] Also provided are devices as recited in any of the preceding embodiments for use in the complete or partial reversal of narcotic depression, including respiratory depression, induced by natural and synthetic narcotics.

[0133] In some embodiments, the patient is an opioid overdose patient or a suspected opioid overdose patient.

[0134] In some embodiments, the patient is in a lying, supine, or recovery position. In some embodiments, the patient is in a lying position. In some embodiments, the patient is in a supine position. In some embodiments, the patient is in a recovery position.

[0135] In some embodiments, the therapeutically effective amount of an opioid antagonist is delivered by an untrained individual.

[0136] Also provided are kits comprising a device described herein and written instructions for using the device. Also provided are kits comprising a device described herein and an opioid agonist. In some embodiments the kit further comprises written instructions. In some embodiments, the opioid agonist is selected from codeine, morphine, methadone, fentanyl, oxycodone HC1, hydrocodone bitartrate, hydromorphone, oxymorphone, meperidine, propoxyphene, opium, heroin, and certain narcotic-antagonist analgesics, such as, nalbuphine, pentazocine and butorphanol. In some embodiments, the opioid agonist is selected from tapentadol and tramadol.

[0137] Also provided are embodiments wherein any embodiment above may be combined with any one or more of these embodiments, provided the combination is not mutually exclusive.

[0138] Abuse-deterrent formulating technologies have been developed for safer delivery of opioid antagonists, but such formulations are still abused resulting in opioid overdose. One such technology (Abuse Deterrent Prolonged Release Erosion Matrix (ADPREM); Egalet) utilizes a water-degradable polymer matrix technology that erodes from the surface at a constant rate. The matrix consists of one or more plasticizing polymers that cannot be crushed or melted. Another such technology (Abuse Resistant Technology (ART); Elite Laboratories) utilizes a proprietary coating technology consisting of various polymers that can sequester an opioid antagonist (naltrexone) in fragile micropellets that are

indistinguishable from the pellets containing the opioid. The formulation is designed to release sequestered antagonist only if the dosage is crushed or otherwise damaged for extraction. Oral dosage forms are prepared by coating powders, crystals, granules, or pellets with various polymers to impart different characteristics. The formulations can release the active drug in both immediate and sustained release form. Chronodelivery formulations using this technology can effectively delay drug absorption for up to five hours. Aversion (Acura Pharmaceuticals) utilizes certain proprietary combinations of functional excipients (e.g., gelling agents) and active ingredients intended to discourage the most common methods of prescription drug misuse and abuse. Ingredients may include nasal irritants (e.g., capsaicin) and aversive agents (e.g., niacin). In some embodiments, the opioid agonist is in an abuse- deterrent formulation. In some embodiments, the opioid agonist is selected from Acurox® Oxycodone DETERx®, Egalet hydrocodone, Egalet morphine, Egalet oxycodone, Exalgo®, Opana®, and Remoxy®.

Pharmaceutical Formulations

[0139] Also provided are pharmaceutical formulations comprising naloxone for intranasal administration. In some embodiments the pharmaceutical formulations comprise naloxone and a pharmaceutically acceptable carrier. The carrier(s) must be "acceptable" in the sense of being compatible with the other ingredients of the formulation and not overly deleterious to the recipient thereof. Some embodiments of the present invention include a method of producing a pharmaceutical formulation comprising admixing at least one opioid antagonist and a pharmaceutically acceptable carrier. Pharmaceutical formulations are applied directly to the nasal cavity using the devices described herein. In the case of a spray, this may be achieved for example by means of a metering atomizing spray pump or a pre-primed device.

[0140] Liquid preparations include solutions, suspensions and emulsions, for example, water or water-propylene glycol solutions. Additional ingredients in liquid preparations may include: antimicrobial preservatives, such as benzalkonium chloride (which may also act as a cationic surfactant and/or a permeation enhancer), methylparaben, sodium benzoate, benzoic acid, phenyl ethyl alcohol, and the like, and mixtures thereof; surfactants such as Polysorbate 80 NF, poly oxy ethylene 20 sorbitan monolaurate, poly oxy ethylene (4) sorbitan monolaurate, poly oxy ethylene 20 sorbitan monopalmitate, poly oxy ethylene 20 sorbitan monostearate, poly oxy ethylene (4) sorbitan monostearate, polyoxyethylene 20 sorbitan tristearate, poly oxy ethylene (5) sorbitan monooleate, polyoxyethylene 20 sorbitan trioleate, polyoxyethylene 20 sorbitan monoisostearate, sorbitan monooleate, sorbitan monolaurate, sorbitan monopalmitate, sorbitan monostearate, sorbitan trilaurate, sorbitan trioleate, sorbitan tristearate, and the like, and mixtures thereof; a tonicity agent such as: dextrose, lactose, sodium chloride, calcium chloride, magnesium chloride, sorbitol, sucrose, mannitol, trehalose, raffinose, polyethylene glycol, hydroxyethyl starch, glycine, and the like, and mixtures thereof; and a suspending agent such as microcrystalline cellulose,

carboxymethylcellulose sodium NF, polyacrylic acid, magnesium aluminum silicate, xanthan gum, and the like, and mixtures thereof.

[0141] As discussed above, naloxone may optionally be provided as a pharmaceutically acceptable salt including hydrochloride. Salts may be obtained as the direct products of compound synthesis, or the free base may be dissolved in a suitable solvent containing the appropriate acid and the salt isolated by evaporating the solvent or otherwise separating the salt and solvent. Naloxone and its salts may form solvates with standard low molecular weight solvents, including water (to form hydrates).

[0142] In some embodiments, the pharmaceutical formulation further comprises one or more excipients selected from water, an isotonicity agent, a compound which acts as a preservative, cationic surfactant, and/or permeation/penetration enhancer, a stabilizing agent, and an amount of an acid sufficient to achieve a target pH.

[0143] In some embodiments, the pharmaceutical formulation comprises one or more excipients selected from water and NaCl.

[0144] In some embodiments, the pharmaceutical formulation is substantially free of antimicrobial preservatives.

[0145] In some embodiments, the pharmaceutical formulation comprises a compound which is a preservative, cationic surfactant, and/or permeation/penetration enhancer.

[0146] In certain embodiments, the pharmaceutical formulation comprises benzalkonium chloride. The benzalkonium chloride can function as a preservative (even in low amounts), a permeation/penetration enhancer, and/or a cationic surfactant (typically at a higher amount for these latter two). Benzalkonium chloride is represented by the following structure:

in which n is an integer, and a mixture of more than one thereof can be used. In certain embodiments, n is 8, 10, 12, 14, 16, or 18, and in certain embodiments, n is 10, 12, or 14. In certain embodiments, the pharmaceutical formulation comprises about 0.005% to about 1% benzalkonium chloride. In certain embodiments, the pharmaceutical formulation comprises about 0.01% to about 1% benzalkonium chloride. In certain embodiments, the pharmaceutical formulation comprises about 0.005% to about 0.015% benzalkonium chloride. [0147] In some embodiments, the pharmaceutical formulation further comprises one or more excipients selected from water, NaCl, benzalkonium chloride, sodium edetate, disodium edetate, and hydrochloric acid.

[0148] In some embodiments, the pharmaceutical formulation further comprises water, NaCl, benzalkonium chloride, disodium edetate, and hydrochloric acid.

[0149] In some embodiments, the pharmaceutical formulation further comprises:

an isotonicity agent;

a preservative;

a stabilizing agent;

an amount of an acid sufficient to achieve a pH of 3.5-6.5; and

an amount of water sufficient to achieve a final volume of not more than about 100 μΐ,.

[0150] In some embodiments, the pharmaceutical formulation comprises:

between about 0.2 mg and about 2 mg of an isotonicity agent;

between about 0.005 mg and about 0.1 mg of a compound which is a preservative, cationic surfactant, and/or permeation enhancer;

between about 0.1 mg and about 0.5 mg of a stabilizing agent;

an amount of an acid sufficient to achieve a pH of 3.5-5.5; and

an amount of water sufficient to achieve a final volume of not more than about

100 μΐ,.

[0151] In some embodiments, the pharmaceutical formulation comprises:

between about 0.2 mg and about 1.2 mg of an isotonicity agent;

between about 0.005 mg and about 0.015 mg of a compound which is a preservative, cationic surfactant, and/or permeation enhancer;

between about 0.1 mg and about 0.5 mg of a stabilizing agent;

an amount of an acid sufficient to achieve a pH of 3.5-5.5; and

an amount of water sufficient to achieve a final volume of not more than about 100 μί.

[0152] In some embodiments,

the isotonicity agent is NaCl;

the compound which is a preservative, cationic surfactant, and/or permeation enhancer is benzalkonium chloride;

the stabilizing agent is disodium edetate; and

the acid is hydrochloric acid. [0153] In some embodiments, the pharmaceutical formulation comprises:

about 0.74 mg NaCl;

about 0.01 mg benzalkonium chloride;

about 0.2 mg disodium edetate;

an amount of hydrochloric acid sufficient to achieve a pH of 3.5-5.5; and an amount of water sufficient to achieve a final volume of not more than about 100 μΐ,.

[0154] In some embodiments, naloxone is administered as part of a pharmaceutical formulation additionally comprising:

an isotonicity agent; and

between about 0.005% and about 1% (w/v) of a compound which is at least one of a preservative, a cationic surfactant, and a permeation enhancer.

[0155] In some embodiments, the naloxone is naloxone hydrochloride.

[0156] In some embodiments, the pharmaceutical formulation comprises between about 0.2% and about 2% (w/v) of the isotonicity agent. In some embodiments, the pharmaceutical formulation comprises between about 0.2% and about 1.2% (w/v) of the isotonicity agent.

[0157] In some embodiments, the pharmaceutical formulation comprises between about 0.2 to about 2.0 mg of the isotonicity agent. In some embodiments, the pharmaceutical formulation comprises between about 0.2 to about 1.2 mg of the isotonicity agent.

[0158] In some embodiments, the isotonicity agent is NaCl.

[0159] In some embodiments, the pharmaceutical formulation comprises about 0.005% and about 0.015% (w/v) of the compound which is at least one of a preservative, a cationic surfactant, and a permeation enhancer.

[0160] In some embodiments, the pharmaceutical formulation comprises about 0.005% and about 0.01 % (w/v) of the compound which is at least one of a preservative, a cationic surfactant, and a permeation enhancer.

[0161] In some embodiments, the compound which is at least one of a preservative, a cationic surfactant, and a permeation enhancer is benzalkonium chloride.

[0162] In some embodiments, the pharmaceutical formulation additionally comprises a stabilizing agent.

[0163] In some embodiments, the formulation comprises between about 0.1 mg and about 0.5 mg of the stabilizing agent.

[0164] In some embodiments, the stabilizing agent is disodium edetate. [0165] In some embodiments, the pharmaceutical formulation additionally comprises an amount of an acid sufficient to achieve a pH of 3.5-6.5.

[0166] In some embodiments, the pharmaceutical formulation additionally comprises an amount of an acid sufficient to achieve a pH of 3.5-5.5.

[0167] In some embodiments, the acid is hydrochloric acid.

[0168] In some embodiments, the pharmaceutical formulation comprises:

between about 0.2% and about 1.2% (w/v) of the isotonicity agent;

between about 0.1% and about 0.5% (w/v) of a stabilizing agent; and

an amount of an acid sufficient to achieve a pH of 3.5-5.5.

[0169] In some embodiments, the pharmaceutical formulation comprises:

between about 0.2 to about 2.0 mg of the isotonicity agent;

between about 0.1 to about 0.5 mg of a stabilizing agent; and

an amount of an acid sufficient to achieve a pH of 3.5-5.5.

[0170] In some embodiments: the isotonicity agent is sodium chloride; the stabilizing agent is disodium edetate; and the acid is hydrochloric acid.

[0171] In some embodiments, the pharmaceutical formulation comprises about 2, about 4, or about 8 mg of naloxone or a salt or hydrate thereof.

[0172] In some embodiments, the pharmaceutical solution comprises:

about 2% (w/v) naloxone hydrochloride;

about 0.74% (w/v) sodium chloride;

about 0.01% (w/v) benzalkonium chloride; and

about 0.2% (w/v) disodium edetate.

[0173] In some embodiments, the pharmaceutical formulation comprises:

about 2 mg naloxone hydrochloride;

about 0.74 mg NaCl;

about 0.01 mg benzalkonium chloride; and

about 0.2 mg disodium edetate.

[0174] In some embodiments, the pharmaceutical formulation comprises:

about 4% (w/v) naloxone hydrochloride;

about 0.74% (w/v) sodium chloride;

about 0.01% (w/v) benzalkonium chloride; and

about 0.2% (w/v) disodium edetate.

[0175] In some embodiments, the pharmaceutical formulation comprises:

about 4 mg naloxone hydrochloride; about 0.74 mg NaCl;

about 0.01 mg benzalkonium chloride; and

about 0.2 mg disodium edetate.

[0176] In some embodiments, the pharmaceutical formulation comprises an amount of hydrochloric acid sufficient to achieve a pH of 3.5-5.5.

[0177] In some embodiments, the pharmaceutical formulation is storage-stable for about twelve months at about 25 °C and about 60% relative humidity.

[0178] Also provided herein are pharmaceutical formulations for intranasal administration comprising, in an aqueous solution of not more than about 140 μί:

between about 2 mg and about 12 mg of an opioid antagonist;

between about 0.2 mg and about 1.2 mg of an isotonicity agent;

between about 0.005 mg and about 0.015 mg of a compound which is a preservative, cationic surfactant, and/or permeation enhancer;

between about 0.1 mg and about 0.5 mg of a stabilizing agent;

an amount of an acid sufficient to achieve a pH of 3.5-5.5.

[0179] In some embodiments, the opioid antagonist is the only pharmaceutically active compound in the pharmaceutical formulation.

[0180] In some embodiments, the opioid antagonist is naloxone hydrochloride, or a hydrate thereof.

[0181] In some embodiments, the opioid antagonist is naloxone hydrochloride dihydrate.

[0182] In some embodiments, the pharmaceutical formulation comprises an amount equivalent to about 2 mg to about 12 mg of naloxone hydrochloride. In some embodiments, the pharmaceutical formulation comprises an amount equivalent to about 4 mg to about 10 mg of naloxone hydrochloride. In some embodiments, the pharmaceutical formulation comprises an amount equivalent to about 2 mg to about 8 mg of naloxone hydrochloride. In some embodiments, the pharmaceutical formulation comprises an amount equivalent to an amount chosen from about 2 mg naloxone hydrochloride, about 4 mg of naloxone hydrochloride, and about 8 mg naloxone hydrochloride. In some embodiments, the pharmaceutical formulation comprises an amount equivalent to about 2 mg of naloxone hydrochloride. In some embodiments, the pharmaceutical formulation comprises an amount equivalent to about 4 mg of naloxone hydrochloride. In some embodiments, the pharmaceutical formulation comprises an amount equivalent to about 8 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 3.4 mg of naloxone hydrochloride. [0183] In some embodiments, the pharmaceutical formulation comprises about 2 mg or about 4 mg naloxone hydrochloride or a hydrate thereof;

between about 0.2 mg and about 1.2 mg of an isotonicity agent;

between about 0.005 mg and about 0.015 mg of a compound which is a preservative, cationic surfactant, and/or permeation enhancer;

between about 0.1 mg and about 0.5 mg of a stabilizing agent;

an amount of an acid sufficient to achieve a pH of 3.5-5.5.

[0184] In some embodiments, the pharmaceutical formulation comprises about 4 mg naloxone hydrochloride or a hydrate thereof. In some embodiments, the pharmaceutical formulations comprises about 2 mg naloxone hydrochloride or a hydrate thereof.

[0185] In some embodiments,

the isotonicity agent is NaCl;

the compound which is a preservative, cationic surfactant, and/or permeation enhancer is benzalkonium chloride;

the stabilizing agent is disodium edetate; and

the acid is hydrochloric acid.

[0186] In some embodiments, the pharmaceutical formulation comprises:

about 2 mg or about 4 mg naloxone hydrochloride;

about 0.74 mg NaCl;

about 0.01 mg benzalkonium chloride;

about 0.2 mg disodium edetate; and

an amount of hydrochloric acid sufficient to achieve a pH of 3.5-5.5.

[0187] In some embodiments, the pharmaceutical formulation is in an aqueous solution of about 100

[0188] In some embodiments, upon nasal delivery of the pharmaceutical formulation to the patient, less than about 10% of the pharmaceutical formulation leaves the nasal cavity via drainage into the nasopharynx or externally.

[0189] In some embodiments, the plasma concentration versus time curve of the naloxone hydrochloride in the patient has a Tmax of between about 20 and about 30 minutes.

[0190] In some embodiments, the device is actuatable with one hand.

[0191] In some embodiments, the delivery time is less than about 25 seconds. In some embodiments, the delivery time is less than about 20 seconds. [0192] In some embodiments, the 90% confidence interval for dose delivered per actuation is ± about 2%. In some embodiments, the 95% confidence interval for dose delivered per actuation is ± about 2.5%.

[0193] In some embodiments, upon nasal delivery of the pharmaceutical formulation to the patient, less than about 20% of the pharmaceutical formulation leaves the nasal cavity via drainage into the nasopharynx or externally. In some embodiments, upon nasal delivery of the pharmaceutical formulation to the patient, less than about 10% of the pharmaceutical formulation leaves the nasal cavity via drainage into the nasopharynx or externally. In some embodiments, upon nasal delivery of the pharmaceutical formulation to the patient, less than about 5% of the pharmaceutical formulation leaves the nasal cavity via drainage into the nasopharynx or externally.

[0194] In some embodiments, the plasma concentration versus time curve of the opioid antagonist in a patient has a Tmax of less than 30 minutes. In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of less than 25 minutes. In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of about 20 minutes. In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of less than 19 minutes. In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of about 18.5 minutes.

[0195] In some embodiments, delivery of the pharmaceutical formulation to a patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 90%. In some embodiments, delivery of the pharmaceutical formulation to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 95%. In some embodiments, delivery of the pharmaceutical formulation to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 99%.

[0196] In some embodiments, the patient is free from respiratory depression for at least about 1 hour following treatment comprising essentially of delivery of the therapeutically effective amount of the opioid antagonist. In some embodiments, the patient is free from respiratory depression for at least about 2 hours following treatment comprising essentially of delivery of the therapeutically effective amount of the opioid antagonist. In some embodiments, the patient is free from respiratory depression for at least about 4 hours following treatment comprising essentially of delivery of the therapeutically effective amount of the opioid antagonist. In some embodiments, the patient is free from respiratory depression for at least about 6 hours following treatment comprising essentially of delivery of the therapeutically effective amount of the opioid antagonist.

[0197] Also provided herein are pharmaceutical formulations for intranasal administration comprising, in an aqueous solution of not more than about 140 μί:

about 2 mg or about 4 mg naloxone hydrochloride or a hydrate thereof; between about 0.2 mg and about 1.2 mg of an isotonicity agent;

between about 0.005 mg and about 0.015 mg of a compound which is a preservative, cationic surfactant, and/or permeation enhancer;

between about 0.1 mg and about 0.5 mg of a stabilizing agent;

an amount of hydrochloric acid sufficient to achieve a pH of 3.5-5.5.

[0198] In some embodiments,

the isotonicity agent is NaCl;

the compound which is a preservative, cationic surfactant, and/or permeation enhancer is benzalkonium chloride;

the stabilizing agent is disodium edetate; and

the acid is hydrochloric acid.

[0199] In some embodiments, the pharmaceutical formulation comprises:

about 2.2 mg or about 4.4 mg naloxone hydrochloride dihydrate;

about 0.74 mg NaCl;

about 0.01 mg benzalkonium chloride;

about 0.2 mg disodium edetate; and

an amount of hydrochloric acid sufficient to achieve a pH of 3.5-5.5.

[0200] In some embodiments, the pharmaceutical formulation comprises about 4 mg naloxone hydrochloride or a hydrate thereof. In some embodiments, the pharmaceutical formulation comprises about 2 mg naloxone hydrochloride or a hydrate thereof. In some embodiments, the pharmaceutical formulation comprises about 4.4 mg naloxone hydrochloride dihydrate. In some embodiments, the pharmaceutical formulation comprises about 2.2 mg naloxone hydrochloride dihydrate.

[0201] Also provided herein are pharmaceutical formulations for intranasal administration comprising, in an aqueous solution of not more than about 100 μί:

about 4 mg naloxone hydrochloride or a hydrate thereof;

between about 0.2 mg and about 1.2 mg of an isotonicity agent; between about 0.005 mg and about 0.015 mg of a compound which is a preservative, cationic surfactant, and/or permeation enhancer;

between about 0.1 mg and about 0.5 mg of a stabilizing agent;

an amount of an acid sufficient to achieve a pH of 3.5-5.5.

[0202] In some embodiments, the pharmaceutical formulation comprises:

about 4.4 mg naloxone hydrochloride dihydrate;

about 0.74 mg NaCl;

about 0.01 mg benzalkonium chloride;

about 0.2 mg disodium edetate; and

an amount of hydrochloric acid sufficient to achieve a pH of 3.5-5.5.

[0203] Also provided herein are pharmaceutical formulations for intranasal administration comprising, in an aqueous solution of about 100 μί:

about 2 mg naloxone hydrochloride or a hydrate thereof;

between about 0.2 mg and about 1.2 mg of an isotonicity agent;

between about 0.005 mg and about 0.015 mg of a compound which is a preservative, cationic surfactant, and/or permeation enhancer;

between about 0.1 mg and about 0.5 mg of a stabilizing agent;

an amount of an acid sufficient to achieve a pH of 3.5-5.5.

[0204] In some embodiments, the pharmaceutical formulation comprises:

about 2.2 mg naloxone hydrochloride dihydrate;

about 0.74 mg NaCl;

about 0.01 mg benzalkonium chloride;

about 0.2 mg disodium edetate; and

an amount of hydrochloric acid sufficient to achieve a pH of 3.5-5.5.

[0205] In some embodiments, the pharmaceutical formulation comprises about 4.4 mg naloxone hydrochloride dihydrate. In some embodiments, the pharmaceutical formulation comprises about 2.2 mg naloxone hydrochloride dihydrate.

[0206] Provided are devices adapted for nasal delivery of a pharmaceutical formulation to a patient, comprising a therapeutically effective amount of an opioid antagonist selected from naloxone and pharmaceutically acceptable salts thereof, wherein the device is pre-primed, and wherein the therapeutically effective amount, is equivalent to about 2 mg to about 12 mg of naloxone hydrochloride. In some embodiments, the pharmaceutical formulation further comprises one or more excipients selected from water and NaCl. In some embodiments, the pharmaceutical formulation is substantially free of antimicrobial preservatives. In some embodiments, the device is substantially free of benzalkonium chloride, methylparaben, sodium benzoate, benzoic acid, phenyl ethyl alcohol In some embodiments, the device is filled with the pharmaceutical formulation in a sterile environment. In some embodiments, the pharmaceutical formulation is storage-stable for about twelve months at about 25 °C. In some embodiments, the pharmaceutical formulation comprises less than 0.1% w/w antimicrobial preservatives. In some embodiments, the pharmaceutical formulation comprises 0.01% w/w or less antimicrobial preservatives. In some embodiments, the pharmaceutical formulation comprises 0.01% w/w - 0.001% w/w antimicrobial preservatives. In some embodiments, the pharmaceutical formulation comprises less than 0.001% w/w antimicrobial preservatives.

[0207] Also provided are devices for "combination-therapy" comprising pharmaceutical formulations comprising at least one opioid antagonist described herein, together with at least one known pharmaceutical agent and a pharmaceutically acceptable carrier. In some embodiments, the pharmaceutical formulation comprises a short-acting opioid antagonist and a long-acting opioid antagonist. In some embodiments, the pharmaceutical formulation comprises naloxone and naltrexone. In some embodiments, the pharmaceutical formulation comprises naloxone and methylnaltrexone. In some embodiments, the pharmaceutical formulation comprises naloxone and nalmefene.

[0208] Also provided are embodiments wherein any embodiment above may be combined with any one or more of these embodiments, provided the combination is not mutually exclusive.

Indications

[0209] Also provided are devices for use in treating opioid overdose and symptoms thereof and methods of using the devices. Naloxone prevents or reverses the effects of opioids including respiratory depression, sedation and hypotension. Also, it can reverse the psychotomimetic and dysphoric effects of agonist-antagonists such as pentazocine. Naloxone causes abrupt reversal of narcotic depression which may result in nausea, vomiting, sweating, tachycardia, increased blood pressure, tremulousness, seizures and cardiac arrest, however, there is no clinical experience with naloxone hydrochloride overdosage in humans. In the mouse and rat the intravenous LD50 is 150 ± 5 mg/kg and 109 ± 4 mg/kg respectively. In acute subcutaneous toxicity studies in newborn rats the LD50 (95% CL) is 260 (228-296) mg/kg. Subcutaneous injection of 100 mg/kg/day in rats for 3 weeks produced only transient salivation and partial ptosis following injection: no toxic effects were seen at 10 mg/kg/day for 3 weeks.

[0210] Naloxone hydrochloride injection is indicated for the complete or partial reversal of narcotic depression, including respiratory depression, induced by opioids selected from: natural and synthetic narcotics, propoxyphene, methadone, and certain narcotic-antagonist analgesics: nalbuphine, pentazocine and butorphanol. Naloxone hydrochloride is also indicated for the diagnosis of suspected acute opioid overdosage. For the treatment of known or suspected narcotic overdose in adults an initial dose of 0.4 mg to 2 mg of naloxone hydrochloride intravenously is indicated. If the desired degree of counteraction and improvement in respiratory functions is not obtained, administration may be repeated at 2 to 3 minute intervals. If no response is observed after 10 mg of naloxone hydrochloride have been administered, the diagnosis of narcotic-induced or partial narcotic-induced toxicity should be questioned. The usual initial dose in children is 0.01 mg/kg body weight given IV. If this dose does not result in the desired degree of clinical improvement, a subsequent dose of 0.1 mg/kg body weight may be administered. When using naloxone hydrochloride injection in neonates a product containing 0.02 mg/mL should be used.

[0211] It has also been reported that naloxone hydrochloride is an effective agent for the reversal of the cardiovascular and respiratory depression associated with narcotic and possibly some non-narcotic overdoses. The authors stated that due to naloxone's pharmacokinetic profile, a continuous infusion protocol is recommended when prolonged narcotic antagonist effects are required.

[0212] Accordingly, also provided herein are methods of treating opioid overdose or a symptom thereof, comprising nasally administering to a patient in need thereof a therapeutically effective amount of an opioid antagonist selected from naloxone and pharmaceutically acceptable salts thereof, wherein the therapeutically effective amount is equivalent to about 2 mg to about 12 mg of naloxone hydrochloride or a hydrate thereof. In some embodiments, the therapeutically effective amount of an opioid antagonist selected from naloxone and pharmaceutically acceptable salts thereof is delivered in not more than about 140 of an aqueous carrier solution.

[0213] In certain embodiments, also provided herein are methods of treating opioid overdose or a symptom thereof, comprising nasally administering to a patient in need thereof a therapeutically effective amount of an opioid antagonist selected from naloxone and pharmaceutically acceptable salts thereof, wherein the therapeutically effective amount is equivalent to about 2 mg to about 12 mg of naloxone hydrochloride or a hydrate thereof in not more than about 140 of an aqueous carrier solution.

[0214] In certain embodiments, also provided herein are methods of treating opioid overdose or a symptom thereof, comprising nasally administering to a patient in need thereof a single dose of a therapeutically effective amount of an opioid antagonist selected from naloxone and pharmaceutically acceptable salts thereof, wherein the therapeutically effective amount is equivalent to about 2 mg to about 12 mg of naloxone hydrochloride or a hydrate thereof in not more than about 140 of an aqueous carrier solution.

[0215] In some embodiments, the opioid antagonist is the only pharmaceutically active compound in the pharmaceutical formulation.

[0216] In some embodiments, the opioid antagonist is naloxone hydrochloride. In some embodiments, the opioid antagonist is naloxone hydrochloride dihydrate.

[0217] In some embodiments, the pharmaceutical formulation comprises a solution of naloxone hydrochloride, or a hydrate thereof.

[0218] In some embodiments, the patient is an opioid overdose patient or a suspected opioid overdose patient.

[0219] In some embodiments, the patient is in a lying, supine, or recovery position. In some embodiments, the patient is in a lying position. In some embodiments, the patient is in a supine position. In some embodiments, the patient is in a recovery position.

[0220] In some embodiments, the therapeutically effective amount of an opioid antagonist is delivered by an untrained individual.

[0221] In some embodiments, the therapeutically effective amount is equivalent to about 4 mg to about 10 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to an amount chosen from about 2 mg naloxone hydrochloride, about 4 mg of naloxone hydrochloride, and about 8 mg naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 2 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 4 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 8 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 3.4 mg of naloxone hydrochloride.

[0222] In some embodiments, the symptom is chosen from respiratory depression and central nervous system depression. [0223] In some embodiments, the patient exhibits any of unresponsiveness to stimulus, unconsciousness, stopped breathing; erratic or stopped pulse, choking or gurgling sounds, blue or purple fingernails or lips, slack or limp muscle tone, contracted pupils, and vomiting.

[0224] In some embodiments, the patient is not breathing.

[0225] In some embodiments, the patient is in a lying, supine, or recovery position.

[0226] In some embodiments, the patient is in a lying position.

[0227] In some embodiments, the patient is in a supine position.

[0228] In some embodiments, the patient is a recovery position.

[0229] In some embodiments, the therapeutically effective amount is equivalent to about 2 mg to about 10 mg of naloxone hydrochloride.

[0230] In some embodiments, the therapeutically effective amount is equivalent to an amount chosen from about 2 mg naloxone hydrochloride, about 4 mg of naloxone hydrochloride, and about 8 mg naloxone hydrochloride.

[0231] In some embodiments, the therapeutically effective amount is equivalent to about 2 mg of naloxone hydrochloride.

[0232] In some embodiments, the therapeutically effective amount is equivalent to about 4 mg of naloxone hydrochloride.

[0233] In some embodiments, the therapeutically effective amount is equivalent to about 8 mg of naloxone hydrochloride.

[0234] In some embodiments, the opioid antagonist is the only pharmaceutically active compound in the pharmaceutical formulation.

[0235] In some embodiments, the opioid antagonist is naloxone hydrochloride.

[0236] In some embodiments, the nasally administering is accomplished using a pre-primed device adapted for nasal delivery of a pharmaceutical formulation.

[0237] In some embodiments, upon nasal delivery of the pharmaceutical formulation to the patient, less than about 20% of the pharmaceutical formulation leaves the nasal cavity via drainage into the nasopharynx or externally.

[0238] In some embodiments, upon nasal delivery of the pharmaceutical formulation to the patient, less than about 10% of the pharmaceutical formulation leaves the nasal cavity via drainage into the nasopharynx or externally.

[0239] In some embodiments, upon nasal delivery of the pharmaceutical formulation to the patient, less than about 5% of the pharmaceutical formulation leaves the nasal cavity via drainage into the nasopharynx or externally. [0240] In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of less than 30 minutes.

[0241] In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of less than 25 minutes.

[0242] In some embodiments, the plasma concentration versus time curve of the opioid antagonist in the patient has a Tmax of about 20 minutes.

[0243] In some embodiments, the opioid overdose symptom is selected from: respiratory depression, central nervous system depression, and cardiovascular depression.

[0244] In some embodiments, the opioid overdose symptom is respiratory depression induced by opioids.

[0245] In some embodiments, the respiratory depression is caused by the illicit use of opioids or by an accidental misuse of opioids during medical opioid therapy.

[0246] In some embodiments, the respiratory depression is induced by opioids selected from: natural and synthetic narcotics, propoxyphene, methadone, nalbuphine, pentazocine and butorphanol.

[0247] In some embodiments, the respiratory depression is induced by an opioid selected from codeine, morphine, methadone, fentanyl, oxycodone HC1, hydrocodone bitartrate, hydromorphone, oxymorphone, meperidine, propoxyphene, opium, heroin, tramadol, tapentadol.

[0248] In some embodiments, the patient is free from respiratory depression for at least about

1 hour following treatment comprising essentially of delivery of the therapeutically effective amount of the opioid antagonist.

[0249] In some embodiments, the patient is free from respiratory depression for at least about

2 hours following treatment comprising essentially of delivery of the therapeutically effective amount of the opioid antagonist.

[0250] In some embodiments, the patient is free from respiratory depression for at least about 4 hours following treatment comprising essentially of delivery of the therapeutically effective amount of the opioid antagonist.

[0251] In some embodiments, the patient is free from respiratory depression for at least about 6 hours following treatment comprising essentially of delivery of the therapeutically effective amount of the opioid antagonist.

[0252] Also provided are embodiments wherein any embodiment above may be combined with any one or more of these embodiments, provided the combination is not mutually exclusive. [0253] Also provided are the devices, pharmaceutical formulations, kits, and methods of treatment described herein for use in the treatment of an opioid overdose symptom selected from: respiratory depression, postoperative opioid respiratory depression, altered level consciousness, miotic pupils, cardiovascular depression, hypoxemia, acute lung injury, aspiration pneumonia, sedation, and hypotension. Also provided are the devices,

pharmaceutical formulations, kits, and methods of treatment described herein for use in the reversal of respiratory depression induced by opioids. In some embodiments, the respiratory depression is caused by the illicit use of opioids or by an accidental misuse of opioids during medical opioid therapy. Also provided are the devices, pharmaceutical formulations, kits, and methods of treatment described herein for use in the complete or partial reversal of narcotic depression, including respiratory depression, induced by opioids selected from: natural and synthetic narcotics, propoxyphene, methadone, nalbuphine, pentazocine and butorphanol. In some embodiments, narcotic depression, including respiratory depression, is induced by an opioid agonist selected from codeine, morphine, methadone, fentanyl, oxycodone, hydrocodone, hydromorphone, oxymorphone, meperidine, propoxyphene, opium, heroin, tramadol, and tapentadol.

[0254] Also provided are devices, pharmaceutical formulations, and kits for, and methods of, treating opioid overdose or a symptom thereof, comprising nasally administering to a patient in need thereof a therapeutically effective amount of an opioid antagonist selected from naloxone and pharmaceutically acceptable salts thereof, wherein the therapeutically effective amount is equivalent to about 2 mg to about 12 mg of naloxone hydrochloride. In some embodiments, the patient is not breathing. Also provided are devices adapted for nasal delivery of a pharmaceutical formulation to a patient, comprising a therapeutically effective amount of an opioid antagonist selected from naloxone and pharmaceutically acceptable salts thereof, wherein the device is pre-primed, and wherein the therapeutically effective amount, is equivalent to about 4 mg to about 12 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 2 mg to about 24 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 3 mg to about 18 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 2 mg to about 12 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 4 mg to about 10 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 5 mg to about 11 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 6 mg to about 10 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 2 mg to about 8 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 4 mg to about 8 mg of naloxone hydrochloride. In some embodiments, the

therapeutically effective amount is equivalent to about 7 mg to about 9 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 2 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 3.4 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 4 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 5 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 6 mg of naloxone hydrochloride. In some embodiments, the

therapeutically effective amount is equivalent to about 7 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 8 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 9 mg of naloxone hydrochloride. In some embodiments, the

therapeutically effective amount is equivalent to about 10 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 11 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 12 mg of naloxone hydrochloride. In some embodiments, the opioid antagonist is the only pharmaceutically active compound in pharmaceutical formulation. In some embodiments, the opioid antagonist is naloxone hydrochloride. In some embodiments, the opioid antagonist is anhydrous naloxone hydrochloride. In some embodiments, the opioid antagonist is the only pharmaceutically active compound in the pharmaceutical formulation. In some embodiments, the opioid antagonist is naloxone hydrochloride. In some

embodiments, the pharmaceutical formulation comprises a solution of naloxone

hydrochloride. In some embodiments, the nasally administering is accomplished using a device described herein. In some embodiments, the opioid overdose symptom is selected from: respiratory depression, postoperative opioid respiratory depression, altered level consciousness, miotic pupils, cardiovascular depression, hypoxemia, acute lung injury, aspiration pneumonia, sedation, and hypotension. In some embodiments, the opioid overdose symptom is respiratory depression induced by opioids. In some embodiments, the respiratory depression is caused by the illicit use of opioids or by an accidental misuse of opioids during medical opioid therapy. In some embodiments, the respiratory depression is induced by opioids selected from: natural and synthetic narcotics, propoxyphene, methadone, nalbuphine, pentazocine and butorphanol. In some embodiments, the respiratory depression is induced by an opioid agonist selected from codeine, morphine, methadone, fentanyl, oxycodone HC1, hydrocodone bitartrate, hydromorphone, oxymorphone, meperidine, propoxyphene, opium, heroin, tramadol, and tapentadol.

[0255] Also provided are devices, kits, and pharmaceutical formulations for, and methods of, treating opioid overdose or a symptom thereof, comprising nasally administering to a patient in need thereof a therapeutically effective amount of an opioid antagonist together and at least one known pharmaceutical agent. In some embodiments, the method comprises nasally administering to a patient in need thereof therapeutically effective amounts of a short-acting opioid antagonist and a long-acting opioid antagonist.

[0256] Also provided are devices, kits, and pharmaceutical formulations for, and methods of, reversing the psychotomimetic and dysphoric effects of agonist-antagonists such as pentazocine, comprising nasally administering to a patient in need thereof a therapeutically effective amount of an opioid antagonist selected from naloxone and pharmaceutically acceptable salts thereof, wherein the therapeutically effective amount is equivalent to about 2 mg to about 12 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 4 mg of naloxone hydrochloride dihydrate. In some embodiments, the nasally administering is accomplished using a device described herein.

[0257] Also provided are devices, kits, and pharmaceutical formulations for, and methods of, diagnosis of suspected acute opioid overdosage, comprising nasally administering to a patient in need thereof a therapeutically effective amount of an opioid antagonist selected from naloxone and pharmaceutically acceptable salts thereof, wherein the therapeutically effective amount is equivalent to about 2 mg to about 12 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 4 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 4.4 mg of naloxone hydrochloride dihydrate. In some embodiments, the nasally administering is accomplished using a device described herein.

[0258] Also provided are devices, kits, and pharmaceutical formulations for, and methods of, treating opioid addiction, comprising nasally administering to a patient in need thereof a therapeutically effective amount of an opioid antagonist selected from naloxone and pharmaceutically acceptable salts thereof, wherein the therapeutically effective amount is equivalent to about 2 mg to about 12 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 4 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 4.4 mg of naloxone hydrochloride dihydrate. In some embodiments, the nasally administering is accomplished using a device described herein.

[0259] Also provided are devices, kits, and pharmaceutical formulations for, and methods of, treating septic shock, comprising nasally administering to a patient in need thereof a therapeutically effective amount of an opioid antagonist selected from naloxone and pharmaceutically acceptable salts thereof, wherein the therapeutically effective amount is equivalent to about 2 mg to about 12 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 4 mg of naloxone hydrochloride. In some embodiments, the therapeutically effective amount is equivalent to about 4.4 mg of naloxone hydrochloride dihydrate. In some embodiments, the nasally administering is accomplished using a device described herein.

[0260] Also provided are devices, kits, and pharmaceutical formulations for, and methods of, treating opioid overdose or a symptom thereof, reversing the psychotomimetic and dysphoric effects of agonist-antagonists such as pentazocine, diagnosing suspected acute opioid overdosage, treating opioid addiction, or treating septic shock, comprising nasally administering to a patient in need thereof a therapeutically effective amount of an opioid antagonist, wherein the therapeutically effective amount is about 2 mg to about 12 mg. In some embodiments, the therapeutically effective amount is equivalent to about 4.4 mg of naloxone hydrochloride dihydrate. In some embodiments, the therapeutically effective amount is equivalent to about 4 mg of naloxone hydrochloride. In some embodiments, the patient is an opioid overdose patient. In some embodiments, the patient is not breathing. In some embodiments, the opioid antagonist is the only pharmaceutically active compound in the pharmaceutical formulation. In some embodiments, the nasally administering is accomplished using a device described herein. In some embodiments, the opioid overdose symptom is selected from: respiratory depression, postoperative opioid respiratory depression, altered level consciousness, miotic pupils, cardiovascular depression, hypoxemia, acute lung injury, aspiration pneumonia, sedation, and hypotension. In some embodiments, the opioid overdose symptom is respiratory depression induced by opioids. In some embodiments, the respiratory depression is caused by the illicit use of opioids or by an accidental misuse of opioids during medical opioid therapy. In some embodiments, the respiratory depression is induced by opioids selected from: natural and synthetic narcotics, propoxyphene, methadone, nalbuphine, pentazocine and butorphanol. In some embodiments, the respiratory depression is induced by an opioid agonist selected from codeine, morphine, methadone, fentanyl, oxycodone HC1, hydrocodone bitartrate, hydromorphone,

oxymorphone, meperidine, propoxyphene, opium, heroin, tramadol, and tapentadol.

[0261] Various eating disorders, including binge eating, bulimia nervosa, and stimulus- induced over-eating, develop because the behaviors are reinforced by the endogenous opioidergic system so often and so well that the person no longer can control the behavior. Thus, certain aspects of eating disorders resemble opiate addiction and alcoholism.

Accordingly, also provided are devices, kits, and pharmaceutical formulations for, and methods of, treating an eating disorder selected from binge eating, bulimia, and stimulus- induced over-eating, comprising nasally administering to a patient in need thereof a therapeutically effective amount of an opioid antagonist, wherein the therapeutically effective amount is about 2 mg to about 12 mg. In some embodiments, the therapeutically effective amount is equivalent to about 4 mg of naloxone hydrochloride. In some embodiments, the opioid antagonist is the only pharmaceutically active compound in the pharmaceutical formulation. In some embodiments, the nasally administering is accomplished using a device described herein.

[0262] Also provided are embodiments wherein any embodiment above may be combined with any one or more of these embodiments, provided the combination is not mutually exclusive.

Receptor Occupancy

[0263] Also provided are formulations and devices for use in treating opioid overdose and symptoms thereof and methods of using the formulations and devices, which provide a high level of brain opioid receptor occupancy as may be determined, for example, by positron emission tomography (PET). PET is a noninvasive imaging techniques that can give insight into the relationship between target occupancy and drug efficacy, provided a suitable radioligand is available.

[0264] PET involves the administration to a subject of a positron-emitting radionuclide tracer followed by detection of the positron emission (annihilation) events in the body. The radionuclide tracer is typically composed of a targeting molecule having incorporated therein one or more types of positron-emitting radionuclides. Positron-emitting radionuclides include ⁿC, ¹³N, ¹⁵0, ¹⁸F, ⁵²Fe, ⁶²Cu, ⁶⁴Cu, ⁶⁸Ga, ⁷⁴ As, ⁸²Rb, ⁸⁹Zr, ¹²²I, and ¹²⁴I. Non-metal radionuclides may be covalently linked to the targeting molecule by reactions well known from the state of art. When the radionuclide is a metallic positron-emitter, it is understood that labeling may require the use of a chelating agent. Such chelating agents are well known from the state of the art.

[0265] The positron-emitter labeled compound is administered directly, e.g., IV, or indirectly, e.g., IN, into the subject's vascular system, from where it passes through the blood-brain barrier. Once the tracer has had sufficient time to associate with the target of interest, the individual is placed within in a scanning device comprising ring of scintillation detectors. An emitted positron travels through the individual's tissue for a short (isotope- dependent) distance, until it interacts with an electron. The interaction annihilates both the electron and the positron, producing a pair of photons moving in approximately opposite directions. These are detected when they reach a scintillator in the scanning device. Photons that do not arrive in pairs are ignored. An image is then generated of the part of the individual's brain to which the compound has distributed.

[0266] PET studies are useful for comparing nasal delivery of naloxone using the devices and at the doses described herein, to typical nasal doses of naloxone (such as 2-12 mg), to delivery of naloxone using other nasal devices (such as the MAD™) and by other routes of administration such IM or IV naloxone or other opioid antagonists, such as oral naltrexone or nalmefene. Further comparisons may be made between nasal administration in the upright versus the lying or supine positions. Useful measures that may be determined in such studies are the time to onset of action, brain half-life (indirectly), the percent receptor binding or occupancy of a patient's opioid receptors, for example, the μ-opioid receptors in the reward centers, or respiratory center in the medulla oblongata, and an indirect measure of how long the compound of interest remains in the brain.

[0267] [ⁿC]Carfentanil (CFN) is a μ-opioid agonist used for in vivo PET studies of μ-opioid receptors. One such study involved healthy male volunteers assigned at enrollment to receive either naltrexone or a novel μ-opioid receptor inverse agonist (GSK1521498) (Rabiner et al, Pharmacological differentiation of opioid receptor antagonists by molecular and functional imaging of target occupancy and food reward-related brain activation in humans. Molecular Psychiatry (2011) 16, 826-835). Each participant underwent up to three [ⁿC]-carfentanil PET scans and two fMRI examinations: one [ⁿC]-carfentanil PET scan and one fMRI scan at baseline (before dosing) and up to two PET scans and one fMRI scan following oral administration of a single dose of GSK1521498 or naltrexone. The administered doses of GSK1521498 or naltrexone were chosen adaptively to optimize the estimation of the dose- occupancy relationship for each drug on the basis of data acquired from the preceding examinations in the study. The administered dose range was 0.4-100 mg for GSK1521498, and 2-50 mg for naltrexone. The maximum doses administered were equal to the maximum tolerated dose of GSK1521498 determined in the first-in-human study and the standard clinical dose of naltrexone used for alcohol dependence. The times and doses of the two post- dose [ⁿC]-carfentanil PET scans were chosen adaptively for each subject to optimize estimation of the relationship between plasma concentration and receptor occupancy. Post- dose [ⁿC]-carfentanil PET scans were acquired at 3-36 h after the administration of

GSK1521498 and at 3-88 h after the administration of naltrexone. Post-dose fMRI scans were acquired within 60 min of the first post-dose PET scan. Venous blood samples were collected at regular intervals throughout the scanning sessions. High-performance liquid

chromatography /mass spectrometry/mass spectrometry was used to estimate the plasma concentrations of GSK1521498, naltrexone, and the major metabolite of naltrexone, 6-β- naltrexol. Drug plasma concentration at the start of each PET scan was used to model the relationship between drug concentrations and μ-opioid receptor occupancies. Carfentanil (methyl l-(2-phenylethyl)-4-(phenyl(propanoyl)amino)-4-piperidinecarboxylate 3S, 5S; Advanced Biochemical Compounds, Radeberg, Germany), a potent selective μ-opioid receptor agonist, was labelled with carbon- 11 using a modification of a previously described method implemented using a semiautomated Modular Lab Multifunctional Synthetic Module (Eckert & Ziegler, Berlin, Germany). The final product was reformulated in sterile 0.9% saline containing -10% ethanol (v/v) and satisfied quality control criteria for specific activity and purity before being injected intravenously as a slow bolus over -30 s. PET scanning was conducted in three-dimensional mode using a Siemens Biograph 6 Hi-Rez PET-CT for the naltrexone group and a Siemens Biograph 6 TruePoint PET-CT for the GSK1521498 group (Siemens Healthcare, Erlangen, Germany). A low-dose CT scan was acquired for attenuation correction before the administration of the radiotracer. Dynamic PET data were acquired for 90 min after [ⁿC] -carfentanil injection, binned into 26 frames (durations: 8 χ 15 s, 3 χ 60 s, 5 χ 2 min, 5 x 5 min and 5 x 10 min), reconstructed using Fourier re-binning and a two- dimensional -filtered back projection algorithm and then smoothed with a two-dimensional Gaussian filter (5 mm at full width half maximum). Dynamic PET images were registered to each participant's Tl -weighted anatomical MRI volume and corrected for head motion using SPM5 software (Wellcome Trust Centre for Neuroimaging). Pre-selected regions of interests were defined bilaterally on the Tl -weighted anatomical volume using an in-house atlas and applied to the dynamic PET data to generate regional time-activity curves. The [ⁿC]- carfentanil-specific binding was quantified as binding potential relative to the non- displaceable compartment (BPND)

where ΪΝΟ is the free fraction of the radioligand in the brain, KD is the affinity of [^NC]- carfentanil, and Bavaii is the density of the available μ-opioid receptors. Regional [^NC]- carfentanil BPND was estimated using a reference tissue model with the occipital cortex as the reference region. Drug related occupancy of the μ-opioid receptor was quantified as a reduction of [ⁿC]-carfentanil.

The affinity constant for each drug at the μ-opioid receptor (effective concentration 50 (EC 50)) was estimated by fitting the plasma concentration measured at the start of the PET scan, C^pDrug, to the estimated occupancy:

[0268] The use of a sensitive non-tomographic positron detecting system to measure the dose-response curve of naloxone in human brain has also been reported. [ⁿC]Diprenorphine was administered to normal volunteers in tracer amounts and, 30 min later, various bolus doses of naloxone were given (1.5-160 μg/kg) intravenously and change in

[ⁿC]diprenorphine binding monitored over the next 30 min. Approximately 13 μg/kg of naloxone (approximately 1 mg in an 80 kg man) was required to produce an estimated 50% receptor occupation, consistent with the clinical doses of naloxone used to reverse opiate overdose (0.4 mg-1.2 mg). Melichar et al., Naloxone displacement at opioid receptor sites measured in vivo in the human brain. Eur J Pharmacol. 2003 Jan 17;459(2-3):217-9).

[0269] In some embodiments of the devices, kits, pharmaceutical formulations, and methods disclosed above, delivery of the therapeutically effective amount to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of about 50% or greater. In some embodiments, delivery of the therapeutically effective amount to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 55%. In some embodiments, delivery of the therapeutically effective amount to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 60%. In some embodiments, delivery of the therapeutically effective amount to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 65%. In some embodiments, delivery of the therapeutically effective amount to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 70%. In some embodiments, delivery of the therapeutically effective amount to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 75%. In some embodiments, delivery of the therapeutically effective amount to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 80%. In some embodiments, delivery of the therapeutically effective amount to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 85%. In some embodiments of the devices, kits, pharmaceutical formulations, and methods disclosed above, delivery of the therapeutically effective amount to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 90%. In some embodiments, delivery of the therapeutically effective amount to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 95%. In some embodiments, delivery of the therapeutically effective amount to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of greater than about 99%. In some embodiments, delivery of the therapeutically effective amount to the patient, provides occupancy at Tmax of the opioid antagonist at the opioid receptors in the respiratory control center of the patient of about 100%.

[0270] Also provided are embodiments wherein any embodiment described above may be combined with any one or more of these embodiments, provided the combination is not mutually exclusive.

EXAMPLES

Example 1: Pharmacokinetics and Safety of Intranasal Naloxone in Humans (Study 1).

[0271] A clinical trial was performed for which the primary objectives were to determine the pharmacokinetics (PK) of 2 intranasal (IN) doses (2 mg and 4 mg) of naloxone compared to a 0.4 mg dose of naloxone administrated intramuscularly (IM) and to identify an appropriate IN dose that could achieve systemic exposure comparable to an approved parenteral dose. The secondary objectives were to determine the safety of IN naloxone, specifically with respect to nasal irritation (erythema, edema, and erosion).

[0272] Methodology: This was an inpatient open-label, randomized, 3-period, 3-treatment, 6- sequence, crossover study involving 14 healthy volunteers. Subjects were assigned to one of the 6 sequences with 2 subjects in each sequence (2 sequences had 3 subjects). Each subject received 3 naloxone doses, a single 2 mg IN dose (one spray of 0.1 mL of 10 mg/mL solution in each nostril), a single 4 mg IN dose (2 sprays of 0.1 mL per spray of 10 mg/mL solution in each nostril) and a single 0.4 mg IM dose, in the 3 dosing periods (Table 1). Subjects stayed in the inpatient facility for 11 days to complete the entire study and were discharged on the next day after the last dose. Subjects returned for a final follow-up visit 3-5 days after discharge. After obtaining informed consent, subjects were screened for eligibility to participate in the study including medical history, physical examination, clinical chemistry, coagulation markers, hematology, infectious disease serology, urinalysis, urine drug and alcohol toxicology screen, vital signs and electrocardiogram (ECG). On the day after clinic admission, subjects were administered study drug in randomized order with a 4-day washout period between doses until all three doses were administered. Blood was collected for naloxone PK prior to dosing and approximately 2.5, 5, 10, 15, 20, 30, 45, 60, 120, 180, 240, 300, 360, 480 and 720 min after the start of study drug administration. On days of study drug administration, a 12-lead ECG was performed approximately 60 min prior to dosing and at approximately 60 and 480 min post-dose. Vital signs were measured pre-dose and approximately 30, 60, 120, and 480 min post-dose. On dosing days, the order of assessments was ECG, vital signs, then PK blood collection when scheduled at the same nominal times. ECG and vital signs were collected within the 10-min period before the nominal time of blood collections. At screening, admission, discharge, and follow-up, ECG and vital signs were checked once per day. Vital signs were also checked once on the day after naloxone administration. Clinical laboratory measurements were repeated after the last PK blood draw prior to clinic discharge. AEs were assessed by spontaneous reports by subjects, examination of the nasal mucosa, physical examination, vital signs, ECG, and clinical laboratory parameters.

[0273] Main Criteria for Inclusion/Exclusion: Healthy volunteer adults with a body mass index (BMI) of 18-30 kg/m².

[0274] Investigational Product, Dose and Mode of Administration: Naloxone given IN was at a dose of 2 mg (1 squirt in each nostril delivered 0.1 mL of 10 mg/mL naloxone) and 4 mg (2 squirts in each nostril delivered 0.2 mL/nostril at 10 mg/mL naloxone, using two devices). IN naloxone was administered using a Pfeiffer (Aptar) BiDose liquid device with the subject in a fully supine position.

[0275] Duration of Treatment: Each IN and IM dose was administered once in each subject in random sequence.

[0276] Reference Therapy, Dose and Mode of Administration: Naloxone was given IM at a dose of 0.4 mg in 1.0 mL with a 23-g needle as a single injection in the gluteus maximus muscle.

[0277] PK Evaluation: Blood was collected in sodium heparin containing tubes for naloxone PK prior to dosing and 2.5, 5, 10, 15, 20, 30, 45, 60, 120, 180, 240, 300, 360, 480, and 720 min after the start of study drug administration. Non-compartmental PK parameters including Cmax, Tmax, AUC to infinity (AUCo-∞), AUC to last measurable concentration (AUCo-t), ti/2, λζ, and apparent clearance (CL/F) were determined. Values of ti/₂ were determined from the log-linear decline in plasma concentrations from 2 to 6 or 8 h.

[0278] Safety Evaluation: Heart rate, blood pressure, and respiration rate was recorded before naloxone dosing and at approximately 30, 60, 120, and 480 min after dosing. These vital signs and temperature were also measured at screening, clinic intake, one day after each dosing session and at follow-up. A 12-lead ECG was obtained prior to and approximately 60 and 480 min after each naloxone dose, as well as during screening, clinic intake, and follow- up. ECG and vital signs were taken within the 10-min period before the nominal time for blood collections. AEs were recorded from the start of study-drug administration until clinic discharge. AEs were recorded relative to each dosing session to attempt to establish a relationship between the AE and type of naloxone dose administered. An examination of the nasal passage was conducted at Day-1 to establish eligibility and at pre-dose, 5 min, 30 min, 60 min, 4 h, and 24 h post naloxone administration to evaluate evidence of irritation to the nasal mucosa. Clinical laboratory measurements were done prior to the first drug

administration and on the day of clinic release.

[0279] Statistical Analysis of PK Parameters: Cmax, Tmax and AUC for 2 and 4 mg IN naloxone were compared with those for 0.4 mg IM naloxone. Within an ANOVA framework, comparisons of natural log (LN) transformed PK parameters (Cmax and AUC) for IN versus IM naloxone treatments were performed. The 90% confidence interval (CI) for the ratio (IN/IM) of the least squares means of AUC and Cmax parameters was constructed. These 90% CI were obtained by exponentiation of the 90% confidence intervals for the difference between the least squares means based upon a LN scale. In addition, dose adjusted values for AUCs and Cmax based upon a 0.4 mg dose were calculated (Tables 4-7). The relative extent of absorption (relative bioavailability, F_rei) of intranasal (IN versus IM) was estimated from the dose-corrected AUCs.

[0280] Statistical Analysis of Adverse Events: AEs were coded using the most recent version of the Medical Dictionary for Regulatory Activities (MedDRA). Preferred terms and are grouped by system, organ, class (SOC) designation. AEs are presented as a listing including the start date, stop date, severity, relationship, outcome, and duration.

[0281] Pharmacokinetics Results: The mean dose delivered for the 2 mg IN naloxone dose was 1.71 mg (range 1.50 mg to 1.80 mg) and for the 4 mg IN naloxone dose it was 3.40 mg (range 2.93 mg to 3.65 mg). This was 84-85% of the target dose. The overall % coefficient of variation (%CV) for the delivered dose from all 42 devices was 6.9% (Table 9). Preparation time of the IN doses took less than one third of the time to prepare the IM injection (70 seconds for the IM injection and 20 seconds for the IN administration) (Table 8). The time to prepare the IM injection did not include loading the syringe. Since the one purpose of the study was to determine if peak naloxone plasma concentrations (Cmax) and AUCs following IN 2 mg and IN 4 mg administrations were equivalent to, or greater than IM 0.4 mg dosing, AUCs and Cmax values were compared without considering the dose difference among treatments. The Cmax, AUCo-t, and AUCo-∞ for both the 2 mg IN and 4 mg IN doses were statistically significantly greater than those for the 0.4 mg IM dose (p < 0.001). The geometric least square means for Cmax were 2.18 ng/mL, 3.96 ng/mL, and 0.754 ng/mL for IN 2 mg, IN 4 mg and IM 0.4 mg, respectively. The geometric least square means for AUCo-∞ were 3.32 ng h/mL, 5.47 ng h/mL and 1.39 ng h/mL for IN 2mg, IN 4 mg and IM 0.4 mg respectively. The geometric least squares mean ratios for IN 2 mg/IM 0.4 mg were 290% for Cmax and 239% for AUCo-∞. The ratios for IN 4 mg/IM 0.4 mg were 525% for Cmax and 394% for AUCo There were no statistically significant differences between the routes and doses with respect to Tmax, suggesting peak effects would occur at similar times for all treatments. However, the mean 1 max values did trend lower for the IN route versus IM, and for 4 mg IN versus 2 mg IN. (See Table 2). In comparing the extent of systemic absorption of IN to IM dosing, the F_rei estimates were 55.7% and 46.3% for IN 2 mg and 4 mg, respectively. See Table 3.

[0282] Safety Results: No erythema, edema, erosion, or other sign was observed in the nasal cavity prior to or after any IN administration of naloxone at 2 and 4 mg to both nostrils. One subject experienced mild transient (over 3 min) pharyngeal pain coincident with the application of the 2 mg IN dose. This pain resolved spontaneously. Vital signs, ECG, and clinical laboratory parameters did not reveal any clinically noteworthy changes after naloxone administration. There was no evidence of QTcF prolongation.

Table 1

Order of Naloxone Doses and Route of Administration for each Subject

Table 2:

Summary of Naloxone Pharmacokinetic Parameters Following Naloxone as 0.4 mg Intramuscular (IM), 2 mg Intranasal (IN), and 4 mg IN Administrations

0.4 mg IM 2 mg IN 4 mg IN

Parameter

Mean %CV Mean %CV Mean %CV λζ (1/h) 0.593 16.6 0.588 0.572 8.0 10.2 tin (h) 1.21 20.1 1.19 8.3 1.22 10.2

Table 3:

Summary of Naloxone Pharmacokinetic Parameters Following Naloxone as 0.4 mg Intramuscular (IM), 2 mg Intranasal (IN), and 4 mg IN Administrations with Dose

Normalized to 0.4 mg

Table 4

Statistical Comparison of Geometric Least Squares Mean (GLSM) of Pharmacokinetic

Parameters for IN Naloxone at a Dose of 2 mg to IM Naloxone at a Dose of 0.4 mg with No Dose Adjustment

Table 5 Statistical Comparison of Geometric Least Squares Mean (GLSM) of Pharmacokinetic Parameters for IN Naloxone at a Dose of 4 mg to IM Naloxone at a Dose of 0.4 mg with No Dose Adjustment

Table 6

Statistical Comparison of Geometric Least Squares Mean (GLSM) of Pharmacokinetic

Parameters for IN Naloxone at a Dose of 2 mg to IM Naloxone at a Dose of 0.4 mg with Dose Adjustment to 0.4 mg

Table 7

Statistical Comparison of Comparison of Geometric Least Squares Mean (GLSM) Pharmacokinetic Parameters for IN Naloxone at a Dose of 4 mg to IM Naloxone at a Dose of 0.4 mg with Dose Adjustment to 0.4 mg Parameter GLSM GLSM GLSM 90% CI of p-value

4 mg 0.4 mg Ratio Ratio

IN IM IM/IN%

Cmax/D (ng/mL) 0.466 0.755 61.7 50.5 - 75.5 < 0.001

Tmax (h) 0.292 0.308 - - 0.418

AUCo-t/D (ng h/mL) 0.637 1.35 47.2 42.2 - 52.7 < 0.001

AUCO-OO/D 0.644 1.39 46.3 41.5 - 51.6 < 0.001 (ng h/mL)

tl/2 (h) 1.22 1.19 102 94.0 - 111 0.651

Table 8

Time to Prepare the IM and IN Doses for Administration

Table 9

Estimated IN Dose Delivered (mg)

2 mg 4 mg Dose All

Dose Devices

Total First Second Total Total

Device Device

Median 1.708 1.711 1.704 3.410 1.710

Minimum 1.481 1.315 1.506 2.898 1.315

Maximum 1.838 1.824 1.803 3.616 1.838

Example 2: Pharmacokinetics and Safety of Intranasal Naloxone in Humans (Study 2).

[0283] A second study was undertaken to determine the pharmacokinetics (PK) and bioavailability of intranasally-delivered naloxone compared to intramuscularly-injected naloxone.

[0284] Objectives. Specifically, the study had several objectives. The first was to determine the pharmacokinetics (i.e., the Cmax, Ί max, AUCo-inf and AUCo-t) of 4 intranasal doses - 2 mg, 4 mg (2 nostrils), 4 mg (1 nostril), and 8 mg (2 nostrils) - of naloxone compared to a 0.4 mg dose of naloxone administrated IM and to identify an appropriate IN dose that could achieve systemic exposure comparable to an approved parenteral dose. The second was to determine the pharmacokinetics of two different concentrations (20 mg/mL and 40 mg/mL) of IN naloxone. The third was to determine the safety of IN naloxone, including adverse events, vital signs, and clinical laboratory changes, specifically with respect to nasal irritation (erythema, edema, and erosion).

[0285] Design. The study was an inpatient open-label, randomized, 5-period, 5-treatment, 5- sequence, crossover study involving approximately 30 healthy volunteers, randomized to have at least 24 subjects who complete all study drug administrations and blood collections for PK assessments. Subjects were assigned to one of the 5 sequences and there were 6 subjects in each. Each subject received 5 naloxone treatments during the 5 dosing periods: a single 2 mg IN dose (one 0.1 mL spray of a 20 mg/mL solution in one nostril), a 4 mg IN dose (one 0.1 mL spray of a 20 mg/mL solution in each nostril), a single 4 mg IN dose (one 0.1 mL spray of a 40 mg/mL solution in one nostril), a single 8 mg IN dose (one 0.1 mL spray of a 40 mg/mL solution in each nostril), and a single 0.4 mg IM dose. Subjects stayed in an inpatient facility for 18 days to complete the entire study and were discharged on the next day after the last dose. Subjects returned for a final follow-up visit 3 to 5 days after discharge. [0286] After obtaining informed consent, subjects were screened for eligibility to participate in the study including medical history, physical examination, clinical chemistry, coagulation markers, hematology, infectious disease serology, urinalysis, urine drug and alcohol toxicology screen, vital signs and ECG.

[0287] Inclusion criteria were: men or women 18 to 55 years of age, inclusive; written informed consent; BMI ranging from 18 to 30 kg/m2, inclusive; adequate venous access; no clinically significant concurrent medical conditions; agreement to use a reliable double- barrier method of birth control from the start of screening until one week after completing the study (oral contraceptives are prohibited); and agreement not to ingest alcohol, drinks containing xanthine >500 mg/day, or grapefruit/grapefruit juice, or participate in strenuous exercise 72 hours prior to admission through the last blood draw of the study.

[0288] Exclusion criteria were: any IN conditions including abnormal nasal anatomy, nasal symptoms (i.e., blocked and/or runny nose, nasal polyps, etc.), or having a product sprayed into the nasal cavity prior to drug administration; taking prescribed or over-the-counter medications, dietary supplements, herbal products, vitamins, or recent use of opioid analgesics for pain relief (within 14 days of last use of any of these products); positive urine drug test for alcohol, opioids, ***e, amphetamine, methamphetamine, benzodiazepines, tetrahydrocannabinol (THC), barbiturates, or methadone at screening or admission; previous or current opioid, alcohol, or other drug dependence (excluding nicotine and caffeine), based on medical history; subject consumes greater than 20 cigarettes per day on average, in the month prior to screening, or would be unable to abstain from smoking (or use of any nicotine-containing substance) for at least one hour prior to and 2 hours after naloxone dosing; on standard 12-lead ECG, a QTcF interval >440 msec for males and >450 msec for females; significant acute or chronic medical disease in the judgment of the investigator; a likely need for concomitant treatment medication during the study; donated or received blood or underwent plasma or platelet apheresis within the 60 days prior to the day before study commencement; female who is pregnant, breast feeding, or plans to become pregnant during the study period or within one week after naloxone administration; positive test for hepatitis B surface antigen (HBsAg), hepatitis C virus antibody (HCVAb) or human

immunodeficiency virus antibody (HIVAb) at screening; and current or recent (within 7 days prior to screening) upper respiratory tract infection.

[0289] Naloxone for IM injection manufactured by Hospira was obtained from a licensed distributor at a concentration of 0.4 mg/mL and was given IM at a dose of 0.4 mg in 1.0 mL with a 23-g needle as a single injection in the gluteus maximus muscle. Naloxone for IN administration was obtained from Lightlake Therapeutics, Inc., London, United Kingdom at two concentrations of 20 mg/mL and 40 mg/mL, and was given as doses of 2 mg (one 0.1 mL spray of the 20 mg/mL formulation in one nostril), 4 mg (two 0.1 mL sprays of the 20 mg/mL formulation in two nostrils), 4 mg (one 0.1 mL spray of the 40 mg/mL formulation in one nostril) and 8 mg (two 0.1 mL sprays of the 40 mg/mL formulation in two nostril). IN naloxone was administered using an Aptar single dose device with the subject in a fully supine position. Subjects were to be instructed to not breathe through the nose when the IN dose of naloxone was administered.

[0290] On the day after clinic admission, subjects were administered study drug in randomized order with a 4-day washout period between doses until all 5 treatments were administered. Blood was collected for naloxone PK prior to dosing and approximately 2.5, 5, 10, 15, 20, 30, 45, 60, 120, 180, 240, 300, 360, 480 and 720 minutes after the start of study drug administration, into sodium heparin containing tubes. On days of study drug administration, a 12-lead ECG was performed approximately 60 minutes prior to dosing and at approximately 60 and 480 minutes post-dose. Vital signs were measured pre-dose and approximately 30, 60, 120, and 480 minutes post-dose. On dosing days, the order of assessments were ECG, vital signs, then PK blood collection when scheduled at the same nominal times. The target time of the PK blood collection was considered the most important, and if the collection was more than ±1 minute from the scheduled time for the first 60 minutes of collections or more than ± 5 minutes for the scheduled time points thereafter, this was considered a protocol deviation. ECG and vital signs were collected within the 10 minute period before the nominal time of blood collections. At screening, admission, discharge, and follow-up, ECG and vital signs were checked once per day. Vital signs were also checked once on the day after naloxone administration. Clinical laboratory

measurements were repeated after the last PK blood draw prior to clinic discharge. Adverse events were assessed by spontaneous reports by subjects, by examination of the nasal mucosa, by measuring vital signs, ECG, and clinical laboratory parameters.

[0291] Results are shown below in Table 9, which sets forth the mean from 28 healthy subjects (and SD, in parentheses) plasma concentrations of naloxone following single intranasal administrations and an intramuscular injection, and in Figures 3 and 4.

Table 9.

0 0.00 (0.000 0.00 (0.000 0.00 (0.000 0.00 (0.000 0.00 (0.000

0 ) 0 ) 0 ) 0 ) 0 )

2.5 0.17 (0.219 0.72 (0.856 0.28 (0.423 0.88 0.08 (0.135

(1.21)

5 ) 5 ) 0 ) 0 1 )

5 0.88 (0.758 0.30 (0.336

2.68 (2.65) 1.50 (1.76) 3.73 (4.02)

2 ) 5 )

10 0.56 (0.318

2.11 (1.33) 4.60 (2.59) 3.24 (2.21) 7.61 (5.28)

6 )

15 0.67 (0.312

2.74 (1.07) 5.56 (2.20) 4.00 (2.24) 8.02 (3.60)

8 )

20 0.74 (0.271

2.89 (1.14) 5.82 (1.74) 4.57 (2.30) 8.06 (2.56)

7 )

30 (0.810 0.75 (0.190

2.52 5.15 (1.70) 4.50 (1.93) 7.89 (1.95)

) 0 )

45 (0.636 0.68 (0.171

2.17 4.33 (1.16) 4.03 (1.57) 6.84 (1.69)

) 9 )

60 (0.574 (0.887 0.61 (0.143

1.88 3.69 3.35 (1.17) 5.86 (1.40)

) ) 0 )

120 0.82 (0.335 (0.626 (0.773 (0.927 0.35 (0.107

1.63 1.57 2.86

3 ) ) ) ) 4 )

180 0.39 (0.146 0.80 (0.253 0.77 (0.412 (0.487 0.22 (0.082

1.42

0 ) 0 ) 1 ) ) 7 )

240 0.21 (0.100 0.45 (0.225 0.41 (0.215 0.79 (0.275 0.13 (0.058

5 ) 2 ) 2 ) 1 ) 5 )

300 0.11 (0.051 0.24 (0.123 0.24 (0.143 0.43 (0.166 0.07 (0.047

7 ) 3 ) 6 ) 1 ) 4 )

360 0.06 (0.030 0.13 (0.067 0.14 (0.081 0.25 (0.104 0.04 (0.022

8 ) 9 ) 6 ) 7 ) 0 )

480 0.03 (0.014 0.06 (0.033 0.06 (0.038 0.12 (0.052 0.01 (0.015

1 ) 8 ) 5 ) 2 ) 3 )

720 0.00 (0.009 0.02 (0.013 0.02 (0.019 0.05 (0.025 0.00 (0.003

9 ) 7 ) 6 ) 3 ) 1 )

[0292] For pharmacokinetic analysis, plasma was separated from whole blood and stored frozen at < -20°C until assayed. Naloxone plasma concentrations was determined by liquid chromatography with tandem mass spectrometry. Conjugated naloxone plasma

concentrations may also be determined. Non-compartmental PK parameters including Cmax, Tmax, AUCo-inf, AUCo-t, ti/2, λ_ζ, and apparent clearance (CL/F) were determined.

Pharmacokinetic parameters (Cmax, Tmax, and AUCs) for IN naloxone were compared with those for IM naloxone. Tmax was from the time of administration (spraying into the nasal cavity or IM injection). Dose adjusted values for AUCs and Cmax were then calculated, and the relative extent of intranasal absorption (IN versus IM) estimated from the dose-corrected AUCs. Within an ANOVA framework, comparisons of ln-transformed PK parameters (Cmax and AUC) for intranasal versus IM naloxone treatments were performed. The 90% confidence interval for the ratio (IN/IM) of the geometric least squares means of AUC and Cmax parameters were constructed for comparison of each treatment with IM naloxone. These 90% CIs were obtained by exponentiation of the 90% confidence intervals for the difference between the least squares means based upon an In scale.

[0293] Results are shown below in Table 10, which sets forth the mean plasma PK parameters from 28 healthy subjects (and % CV, in parentheses) of naloxone following single intranasal administrations and an intramuscular injection, and in Table 11, which sets forth the same PK parameters split between the 12 female and 16 male healthy subjects.

Table 10.

CL/F (L/h) 441 (24.5) 426 (22.3) 502 (31.2) 521 (21.7) 230 (22.4)

Relative BA 53.8 (22.2) 55.3 (22.2) 49.2 (30.6) 45.3 (25.1) 100 (%) vs. IM

Table 11.

One 20 Two 20 One 40 Two 40 0.4 mg IM

Paramet m «/m I. IN in «/in I. IN in «/in I. IN mg/niL IN

er

(units) Fema Male Fema Male Fema Male Fema Male Fema Male le le le le le

Cmax 2.79 3.35 6.62 6.64 5.12 5.51 9.52 10.9 1.06 0.792

(ng/ml)

Cmax per 1.39 1.68 1.66 1.66 1.28 1.38 1.19 1.36 2.64 1.98 mg

(ng/mL)

Tmax (h)^a 0.33 0.33 0.33 0.25 0.50 0.50 0.29 0.42 0.33 0.50

AUCt 4.73 4.87 9.81 9.82 7.98 9.38 14.8 16.8 1.83 1.75 (ng mL/h

)

AUCinf 4.78 4.93 9.91 9.92 8.06 9.48 15.0 16.9 1.88 1.79

(ng mL/h

)

AUCinf 2.39 2.46 2.48 2.48 2.01 2.37 1.87 2.12 4.69 4.47 per mg

(ng mL/h

)

Lambda 0.397 0.349 0.279 0.312 0.294 0.338 0.299 0.340 0.614 0.515 z (hr-^!)^b 8 2 6 2 6 6 4 7 0 2

Half-life 1.58 1.80 2.18 2.03 2.12 1.93 1.90 1.91 1.08 1.28 (h) ^b

AUC % 0.971 1.19 0.986 1.02 0.970 1.12 1.12 0.992 2.31 2.32 Extrapol

ate

CL/F 449 434 419 431 555 462 558 494 222 236 (L/h) [0294] In the tables above, the notation a indicates median (range) is disclosed, and the notation b indicates harmonic mean is disclosed.

[0295] Additional exploratory analyses could include:

1) 90% CI for dose corrected AUC and Cmax between the 20 mg/mL formulation

treatment and 40 mg/mL formulation for both a single administration and two dose administration (once in each nostril) for dose linearity purpose;

2) 90% CI adjusted for dose for geometric ratios of one 0.1 mL spray (in one nostril) vs. a two 0.1 mL sprays (one spray in each nostril) from an 20 mg/mL formulation; and

3) 90% CI adjusted for dose for geometric ratios of one 0.1 mL spray (in one nostril) vs. a two 0.1 mL sprays (one spray in each nostril) from an 40 mg/mL formulation;

[0296] AEs were coded using the most recent version of the Medical Dictionary for

Regulatory Activities (MedDRA) preferred terms and grouped by system, organ, class (SOC) designation. Separate summaries will be provided for the 5 study periods: after the administration of each dose of study drug up until the time of the next dose of study drug or clinic discharge. Listings of each individual AE including start date, stop date, severity, relationship, outcome, and duration were provided. Results are given below in Tables 12 and 13. Table 12 shows the events related to nasal irritation - erythema, edema, other, and total - observed in the nasally -treated group. Nasal irritation did not appear to be positively related to the dose of naloxone given.

Table 12.

[0297] Table le shows additional events related to administration either nasally or intramuscularly. Overall, few adverse events were reported.

Table 13.

[0298] Additionally, vital signs, ECG, and clinical laboratory parameters did not reveal any clinically noteworthy changes after naloxone administration. There was no evidence of QTcF prolongation.

Example 3: Naloxone Nasal Spray Formulations and Stability.

[0299] Naloxone has been formulated as a disposable Luer-Jet Luer-lock pre-filled syringe and nasal atomizer kit product, comprising 1 mg/ml naloxone hydrochloride as an active agent, 8.35 mg/ml NaCl as an isotonicity agent, HC1 q.s. to target pH, and purified water q.s. to 2.0 ml. Benzalkonium chloride may be added as a preservative, cationic surfactant, and/or permeation enhancer, and supports the stability of a multi-dose product. Such syringes, while functional, can be ungainly to use by untrained personnel, and deliver a large volume of solution.

[0300] Examples of a lOmg/ml formulation are given below in Table 14.

Table 14

[0301] Literature data has indicated that naloxone is sensitive to environmental factors, such as air, light and colors in certain vials, which may induce a risk for degradation.

Consequently disodium edetate was added to the above formulation.

[0302] Pharmaceutical compositions comprising naloxone hydrochloride (10 mg/mL) were stored at 25 °C and 60% relative humidity in upright clear glass vials (200 μί) stoppered with a black plunger. Vials were either nude (Batch 1), or mounted in the Pfeiffer BiDose device (Batch 2). In addition to naloxone hydrochloride, the pharmaceutical compositions further comprised water, benzalkonium chloride, and disodium edetate. The vials were assayed at 0, 3, 6, 9, and 12 months for naloxone content. It is evident from the results of the study, reported as a percentage of the label claim in Table 15 below, that these pharmaceutical compositions are storage-stable for at least 9-12 months at 25 °C and 60% relative humidity.

Table 15

[0303] Examples of 20mg/ml and a 40mg/ml formulation are given below in Table 16, along with an example of permitted variation as part of the total formulation.

Table 16

[0304] The naloxone hydrochloride nasal spray above is an aqueous solution which may be presented in a Type I glass vial closed with a chlorobutyl rubber plunger which in turn is mounted into a unit-dose nasal spray device (such as an Aptar UDS liquid UnitDose device). The solution should be a clear and colorless or slightly yellow liquid. In certain embodiments, the device is a non-pressurized dispenser delivering a spray containing a metered dose of the active ingredient. In certain embodiments, each delivered dose contains 100 μΐ.

[0305] Pharmaceutical compositions comprising naloxone hydrochloride (20 or 40 mg/mL) were tested for stability in room temperature/light conditions, room temperature/dark conditions and in 25 °C/60 % RH (protected from light). It was tested for pH, purity, and impurities at an initial time point, 2 months and 10 months. Results are given in Table 17.

Table 17

Example 4: Opioid Receptor Occupancy After Intranasal Naloxone

[0306] A study was conducted to determine the extent of brain μ-opioid receptor (MOR) occupancy achievable in the brain in humans by nasal administration of a spray formulation of the short-acting opioid receptor antagonist naloxone. Nasal naloxone administration is expected to have utility in the treatment of opioid overdose, reward-based disorders, and addictive behaviors.

[0307] A placebo-controlled study was conducted in healthy male volunteers at a single center. Eight healthy male subjects were included in Part 1 of the study and six healthy male subjects were included in Part 2. Healthy male volunteers, age 20-40 years, in good general health ascertained by detailed medical history, laboratory tests and physical examination, with a BMI of 18-28 kg/m2, weight 60-90 kg, and written informed consent (IC) obtained. No previous medical or occupational exposure to significant doses of ionizing radiation. [0308] Intravenous bolus doses of up to 516 MBq [ⁿC]carfentanil were administered twice on separate days to each subject to investigate MOR occupancy by naloxone. Positron emission tomography (PET) was used to image CNS uptake and receptor binding of the selective MOR tracer [ⁿC]carfentanil in vivo. Each subject underwent the two PET scans on each of the two scanning days: one control scan with intranasal application of saline placebo and one scan with intranasal application of naloxone hydrochloride as a spray formulation. The placebo control session was needed for model validation and as a control for context- dependent interference by endogenous opioid peptides. The scanning time on both visits was 80 min. PET data collection was with a high-resolution PET camera (HRRT) in list mode. The occipital cortex was used as a reference region in the data analysis with an LSRTM (linearized simplified reference tissue model) approach. Pseudo-equilibrium of

[ⁿC]carfentanil distribution and binding was expected to develop, and did develop, in 20 minutes after tracer administration (bolus dose), after which naloxone or placebo was administered intranasally and [ⁿC]carfentanil BiPND was determined by PET scanning for another 60 minutes. The order of the PET scan days - Part 1 and Part 2 - was based on balanced randomisation. In Part 1 of the study, participants (n=4+4) received their IN doses of placebo and naloxone during the PET scan, at 20 min after the [ⁿC]carfentanil injection; PET scan data were collected until 60 min after the IN drug administration. In Part 2 of the study (n=3+3), a later PET scan time was investigated in new subjects, with placebo and naloxone administered five hours before [ⁿC]carfentanil and the start of PET scanning, to explore naloxone MOR occupancy over a longer time frame. Brain MRI scans were used for anatomical reference as described below.

[0309] Plasma samples for the determination of naloxone concentrations and calculation of pharmacokinetic variables were collected at 3, 6, 9, 12, 15, 20, 25, 30, 40, 50, 60, 80, and 100 min, as well as at 2, 3, 4 and 6 h after IN administration of naloxone. Concentration vs. time curves were generated by non-compartmental analysis with WinNonlin^® Phoenix 6.4 software (Pharsight Corporation, Mountain View, CA, USA), and pharmacokinetic parameters such as maximum concentration (Cmax) of naloxone in plasma, time to peak concentration (tmax), area under the concentration by time curve (AUC) to 6 hours (AUCo-6), AUC to the last measurable concentration (AUCo-t), elimination half-life (t½) and AUC extrapolated to infinity (AUCo-∞). Terminal time points were selected based on best-fit criteria and review of the selected points. The linear trapezoidal rule was used to estimate AUC. [0310] Investigational drug, dose and mode of administration: Twenty minutes after administration of [ⁿC]carfentanil tracer, single 2 and 4 mg doses of intranasal (IN) naloxone hydrochloride (20 and 40 mg/ml), 0.1 ml into one nostril, were administered. Four subjects received the higher (4 mg) dose and four subjects received the lower (2 mg) dose. The 20 mg/ml formulation and 40 mg/ml formulation disclosed in Table 16, each in a single-dose nasal spray device, were administered, with the subject in a fully supine position.

[0311] Duration of treatment: Each subject received one single dose of naloxone

hydrochloride, and attended four study visits: a screening visit, two PET visits (day 1 and day 2) and an end-of-study visit. A wash-out period of at least 5 days between the PET visits was included. Day 1 took place 28 days' time after the screening visit and the end-of-study visit took place 14 days' time after day 2. The total maximum duration of the study for any single subject was approximately 2 months.

[0312] Comparative drug(s)/placebo, dose and mode of administration: IN administration of saline placebo during a control PET scan were used to mimic IN administration of naloxone. Placebo containers were not identical to the IMP dispensers, but the subjects and the investigators were kept blinded to the study medication by employing an unblinded member of the study personnel to administer the medications.

[0313] Assessments.

[0314] Efficacy: PET was used to image CNS uptake and receptor binding of [ⁿC]carfentanil and to calculate the extent and time course of MOR occupancy achieved after IN naloxone administration in brain regions of interest. The target radioactivity of each administered bolus injection was 500 MBq, and the carfentanil mass was not allowed to exceed 2.0 μg per injected dose. PET data were acquired with a High Resolution Research Tomograph (HRRT, Siemens Medical Solutions, Knoxville, TN, USA), and image reconstruction and

preprocessing of the data were conducted similarly with earlier studies.

[0315] PET data were analyzed in regions-of-interest (ROI) for binding potential relative to non-displaceable tracer uptake in brain tissue, BPND, reflecting MOR availability through the equation

where fND is the fraction of the radioligand that is free in the non-displaceable compartment, Bavaii is the number of receptors available for ligand binding, and KD is the affinity of the ligand (Innis et al, 2007). Automated ROIs were generated with the help of individual Tl MRI anatomical data and FreeSurfer (version

5.3; h ti : //s urf er. nmr. TO h . har v ar d. edi Q and Statistical Parametric Mapping (SPM8;

Wellcome Institute, London, UK) software, resulting in 60 ROIs. Post-hoc selection was employed in the ROI analysis in terms of highest average (Part 1+2, n=14) BPpiacebo estimates. The fifteen most receptor-dense brain regions are given below in Table

Table 18.

The lateral occipital cortex served as a reference region, being devoid of MORs.

[0316] Methods for regional BPND calculation in Part 1 of the study were chosen post-hoc based on Bayesian information criteria (BIC) and Akaike weights. Methods included in the model selection were variants of the simplified reference tissue model (SRTM), yielding BPND as the main parameter of interest. A linearized version of SRTM (LSRTM) was implemented according to a later definition called linear parametric neurotransmitter PET (Ip-ntPET). In the current study Ip-ntPET was used to generate time-series data of BPND at a frequency of 1/min (0 - 20 mins), 1/2 min (20 - 40 mins) and 1/4 min (40 - 60 mins) following IN naloxone administration, reflecting the dynamic process of radioligand displacement. Subsequently, MOR occupancy (RO) was determined at these time points relative to MOR availability during the same individual's placebo scan:

BP Naloxone

(t)

RO(t) 1 Placebo x l00%

BP,

where t is the time of BPND estimation under the naloxone treatment. Matlab (version R2011b, The MathWorks Inc., Natick, MA, USA) was used to calculate pharmacodynamic (PD) parameters BPpiacebo (BPcontroi), BPNaioxone (minimum in the time-serie BPND(T)), peak receptor occupancy (ROmax), and time to reach half of ROmax (Ti/2(RO)). In part 2 of the study, PD parameters were calculated by using conventional SRTM (Lammertsma and Hume, 1996), reflecting the assumption of nearly stable MOR availability over the late phase (300 - 360 min) post-naloxone.

[0317] Region-of-interest analysis was done is based on automatic parceling of the brain with the FreeSurfer. Tl-weighted (Tlw) MRI data were first preprocessed using the FreeSurfer (version 5.3; available at surfer.nmr.mgh.harvard.edu) software to obtain automated cortical parcellation. FreeSurfer was used to generate a high-definition cortical parcellation on the basis of the individual cortical folding patterns (Desikan et al. 2006), resulting in 35 cortical gray matter regions-of-interest (ROIs) in both hemispheres, which were subsequently combined over hemispheres to form aggregate ROIs. The automated occipital cortex ROI was manipulated prior to reference tissue TAC extraction to minimize contribution of the specific tracer uptake and thus to allow more robust measurement of the nondisplaceable tracer uptake. In addition to cortical regions, FreeSurfer based automated atlas

individualization was used to define the hippocampus, amygdala, pallidum, and cerebellum ROIs. Unified segmentation algorithm (Ashburner and Friston 2005) as provided in the Statistical Parametric Mapping (version 8, SPM8; Wellcome Institute, London, UK) software was used to find a deformation field that maps the image coordinates to and from the standard image space as defined by the Montreal Neurological Institute (MNI) template (MNI152); in the process the probability maps of the gray and white matter and that of the cerebrospinal fluid and the forward and inverse deformation fields were acquired. The inverse deformation fields were employed in the individualization of subcortical ROI atlases of the striatum, thalamus, medulla oblongata and the ascending arousal network (AAN) regions, in a similar manner as described earlier in (Johansson et al. 2016a). In short, the striatal connectivity- based (CB) atlas of Tziortzi and colleagues (Tziortzi et al. 2014) (7 subregions, 25% probability threshold), the thalamic CB atlas of Behrens and colleagues (Behrens et al. 2003) (7 subregions, 25% probability threshold), the Harvard AAN atlas (Edlow et al. 2012) (6 subregions), and manually defined medulla oblongata ROIs were individualized using the inverse deformation fields, and the resulting subcortical parcellations were visually inspected for spatial coherence. Thus, in total 60 aggregate ROIs of both hemispheres were

automatically generated on the basis of the Tlw MRI data (see complete list of regions in the supplementary material).

[0318] Motion compensated PET imaging data were averaged over the frames to form a high-quality PET sum image from each session for PET to MRI coregistration. Rigid registration parameters were estimated using normalized mutual information algorithm in SPM8, and subsequently employed to map the dynamic PET imaging data into MRI coordinates. The MRI-matched dynamic PET images were analysed for average radioactivity within the automated ROIs to form the regional TAC data representations.

[0319] Safety: Vital signs and subjective symptoms were monitored during the PET visits. Subjects remained at the study centre for a minimum of 6 h after naloxone administration, after which the subjects were discharged based on clinical evaluation with a safety checklist.

[0320] Pharmacokinetics: Venous blood samples were collected for determination of concentrations of naloxone at pre-defined time points in order to determine the

pharmacokinetics of naloxone after intranasal administration.

[0321] Evaluation and statistical methods.

[0322] Efficacy: Differences in tracer uptake between the control (placebo) condition and the naloxone treatment were considered the primary outcome variable and analysed with analysis of variance (ANOVA) and descriptive statistics. Binding data from different brain regions and data acquisition intervals was analysed to estimate the differences between the naloxone and control conditions.

[0323] Safety: Demographic and other baseline data, laboratory safety determinations, physical examination findings, BP, HR, AEs and concomitant treatments were summarised with descriptive statistics or listed.

[0324] Pharmacokinetics: Pharmacokinetic variables of naloxone were determined from the concentration-time data using non-compartmental methods and described using descriptive statistics.

[0325] Results: Administration of 2 mg IN naloxone to subjects resulted in a mean terminal brain mu opioid receptor (MOR) occupancy of 59 - 104 % with an average occupancy of about 74% across the top 15 brain regions. Administration of 4 mg IN naloxone to subjects resulted in MOR occupancy of 82 - 102 %, with an average occupancy of about 91% across the top 15 brain regions one hour post-dose. Furthermore, there was good agreement between receptor occupancy and plasma naloxone concentrations. PET transverse imaging demonstrated that intranasally-administered naloxone at the tested 2 mg and 4 mg doses effectively displaced [ⁿC]carfentanil tracer from MORs in brain tissue, and occupied MORs in neural circuitry and structures involved in reward, such as the thalamus, basal ganglia, and nucleus accumbens in a dose-dependent manner.

[0326] MOR occupancy by naloxone was achieved rapidly after i.n. naloxone spray. The ti/2 of appearance of occupancy (i.e., the time at which approximately half of MOR were occupied) was 12 - 27 minutes (average of approximately 16 minutes across the top 15 brain regions) after administering 2 mg of naloxone, and 8 - 14 minutes (average of approximately 10 minutes across the top 15 brain regions) after 4 mg of naloxone.

[0327] In addition to the top 15 brain regions, as a brain region of special interest for the treatment of opioid overdose, the medulla oblongata, important for the regulation of breathing, was among the regions showing the fastest and strongest [l lCJcarfentanil displacement by naloxone. MOR occupancy by naloxone of 117 % and 98 % on the average was observed in the medulla oblongata one hour after administering 4 mg and 2 mg of naloxone i.n., with estimated tl/2 of appearance of naloxone occupancy of 7 minutes and 11 minutes on the average.

[0328] At 5-6 hours, occupancy of opioid receptors following both doses was extremely low, indicating that that the effect is not sustained.

[0329] Results are given below in Tables 19 and 20.

Table 19: 2 mg naloxone

Pars opercularis 0.81 0.17 80 17 37.35

Unknown 0.88 0.2 80 18 16.82

Medial orbitofrontal 0.79 0.14 82 14 46.08

Superior frontal 0.75 0.14 82 16 60.14

Caudal middle frontal 0.74 0.14 82 17 39.18

Pallidum 0.7 0.2 71 1 1 21.26

Middle temporal 0.7 0.13 81 16 58.38

Banks sts 0.69 0.17 76 19 32.32

Occipital str 0.72 -0.05 113 22 6.88

Locus coeruleus 0.74 -0.14 130 21 7.26

Inferior temporal 0.66 0.12 81 16 62.95

Rostral middle frontal 0.7 0.1 1 85 16 65.48

Superior temporal 0.67 0.14 80 18 50.84

Supramarginal 0.68 0.15 77 17 43.31

Pars triangularis 0.64 0.09 86 17 34.8

Cerebellum 0.73 0.05 97 16 64.1

Pars orbitalis 0.61 0.1 1 82 17 32.03

Median raphe 0.71 -0.3 158 20 6.47

Entorhinal 0.55 0.07 91 20 20.37

Precentral 0.57 0.09 85 18 39.29

Inferior parietal 0.56 0.13 76 15 47.77

Fusiform 0.53 0.04 95 18 49.78

Precuneus 0.54 0.07 88 19 20.34

Paracentral 0.51 0.05 91 20 27.95

Frontal pole 0.53 -0.02 104 14 26.84

Medulla oblongata 0.5 0.01 98 1 1 17.3

Isthmus cingulate 0.47 99 17 16.94

Transverse temporal 0.41 0.02 96 14 7.25

Parahippocampal 0.39 -0.07 121 22 23.91

Postcentral 0.42 0.05 87 16 35.27

Superior parietal 0.4 0.05 88 18 34.83

Hippocampus 0.38 0.13 72 1 1 17.83

Pendunculopontine 0.3 1 -2.59 22 3.98

Parabrachial complex 0.32 -0.1 1 670 14 5.88

Lingual 0.1 18

Lateral occipital 0.12 0.01 95 18 21.16

Cuneus 0.01 -2.5 14

Pericalcarine 0.01 -0.38 254 10.56

Table 20: 4 mg naloxone

Mean naloxone tl/2 of

naloxone mean mu opioid appearance mean t- mean mu opioid

Region of Interest BPNaloxone receptor of statistics of

BPpiacebo receptor

Min occupancy occupancy occupancy

occupancy

(%) (min)

at 5-6 h (%)

Prefrontal thalamus 2.8 0.51 82 9 55.38 10

Limbic striatum 2.39 0.35 85 9 51 9 Temporal thalamus 1.91 0.3 84 9 42.92 10

Amygdala 1.85 0.31 84 11 33.39 10

Temporal striatum 1.67 0.27 84 8 14.5 13

Executive striatum 1.37 0.13 90 10 55.61 9

Posterior parietal thalamus 1.16 0.13 89 10 32.67 11

Dorsal raphe 1.28 -0.02 102 8 11.66 13

Caudal anterior cingulate 1.15 0.18 84 9 36.62 12

Insula 1.08 0.12 89 11 54.31 10

Rostral motor striatum 1.05 0.06 94 12 20.07 10

Sensory thalamus 1.05 100 14 16.82 3

Primary motor thalamus 0.97 0.02 99 14 17.21 7

Rostral anterior cingulate 1.08 0.1 90 9 48.2 6

Premotor thalamus 0.91 101 13 22.17 9

Ventral tegmental area 0.91 -0.22 128 12 5.37

Caudal motor striatum 1 0.12 87 8 16.49

Occipital thalamus 0.9 0.1 88 10 16.4

Temporal pole 0.94 0.02 99 12 36.11

Parietal striatum 0.95 0.07 92 10 23.75

Lateral orbitofrontal 0.84 0.09 90 9 54.48

Posterior cingulate 0.92 0.11 87 11 35.35

Pars opercularis 0.84 0.12 86 12 38.68

Unknown 0.96 0.02 99 11 21.3

Medial orbitofrontal 0.83 0.08 91 9 50.97

Superior frontal 0.81 0.09 89 10 63.49

Caudal middle frontal 0.81 0.11 87 10 42.85

Pallidum 0.78 0.03 96 8 25.8

Middle temporal 0.75 0.07 93 10 63.13

Banks sts 0.75 0.12 85 10 30.24

Occipital striatum 0.75 -0.08 111 11 10

Locus coeruleus 0.82 -0.33 137 15 8.57

Inferior temporal 0.73 0.05 95 11 67.12

Rostral middle frontal 0.73 0.06 92 10 54.67

Superior temporal 0.73 0.04 95 11 53.97

Supramarginal 0.76 0.1 88 10 47.44

Pars triangularis 0.69 0.04 96 11 37.29

Cerebellum 0.67 -0.06 109 10 60.4

Pars orbitalis 0.65 0.04 96 10 32.58

Median raphe 0.66 -0.36 155 20 6.75

Entorhinal 0.63 -0.1 117 13 25.33

Precentral 0.64 0.07 89 10 45.73

Inferior parietal 0.59 0.08 88 10 50.15

Fusiform 0.56 -0.03 107 12 41.69

Precuneus 0.63 0.08 88 12 31.09

Paracentral 0.64 0.05 92 12 31

Frontal pole 0.5 -0.08 120 13 23.47

Medulla oblongata 0.58 -0.1 117 7 17.86 Isthmus cingulate 0.5 100 11 21.36

Transverse temporal 0.51 -0.03 108 15 11.41

Parahippocampal 0.44 -0.15 134 14 25.37

Postcentral 0.49 0.03 94 10 37.03

Superior parietal 0.46 0.05 89 10 33.61

Hippocampus 0.37 -0.05 116 14 21.98

Pendunculopontine nucleus 0.24 -0.44 376 18 6.67

Parabrachial complex 0.37 -0.41 254 14 8.36

Lingual 0.11 -0.53 770 6.4

Lateral occipital 0.12 -0.01 123 9 22.05

Cuneus 0.07 -0.76 910 4.09

Pericalcarine 0.02 -0.11 72 9.42

[0330] Pharmacokinetic Analysis.

[0331] Pharmacokinetic data was also collected during the PK study. Non-compartmental PK parameters including Cmax, tmax, AUC to 6 hours (AUCo-β), AUC to last measurable concentration (AUCo-t), and data quality allowing, also elimination rate constant (λζ), elimination half-life (t½) and AUC extrapolated to infinity (AUCo-∞) were estimated using a validated PK software program, WinNonlin® Phoenix 6.4. Selection of terminal time points was made based on the software and review of the selected points. The trapezoidal rule was used to estimate AUC, with linear calculation for increasing values and ln-transformed values used for decreasing values. The following definitions were applied to the PK parameters:

• AUCo-t: Area under the plasma concentration-time curve from time 0 to the time (t) of last quantifiable concentration (Ct) calculated by the trapezoidal rule.

• AUCo-∞: Area under the plasma concentration-time curve from time 0 extrapolated to infinity. The terminal area from Ct to infinity was calculated as Ct/ λζ, thus AUCo-∞ =

• Cmax: The maximum observed plasma concentration.

• tmax: The observed time to reach maximum plasma concentration from the time of naloxone administration.

• λζ: The terminal-phase exponential rate constant as calculated from the negative slope of the regression line for the terminal linear portion of the ln-transformed plasma concentration versus time curve.

• ti/₂: The apparent terminal exponential half-life of naloxone in plasma, calculated as

[0332] Results are given below in Table 21. Table 201

[0333] Provided herein are methods of treatment of reward-based disorders comprising intranasally administering a dose of naloxone or a salt or hydrate thereof that

i) achieves μ-opioid receptor (MOR) occupancy by naloxone of > about 50% in the brain, or a region thereof, in less than about 15 minutes; and

ii) is cleared form the brain to a level that yields MOR occupancy by naloxone of < about 15% within six hours.

[0334] Also provided are methods of achieving at least about 70% μ-opioid receptor (MOR) occupancy by naloxone in the brain of a subject, or in a region thereof, within one hour, comprising administering to a subject in need thereof a pharmaceutical formulation for intranasal administration comprising about 2 to about 12 mg of naloxone or a salt or hydrate thereof.

[0335] Also provided are methods of achieving at least about 50% μ-opioid receptor (MOR) occupancy by naloxone in the brain of a subject in less than about 15 minutes by intranasally administering at least about 4 mg of naloxone or a salt or hydrate thereof.

[0336] Also provided are methods of achieving at least about 50% μ-opioid receptor (MOR) occupancy by naloxone in the brain of a subject in less than about 30 minutes by intranasally administering at least about 2 mg of naloxone or a salt or hydrate thereof.

[0337] Also provided are methods of achieving at least about 90% occupancy by naloxone of the μ-opioid receptors in the medulla oblongata of a subject in one hour by intranasally administering about 2 to about 12 mg of naloxone or a salt or hydrate thereof. [0338] Also provided are methods of achieving 50% μ-opioid receptor (MOR) occupancy by naloxone in the medulla oblongata of a subject in less than about 10 minutes by intranasally administering at least about 4 mg of naloxone or a salt or hydrate thereof.

Other Embodiments

[001] The detailed description set-forth above is provided to aid those skilled in the art in practicing the present disclosure. However, the disclosure described and claimed herein is not to be limited in scope by the specific embodiments herein disclosed because these embodiments are intended as illustration of several aspects of the disclosure. Any equivalent embodiments are intended to be within the scope of this disclosure. Indeed, various modifications of the disclosure in addition to those shown and described herein will become apparent to those skilled in the art from the foregoing description, which do not depart from the spirit or scope of the present inventive discovery. Such modifications are also intended to fall within the scope of the appended claims.

Claims

What is claimed is:

1. A method of treatment of a reward-based disorder by intranasally administering a dose of naloxone or a salt or hydrate thereof that

iii) achieves μ-opioid receptor (MOR) occupancy by naloxone of > about 50% in the brain, or a region thereof, in less than about 15 minutes; and

iv) is cleared form the brain to a level that yields MOR occupancy by naloxone of < about 15% within six hours.

2. The method as recited in claim 1, wherein the reward-based disorder is a substance-use disorder.

3. The method as recited in claim 2, wherein the substance-use disorder is alcohol use

disorder.

4. The method as recited in claim 1, wherein the reward-based disorder is an eating disorder.

5. The method as recited in claim 4, wherein the eating disorder is bulimia nervosa.

6. The method as recited in claim 4, wherein the eating disorder is binge eating disorder.

7. The method as recited in claim 1, wherein the reward-based disorder is pathological

gambling.

8. The method as recited in claim 1, wherein the reward-based disorder is a neuropsychiatric disorder in which the subject performs self-injurious and/or inappropriate behaviors which result in the release of one or more endogenous opioids.

9. The method as recited in any of claims 1-8, wherein the intranasal naloxone is

administered prior to exposure to an abusable substance or self-injurious and/or inappropriate behaviors.

10. The method as recited in any of claims 1-8, wherein the intranasal naloxone is

administered about 1-2 hours prior to exposure to an abusable substance or self-injurious and/or inappropriate behaviors.

11. The method as recited in any of claims 1-8, wherein the intranasal naloxone is

administered contemporaneously with exposure to an abusable substance or self-injurious and/or inappropriate behaviors.

12. The method as recited in any of claims 1-11, wherein at least 75% occupancy of the μ- opioid receptors in the brain of a subject, or a region thereof, is achieved within one hour.

13. The method as recited in claim 12, wherein at least 80% occupancy of the μ-opioid

receptors in the brain of a subject, or a region thereof, is achieved within one hour.

14. The method as recited in claim 13, wherein at least 85% occupancy of the μ-opioid receptors in the brain of a subject, or a region thereof, is achieved within one hour.

15. The method as recited in claim 14, wherein at least 90% occupancy of the μ-opioid

receptors in the brain of a subject, or a region thereof, is achieved within one hour.

16. The method as recited in claim 15, wherein at least 95% occupancy of the μ-opioid

receptors in the brain of a subject, or a region thereof, is achieved within one hour.

17. The method as recited in claim 16, wherein at least 98% occupancy of the μ-opioid

receptors in the brain of a subject, or a region thereof, is achieved within one hour.

18. The method as recited in any of claims 1-8, wherein the naloxone is naloxone

hydrochloride.

19. The method as recited in claim 18, wherein the naloxone hydrochloride is presented as part of a pharmaceutical formulation for intranasal administration comprising:

about 2 to about 12 mg of naloxone or a salt or hydrate thereof;

an isotonicity agent; and

between about 0.005% and about 1% (w/v) of a compound which is at least one of a preservative, a cationic surfactant, and a permeation enhancer.

20. The method as recited in claim 19, comprising between about 0.2% and about 2% (w/v) of the isotonicity agent.

21. The method as recited in claim 20, comprising between about 0.2 to about 2.0 mg of the isotonicity agent.

22. The method as recited in claim 21, wherein the isotonicity agent is NaCl.

23. The method as recited in claim 19, comprising about 0.005% and about 0.015% (w/v) of the compound which is at least one of a preservative, a cationic surfactant, and a permeation enhancer.

24. The method as recited in claim 23, comprising about 0.005% and about 0.01% (w/v) of the compound which is at least one of a preservative, a cationic surfactant, and a permeation enhancer.

25. The method as recited in claim 24, wherein the compound which is at least one of a

preservative, a cationic surfactant, and a permeation enhancer is benzalkonium chloride.

26. The method as recited in claim 19, wherein the pharmaceutical formulation additionally comprises a stabilizing agent.

27. The method as recited in claim 26, wherein the formulation comprises between about 0.1 mg and about 0.5 mg of the stabilizing agent.

28. The method as recited in claim 27, wherein the stabilizing agent is disodium edetate.

29. The method as recited in claim 19, wherein the pharmaceutical formulation additionally comprises an amount of an acid sufficient to achieve a pH of 3.5-6.5.

30. The method as recited in claim 29, wherein the pharmaceutical formulation additionally comprises an amount of an acid sufficient to achieve a pH of 3.5-5.5.

31. The method as recited in claim 30, wherein the acid is hydrochloric acid.

32. The method as recited in claim 19, wherein the pharmaceutical formulation comprises: between about 0.2% and about 1.2% (w/v) of the isotonicity agent;

between about 0.1% and about 0.5% (w/v) of a stabilizing agent; and

an amount of an acid sufficient to achieve a pH of 3.5-5.5.

33. The method as recited in claim 19 wherein the pharmaceutical formulation comprises: between about 0.2 to about 2.0 mg of the isotonicity agent;

between about 0.1 to about 0.5 mg of a stabilizing agent; and

an amount of an acid sufficient to achieve a pH of 3.5-5.5.

34. The method of either of claims 31 and 32, wherein:

the isotonicity agent is sodium chloride;

the stabilizing agent is disodium edetate; and

the acid is hydrochloric acid.

35. The method as recited in claim 19, wherein the pharmaceutical solution comprises: about 2% (w/v) naloxone hydrochloride;

about 0.74% (w/v) sodium chloride;

about 0.01% (w/v) benzalkonium chloride; and

about 0.2% (w/v) disodium edetate.

36. The method as recited in claim 19, wherein the pharmaceutical formulation comprises: about 2 mg naloxone hydrochloride;

about 0.74 mg NaCl;

about 0.01 mg benzalkonium chloride; and

about 0.2 mg disodium edetate.

37. The method as recited in claim 19, wherein the pharmaceutical formulation comprises: about 4% (w/v) naloxone hydrochloride;

about 0.74% (w/v) sodium chloride;

about 0.01% (w/v) benzalkonium chloride; and

about 0.2% (w/v) disodium edetate.

38. The method as recited in claim 19, wherein the pharmaceutical formulation comprises: about 4 mg naloxone hydrochloride; about 0.74 mg NaCl;

about 0.01 mg benzalkonium chloride; and

about 0.2 mg disodium edetate.

39. The method of any preceding claim, wherein the pharmaceutical formulation comprises about 2, about 4, or about 8 mg of naloxone or a salt or hydrate thereof.

40. The method as recited in claim 39, wherein the pharmaceutical formulation comprises an amount of hydrochloric acid sufficient to achieve a pH of 3.5-5.5.

41. The method as recited in claim 40, wherein the pharmaceutical formulation is an aqueous solution of not more than about 140 μί.

42. The method as recited in claim 41, wherein the pharmaceutical formulation is an aqueous solution of not more than about 100 μί.

43. The method as recited in any of claims 1-42, wherein the pharmaceutical formulation is contained within and is delivered to the nasal mucosa of a subject by a single-use, preprinted device for intranasal administration.

44. The method as recited in any of claims 1-42, wherein the pharmaceutical formulation is contained within and is delivered to the nasal mucosa of a subject by a bi-dose, preprinted device for intranasal administration.

45. The method as recited in any of claims 1-42, wherein the pharmaceutical formulation is contained within and is delivered to the nasal mucosa of a subject by a multi-dose device for intranasal administration.

46. The method as recited in any preceding claim, wherein the brain region is located in the reward circuitry.

47. The method as recited claim 46, wherein the brain region is part of the cortico-basal ganglia-thalamo-cortical loop.

48. The method as recited claim 47, wherein the brain region is chosen from a structure in the striatum and a structure in the basal ganglia.

49. The method as recited claim 48, wherein the brain region is chosen from the nucleus accumbens and ventral striatum.

50. The method as recited claim 47, wherein the brain region is chosen from the nucleus accumbens and ventral tegmental area.

51. A method of achieving at least about 70% μ-opioid receptor (MOR) occupancy by

naloxone in the brain of a subject, or in a region thereof, within one hour, comprising administering to a subject in need thereof a pharmaceutical formulation for intranasal administration comprising about 2 to about 12 mg of naloxone or a salt or hydrate thereof.

52. The method as recited in claim 51, wherein at least 75% occupancy of the μ-opioid

receptors in the brain of a subject, or a region thereof, is achieved within one hour.

53. The method as recited in claim 51, wherein at least 80% occupancy of the μ-opioid

receptors in the brain of a subject, or a region thereof, is achieved within one hour.

54. The method as recited in claim 51, wherein at least 85% occupancy of the μ-opioid

receptors in the brain of a subject, or a region thereof, is achieved within one hour.

55. A method of achieving at least about 50% μ-opioid receptor (MOR) occupancy by

naloxone in the brain of a subject in less than about 15 minutes by intranasally administering at least about 4 mg of naloxone or a salt or hydrate thereof.

56. The method as recited in claim 55, wherein at least 50% occupancy of the μ-opioid

receptors in the brain of a subject, or a region thereof, is achieved in less than about 10 minutes.

57. A method of achieving at least about 50% μ-opioid receptor (MOR) occupancy by

naloxone in the brain of a subject in less than about 30 minutes by intranasally administering at least about 2 mg of naloxone or a salt or hydrate thereof.

58. The method as recited in claim 57, wherein at least 50% occupancy of the μ-opioid

receptors in the brain of a subject, or a region thereof, is achieved in less than about 27 minutes.

59. The method as recited in claim 57, wherein at least 50% occupancy of the μ-opioid

receptors in the brain of a subject, or a region thereof, is achieved in less than about 25 minutes.

60. The method as recited in claim 57, wherein at least 50% occupancy of the μ-opioid

receptors in the brain of a subject, or a region thereof, is achieved in less than about 20 minutes.

61. The method as recited in claim 57, wherein at least 50% occupancy of the μ-opioid

receptors in the brain of a subject, or a region thereof, is achieved in less than about 16 minutes.

62. A method of achieving at least about 90% occupancy by naloxone of the μ-opioid

receptors in the medulla oblongata of a subject in one hour by intranasally administering about 2 to about 12 mg of naloxone or a salt or hydrate thereof.

63. The method as recited in claim 62, wherein the method achieves at least about 95%

occupancy.

64. The method as recited in claim 62, wherein the method achieves at least about 98% occupancy.

65. A method of achieving at least about 50% μ-opioid receptor (MOR) occupancy by

naloxone in the medulla oblongata of a subject in less than about 15 minutes by intranasally administering at least about 2 mg of naloxone or a salt or hydrate thereof.

66. The method as recited in claim 65, wherein at least about 50% MOR occupancy by

naloxone in the medulla oblongata of a subject is achieved in less than about 12 minutes.

67. The method as recited in claim 65, wherein at least about 50% MOR occupancy by

naloxone in the medulla oblongata of a subject is achieved in less than about 11 minutes.

68. A method of achieving 50% μ-opioid receptor (MOR) occupancy by naloxone in the medulla oblongata of a subject in less than about 10 minutes by intranasally administering at least about 4 mg of naloxone or a salt or hydrate thereof.

69. The method as recited in claim 68, wherein at least about 50% MOR occupancy by

naloxone in the medulla oblongata of a subject is achieved in less than about 8 minutes.

70. The method as recited in claim 68, wherein at least about 50% MOR occupancy by

naloxone in the medulla oblongata of a subject is achieved in less than about 7 minutes.

71. The method as recited in any of claims 65-70 which achieves at least about 70%

occupancy by naloxone in the medulla oblongata of a subject in one hour.

72. The method as recited in claim 71 which achieves at least about 80% occupancy by

naloxone in the medulla oblongata of a subject in one hour.

73. The method as recited in claim 71 which achieves at least about 90% occupancy by

naloxone in the medulla oblongata of a subject in one hour.

74. The method as recited in claim 71 which achieves at least about 95% occupancy by

naloxone in the medulla oblongata of a subject in one hour.

75. The method as recited in claim 71 which achieves at least about 98% occupancy by

naloxone in the medulla oblongata of a subject in one hour.

76. The method as recited in any of claims 51-75, wherein the naloxone is administered as part of a pharmaceutical formulation additionally comprising:

an isotonicity agent; and

between about 0.005% and about 1% (w/v) of a compound which is at least one of a preservative, a cationic surfactant, and a permeation enhancer.

77. The method as recited in any of claims 51-76, wherein the naloxone is naloxone

hydrochloride.

78. The method as recited in any of claims 51-77, comprising between about 0.2% and about 2% (w/v) of the isotonicity agent.

79. The method as recited in claim 78, comprising between about 0.2 to about 2.0 mg of the isotonicity agent.

80. The method as recited in claim 79, wherein the isotonicity agent is NaCl.

81. The method as recited in any of claims 51-80, comprising about 0.005% and about

0.015% (w/v) of the compound which is at least one of a preservative, a cationic surfactant, and a permeation enhancer.

82. The method as recited in claim 81, comprising about 0.005% and about 0.01% (w/v) of the compound which is at least one of a preservative, a cationic surfactant, and a permeation enhancer.

83. The method as recited in claim 82, wherein the compound which is at least one of a preservative, a cationic surfactant, and a permeation enhancer is benzalkonium chloride.

84. The method as recited in any of claims 51-83, wherein the pharmaceutical formulation additionally comprises a stabilizing agent.

85. The method as recited in claim 84, wherein the formulation comprises between about 0.1 mg and about 0.5 mg of the stabilizing agent.

86. The method as recited in claim 85, wherein the stabilizing agent is disodium edetate.

87. The method as recited in any of claims 51-86, wherein the pharmaceutical formulation additionally comprises an amount of an acid sufficient to achieve a pH of 3.5-6.5.

88. The method as recited in claim 87, wherein the pharmaceutical formulation additionally comprises an amount of an acid sufficient to achieve a pH of 3.5-5.5.

89. The method as recited in claim 88, wherein the acid is hydrochloric acid.

90. The method as recited in claim 77, wherein the pharmaceutical formulation comprises: between about 0.2% and about 1.2% (w/v) of the isotonicity agent;

between about 0.1% and about 0.5% (w/v) of a stabilizing agent; and

an amount of an acid sufficient to achieve a pH of 3.5-5.5.

91. The method as recited in claim 77, wherein the pharmaceutical formulation comprises: between about 0.2 to about 2.0 mg of the isotonicity agent;

between about 0.1 to about 0.5 mg of a stabilizing agent; and

an amount of an acid sufficient to achieve a pH of 3.5-5.5.

92. The method of either of claims 90 and 91, wherein:

the isotonicity agent is sodium chloride;

the stabilizing agent is disodium edetate; and the acid is hydrochloric acid.

93. The method of any preceding claim, wherein the pharmaceutical formulation comprises about 2, about 4, or about 8 mg of naloxone or a salt or hydrate thereof.

94. The method as recited in any of claims 51-75, wherein the pharmaceutical solution

comprises:

about 2% (w/v) naloxone hydrochloride;

about 0.74% (w/v) sodium chloride;

about 0.01% (w/v) benzalkonium chloride; and

about 0.2% (w/v) disodium edetate.

95. The method as recited in any of claims 51-75, wherein the pharmaceutical formulation comprises:

about 2 mg naloxone hydrochloride;

about 0.74 mg NaCl;

about 0.01 mg benzalkonium chloride; and

about 0.2 mg disodium edetate.

96. The method as recited in any of claims 51-75, wherein the pharmaceutical formulation comprises:

about 4% (w/v) naloxone hydrochloride;

about 0.74% (w/v) sodium chloride;

about 0.01% (w/v) benzalkonium chloride; and

about 0.2% (w/v) disodium edetate.

97. The method as recited in any of claims 51-75, wherein the pharmaceutical formulation comprises:

about 4 mg naloxone hydrochloride;

about 0.74 mg NaCl;

about 0.01 mg benzalkonium chloride; and

about 0.2 mg disodium edetate.

98. The method as recited in any of claims 94-97, wherein the pharmaceutical formulation comprises an amount of hydrochloric acid sufficient to achieve a pH of 3.5-5.5.

99. The method as recited in any of claims 51-98, wherein the pharmaceutical formulation is an aqueous solution of not more than about 140 μί.

100. The method as recited in claim 99, wherein the pharmaceutical formulation is an aqueous solution of not more than about 100 μί.

101. The method as recited in any of claims 51-100, wherein the pharmaceutical formulation is contained within and is delivered to the nasal mucosa of a subject by a single-use, pre-primed device for intranasal administration.

102. The method as recited in any of claims 51-100, wherein the pharmaceutical

formulation is contained within and is delivered to the nasal mucosa of a subject by a bi- dose, pre-primed device for intranasal administration.

103. The method as recited in any of claims 51-100, wherein the pharmaceutical

formulation is contained within and is delivered to the nasal mucosa of a subject by a multi-dose device for intranasal administration.

104. The method as recited in any preceding claim, wherein the brain region is located in the reward circuitry.

105. The method as recited claim 104, wherein the brain region is part of the corti co-basal ganglia-thalamo-cortical loop.

106. The method as recited claim 104, wherein the brain region is chosen from a structure in the striatum and a structure in the basal ganglia.

107. The method as recited claim 104, wherein the brain region is chosen from the nucleus accumbens and ventral striatum.

108. The method as recited claim 104, wherein the brain region is chosen from the nucleus accumbens and ventral tegmental area.

109. The method as recited in any preceding claim, wherein the brain region is chosen from the prefrontal thalamus, limbic striatum, temporal thalamus, amygdala, temporal striatum, executive striatum, posterior parietal thalamus, dorsal raphe, caudal anterior cingulate, insula, rostral motor striatum, sensory thalamus, primary motor thalamus, rostral anterior cingulate, premotor thalamus, and medulla oblongata.

110. The method as recited in any preceding claim, wherein the brain region is in a

respiratory control center.

111. The method as recited in any preceding claim, wherein the brain region is the medulla oblongata.