Opioid-sparing compositions and methods of use thereof

Abstract

The present disclosure relates to opioid-sparing compositions and their uses for reducing opioid use. Such compositions and methods may be used to reduce pain, reduce opioid use, or increase mobility in subjects who use opioids.

Description

[Technical field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application claims priority to Australian Application No. 202190147, filed January 22, 2021, Australian Application No. 2021900250, filed February 4, 2021, and U.S. Application No. 63 / 298,391, filed January 11, 2022, each of which is incorporated by reference in its entirety herein.

[0002] The present disclosure relates to opioid-sparing compositions and their uses for reducing opioid use. Such compositions and methods may be used to reduce pain, reduce opioid use, or increase mobility in subjects who use opioids. [Background technology]

[0003] Opioids, also known as opioid agonists, are a group of drugs that exhibit opium or morphine-like properties. Opioids are primarily used as moderate to strong analgesics, but they also have many other pharmacological effects, including drowsiness, respiratory depression, mood changes, and mental confusion without loss of consciousness. Long-term opioid use is associated with various types of pain.

[0004] Low back pain is a chronic disease associated with inflammation and pain that requires ongoing opioid use as part of routine pain management. The condition affects approximately two-thirds of the adult population in the United States, significantly increasing physician visits and impacting disability.

[0005] Various therapeutic agents have been used to treat pain and / or inflammation, including chronic pain and / or inflammation, but even after long-term administration of such agents, the treatment often remains ineffective.

[0006] Clearly, there is a need in the art for improved methods of managing pain in opioid users. Summary of the Invention [Problem to be solved by the invention]

[0007] The inventors have surprisingly found that administering mesenchymal progenitor or stem cells (MLPSCs) reduces pain, reduces opioid use, or increases EQ-5D scores in subjects using opioids. [Means for solving the problem]

[0008] Thus, in one embodiment, the disclosure relates to a method of reducing pain, or reducing opioid use, or increasing EQ-5D score, comprising administering to a subject a composition comprising mesenchymal precursor or stem cells (MLPSCs), and the subject is using opioids. For example, the disclosure relates to a method of reducing pain, comprising administering to the subject a composition comprising mesenchymal precursor or stem cells (MLPSCs), and the subject is using opioids. In another embodiment, the disclosure relates to a method of reducing opioid use, comprising administering to the subject a composition comprising mesenchymal precursor or stem cells (MLPSCs), and the subject is using opioids. In another embodiment, the disclosure relates to a method of increasing EQ-5D score, comprising administering to the subject a composition comprising mesenchymal precursor or stem cells (MLPSCs), and the subject is using opioids.

[0009] In one embodiment, the composition comprises hyaluronic acid (HA).In one embodiment, the opioid spared by the composition is morphine. In one embodiment, the disclosed methods reduce pain and opioid use, hi another embodiment, the disclosed methods reduce pain and improve function while simultaneously reducing opioid use.

[0010] In one embodiment, the subject is using opioids for pain. In one embodiment, the pain is axial pain. In one embodiment, the axial pain is due to nerve root compression as defined by MRI.

[0011] In light of the inventors' findings, the inventors have arrived at an opioid-sparing composition that can be administered to reduce opioid use over time. Thus, in another embodiment, the present disclosure relates to an opioid-sparing composition comprising mesenchymal precursor or stem cells (MLPSCs). In one embodiment, the composition also comprises hyaluronic acid (HA). For example, the composition may comprise 1% HA. In one embodiment, the composition comprises 1% HA and culture-expanded MLPSCs. In one embodiment, the opioid-sparing composition is administered to a subject using opioids, preferably the subject using opioids for pain. In one embodiment, the opioid-sparing composition reduces opioid use by the subject. In one embodiment, opioid use is reduced 36 months after administration of the composition. In one embodiment, the opioid-sparing composition causes the subject to discontinue opioid use. In one embodiment, opioid use is discontinued 36 months after administration of the composition.

[0012] The compositions and methods of the present disclosure can be used in the context of various types of pain. In one embodiment, the pain is chronic pain. In another embodiment, the pain is low back pain. In one embodiment, the low back pain is associated with a degenerated intervertebral disc. In another embodiment, the low back pain is associated with an intervertebral disc. For example, the intervertebral disc may have a substantially unreduced disc height compared to an adjacent healthy disc of the subject. In another embodiment, the low back pain is of non-nerve root origin. In another embodiment, the pain is associated with one or more of a herniated disc up to 3mm protrusion, nerve ingrowth into the disc, or inflammation of the disc. In one embodiment, the nerve ingrowth or inflammation is within the disc space, or the nucleus pulposus, or the fibrous annulus of the disc.

[0013] In one embodiment, opioid use is reduced one month after administration of the composition. In another embodiment, opioid use is reduced three months after administration of the composition. In another embodiment, opioid use is reduced 12 months after administration of the composition. In another embodiment, opioid use is reduced 24 months after administration of the composition. In another embodiment, opioid use is reduced 36 months after administration of the composition. In another embodiment, opioid use is discontinued 36 months after administration of the composition.

[0014] In one embodiment, opioid use is reduced relative to the subject's average baseline morphine equivalents prior to administration of the composition.

[0015] In one embodiment, the subject has been using opioids for at least 1 month prior to administering the composition, in another embodiment, the subject has been using opioids for at least 3 months prior to administering the composition, in another embodiment, the subject has been using opioids for at least 6 months prior to administering the composition.

[0016] In one embodiment, the subject has been experiencing pain for 6-68 months, hi another embodiment, the subject has not experienced pain for more than 68 months.

[0017] In one embodiment, the subject's opioid use is reduced by about 20% relative to baseline opioid use prior to administration of the composition. In another embodiment, the subject's opioid use is reduced by about 30% relative to baseline opioid use prior to administration of the composition. In another embodiment, the subject's opioid use is reduced by about 40% relative to baseline opioid use prior to administration of the composition.

[0018] In one embodiment, the subject experiences a reduction in visual analog scale (VAS) score relative to the VAS score prior to administration of the composition. In another embodiment, the subject's VAS pain response is 30%. In another embodiment, the subject's VAS pain response is 50%.

[0019] In one embodiment, the subject has an increase in EQ-5D score from baseline. In one embodiment, the increase is determined based on EQ-5D VAS score. In one embodiment, the increase is observed 12 months after administration of the composition of the present disclosure. In one embodiment, the increase is observed 36 months after administration of the composition of the present disclosure. In one embodiment, the increase is determined based on EQ-5D index score. In one embodiment, the increase is observed 12 months after administration of the composition of the present disclosure. In another embodiment, the increase is observed 24 months after administration of the composition of the present disclosure. In another embodiment, the increase is observed 36 months after administration of the composition of the present disclosure.

[0020] In one embodiment, the subject achieves an ODI functional response of 10. In another embodiment, the subject achieves an ODI functional response of 15. In another embodiment, the subject achieves an ODI functional response of 10 and a VAS pain response of 30%. In another embodiment, the subject achieves an ODI functional response of 15 and a VAS pain response of 50%. In one embodiment, the subject is administered a composition comprising MLPSCs and HA. In one embodiment, the subject achieves an ODI functional response of 10 12 months after administration of the composition of the present disclosure. In one embodiment, the subject is opioid-free prior to administration of the composition. In one embodiment, the subject achieves an ODI functional response of 10 36 months after administration of the composition of the present disclosure. In one embodiment, the subject is opioid-free prior to administration of the composition.

[0021] In another embodiment, the subject achieves an ODI functional response of 10 and a VAS pain response of 30%, the subject is using opioids prior to administration of the composition of the present disclosure, and the subject has not reported back pain for more than 68 months. In one embodiment, an ODI functional response of 10 and a VAS pain response of 30% are observed 24 months after administration of the composition of the present disclosure. In one embodiment, an ODI functional response of 10 and a VAS pain response of 30% are observed 36 months after administration of the composition of the present disclosure.

[0022] In one embodiment, the subject is free of significant pain 12 months after administration of the composition, hi another embodiment, the subject is free of significant pain 24 months after administration of the composition.

[0023] In one embodiment, the subject has an ODI score of 25-70%. In another embodiment, the subject has an ODI score of 30-60%.

[0024] In one embodiment, the MLPSCs are STRO-1+. In one embodiment, the MLPSCs are mesenchymal stem cells (MSCs). In one embodiment, the cells are allogeneic. In one embodiment, the cells are culture-expanded. In one embodiment, the cells are TNAP+ prior to culture-expanding. In one embodiment, the cells are cryopreserved.

[0025] In one embodiment, the method of the present disclosure comprises the step of: 7 ~2×10 8 Thus, the compositions of the present disclosure include administering 1×10 cells. 7 ~2×10 8 The cell may include cells.

[0026] In one example, the composition of the disclosure comprises allogeneic mesenchymal progenitor cells (MPCs) derived from human bone marrow that have been isolated from bone mononuclear cells using an anti-STRO-3 antibody, expanded ex vivo, and cryopreserved.

[0027] In one embodiment, the subject is opioid abstinent for 36 months after administration of the composition.

[0028] In another embodiment, the present disclosure relates to the manufacture of a medicament for discontinuing opioid use in a subject. In one embodiment, a composition disclosed herein is used to manufacture the medicament. In one embodiment, opioid use is discontinued 36 months after administering a medicament disclosed herein to the subject. For example, the medicament may be administered to a subject with chronic pain. In one embodiment, the subject has back pain. [Brief description of the drawings]

[0029] [Figure 1] LS mean VAS pain change from baseline in opioid users with MPC+HA compared to placebo had significantly greater mean pain reduction from baseline at all time points over 24 months. [Diagram 2] MPC+HA significantly increased the proportion of patients at 24 months with a VAS pain response of 50% and 30% compared with placebo in opioid users. [Diagram 3] Minimal to no pain (LBP VAS ≦20) was significantly increased in opioid users with MPC+HA compared with placebo at 6, 12, 18, and 24 months. [Figure 4] Comparison of the ODI and EQ5D index as measures of functioning in opioid users means that the change from baseline in the EQ5D index is a better discriminator of MPC treatment effect. [Diagram 5] The EQ5D is a better discriminator than the ODI to determine MIC treatment success in opioid users. [Figure 6] MPC+HA significantly increased the proportion of patients achieving a composite treatment response of 50% VAS / 0.03EQ5D and 30% VAS / 0.03EQ5D at 24 months. [Figure 7] Overall treatment success of the LBP-EQ5D index and overall treatment success of the MIC in opioid users with MPC+HA significantly increased the proportion of patients who achieved a composite treatment response of 30% VAS / 0.03 EQ5D at both 12 and 24 months. [Figure 8] Overall treatment success of the LBP-EQ5D index and overall treatment success of the MIC in opioid users with MPC+HA significantly increased the proportion of patients who achieved a composite treatment response of 30% VAS / 0.03 EQ5D at both 12 and 24 months. [Figure 9]MPC+HA significantly reduces opioid morphine milligram equivalent use over 24 months in patients with baseline opioid use. [Figure 10] MPC+HA reduces morphine milligram equivalents over 24 months in opioid users. [Figure 11] MPC+HA: VAS 30% + opioid reduction*. (*All subjects were opioid users at baseline and had opioid values ​​at each time point assessed). [Figure 12] MPC+HA: VAS 50% + opioid reduction*. [Figure 13] MPC+HA: Combined response; ODI-10+opioid reduction*. [Figure 14] MPC+HA: Combined response; ODI-15+opioid reduction*. [Figure 15] MPC+HA: Combined response: VAS 30% + ODI-10 + Opioid reduction*. [Figure 16] MPC+HA: Combined response: VAS 50% + ODI-15 + Opioid reduction*. [Figure 17] MPC+HA: Treatment success; VAS+ODI response + opioid reduction from baseline* at both 12 and 24 months and no intervention.Treatment success VAS / ODI: Subjects with a 50% reduction in VAS score from baseline and a 15 point improvement in ODI score from baseline at both 12 and 24 months and no post-treatment intervention by 24 months and a reduction in opioids at 24 months.Subjects with a 30% reduction in VAS score from baseline and a 10 point improvement in ODI score from baseline at both 12 and 24 months and no post-treatment intervention by 24 months and a reduction in opioids at 24 months. [Figure 18]MPC+HA: Treatment success; VAS+EQ5D response+opioid reduction from baseline* and no intervention at both 12 and 24 months.Treatment success VAS / EQ5D index: Subjects with a 50% reduction in VAS score from baseline and an improvement in EQ5D index score of 0.03 points from baseline at both 12 and 24 months and no post-treatment interventions through 24 months and a reduction in opioids at 24 months.Subjects with a 30% reduction in VAS score from baseline and an improvement in EQ5D index score of 0.03 points from baseline at both 12 and 24 months and no post-treatment interventions through 24 months and a reduction in opioids at 24 months. [Figure 19] Change from baseline in LS mean VAS low back pain - All subjects (n=391). [Figure 20] Change from baseline in LS mean VAS low back pain-CLBP < median (n=194). [Figure 21] Change from baseline in LS mean ODI-CLBP < median (n=197). [Figure 22] LHS:ODI 10-point MIC responder-CLBP ≤ median; RHS:MIC 30% VAS / 10-point ODI treatment success-CLBP ≤ median. [Figure 23] EQ5D index CFB-all subjects (LHS); CLBP duration < median (RHS). [Figure 24] EQ5D MCIC index responders-all subjects (LHS); CLBP duration < median (RHS). [Diagram 25] 30% VAS-EQ5D 0.03 points index MIC treatment success-all subjects (LHS); CLBP duration < median (RHS). [Figure 26] 5% VAS-EQ5D 0.03 points index MIC treatment success-all subjects (LHS); CLBP duration < median (RHS). [Figure 27]LHS: VAS 30% / ODI 10%MIC treatment successCLBP duration < median; RHS: VAS 30% / EQ5d 0.03 pointsMIC treatment successCLBP < median.ODIMIC treatment success-subjects with a 30% reduction in low back pain VAS score from baseline and a 10 point improvement in ODI from baseline and no post-treatment intervention assessed.EQ5D index scoreMIC treatment success-subjects with a 30% reduction in low back pain VAS score from baseline and a 0.03 point improvement in EQ5D index score from baseline and no post-treatment intervention assessed throughout the time points. [Figure 28] LS mean change in average pain over 24 hours as measured by VAS - Prespecified subgroup of baseline opioid users based on patients' electronic diary analgesic use entries. [Figure 29] LS mean change in average pain over 24 hours as measured by VAS - all subjects. [Diagram 30] Proportion of subjects at 24 months with mean analgesic reduction from baseline. [Diagram 31] Proportion of baseline opioid users who were opioid-free at 6, 12, 18, 24, and 36 months. [Diagram 32] Mean Pain Minimal Important Change (MIC; 30% reduction) Responder Analysis - A prespecified subgroup of subjects with CLBP duration less than the median (68.8 months). [Diagram 33] LS Mean Change in Function Measured by ODI-Opioid Users and Non-Opioid Users Subjects with Median CLBP Duration up to 36 Months. [Diagram 34] LS mean change in morphine equivalent dose among opioid users through 36 months. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0030] General Techniques and Definitions Unless specifically defined otherwise, all technical and scientific terms used herein are intended to have the same meaning as commonly understood by one of ordinary skill in the art (e.g., in cell culture, molecular biology, stem cell culture, immunology, and biochemistry).

[0031] Unless otherwise indicated, the cell culture techniques and assays utilized in this disclosure are standard procedures, well known to those skilled in the art. Such techniques are described in J. Perbal, A Practical Guide to Molecular Cloning, John Wiley and Sons (1984), J. Sambrook et al., Molecular Cloning: A Laboratory Manual, Cold Spring Harbor Laboratory Press (1989), TA Brown (editor), Essential Molecular Biology: A Practical Approach, Volumes 1 and 2, IRL Press (1991), D. M. Glover and B. D. Hames (editors), and F. M. Usubel et al. (editors), Current Protocols in Molecular Biology, Greene Pub. Associates and Wiley-Interscience (1988, including all updates to date), Ed Harlow and David Lane (editors), Antibodies: A Laboratory Manual, Cold Spring Harbor Laboratory, (1988), and J. E. Coligan et al. (editors), Current Protocols in Immunology, John It is described and explained in such publications as Wiley & Sons (including all current updates).

[0032] The term "and / or", e.g., "X and / or Y", is understood to mean either "X and Y" or "X or Y", and is interpreted as explicitly endorsing both meanings or either meaning.

[0033] As used herein, unless stated to the contrary, the term "about" refers to + / - 10%, more preferably + / - 5% of the specified value.

[0034] The terms "level" and "amount" are used to define the amount of a particular substance in a sample from a subject or in a cell culture medium (or sample therefrom). For example, a particular concentration, weight, percentage (e.g., v / v%) or ratio may be used to define the level of a particular substance in a sample. In one example, the level is expressed in terms of how much of a particular marker is expressed by the cells of the present disclosure under culture conditions. In one example, expression refers to cell surface expression. In another example, the level is expressed in terms of how much of a particular marker is released from the cells described herein under culture conditions. In one example, a sample is obtained from a patient or subject (e.g., a blood sample) and the level of the substance in the sample is measured to determine the level of the substance in the sample.

[0035] In one embodiment, the levels are expressed in pg / ml. 6 Expressed in pg per cell.

[0036] In one embodiment, the level of a particular marker in a cell culture medium is determined under culture conditions. The term "culture conditions" is used to refer to cells growing in culture. In one embodiment, culture conditions refer to an actively dividing population of cells. Such cells may be in an exponential growth phase, in one embodiment. For example, the level of a particular marker may be determined by taking a sample of the cell culture medium and measuring the level of the marker in the sample. In another embodiment, the level of a particular marker may be determined by taking a sample of the cells and measuring the level of the marker in a cell lysate. One skilled in the art will appreciate that secreted markers are measured by sampling the culture medium, while cell surface expressed markers can be measured by evaluating a sample of the cell lysate. In one embodiment, the sample is taken when the cells are in an exponential growth phase. In one embodiment, the sample is taken after at least two days in culture.

[0037] Culturing to expand cells from a cryopreserved intermediate refers to thawing cells that have been subjected to deep freezing and in vitro culture under conditions suitable for cell growth.

[0038] In one example, the "level" or "amount" of a particular marker is determined after the cells have been cryopreserved and then seeded in culture. For example, the level is determined after a first cryopreservation of the cells. In another example, the level is determined after a second cryopreservation of the cells. For example, the cells may be cultured from a cryopreserved intermediate and cryopreserved a second time before being reseeded in culture so that the level of the particular marker can be determined under culture conditions.

[0039] The term "opioid sparing agent" is used in the context of the present disclosure to refer to a composition that can be administered to a subject using opioids to facilitate a reduction in the subject's opioid intake. In other words, a subject administered an opioid sparing agent of the present disclosure can take lower doses of opioids over time. In one example, the opioid sparing agent reduces the subject's pain and / or increases their mobility.

[0040] As used herein, the terms "treating," "treating," "treatment," "reducing pain," "reducing opioid use," and "increasing mobility" include administering a population of mesenchymal lineage stem or progenitor cells and / or their progeny and / or soluble factors derived therefrom and / or extracellular vesicles derived therefrom to reduce pain and / or reduce opioid use and / or increase mobility in a subject using opioids.

[0041] As used herein, the term "subject" refers to a human subject. For example, the subject may be an adult. In another embodiment, the subject may be a child. In another embodiment, the subject may be an adolescent. Terms such as "subject," "patient," or "individual" are terms that may be used interchangeably in this disclosure, where the context requires. Subjects in need of treatment include subjects who are using opioids. For example, the subject may be using opioids for pain, such as back pain. In one embodiment, the subject's pain and opioid use is ongoing. For example, the subject may have pain for 2, 3, 4, 5, 6, 12, 24 months or more. Thus, in one embodiment, the subject may be using opioids for 1, 2, 3, 4, 5, 6, 12, 24 months or more. In one embodiment, the subject is using morphine. In one embodiment, the subject has not reported back pain for more than 68 months.

[0042] In another embodiment, the subject has an Oswestry Disability Index (ODI) score of 25-70%. In another embodiment, the subject has an ODI score of 30-60%. The ODI score can be used to define patients as follows: 0%-20%: minimally disabled; 21%-40%: moderately disabled; 41%-60%: severely disabled; 61%-80%: crippling back pain; 81%-100%: bedridden or with exaggerated symptoms. In one embodiment, the subject has experienced pain for at least 1 month. In another embodiment, the subject has experienced pain for at least 3 months. In another embodiment, the subject has experienced pain for at least 6 months. In another embodiment, the subject has experienced pain for at least 12 months. In another embodiment, the subject has experienced pain for at least 24 months. In another embodiment, the subject has experienced pain for at least 36 months. In another embodiment, the subject has experienced pain for at least 48 months. In another embodiment, the subject has experienced pain for at least 60 months. In another embodiment, the subject has experienced pain for 6-78 months. In another embodiment, the subject has experienced pain for 6-70 months. In another embodiment, the subject has experienced pain for 2-68 months. In another embodiment, the subject has experienced pain for 3-68 months. In another embodiment, the subject has experienced pain for 6-68 months. In another embodiment, the subject has experienced pain for 12-68 months. In another embodiment, the subject has not experienced pain for 68 months or more. In one embodiment, the subject's pain requires treatment with an analgesic. In one embodiment, the analgesic is an opioid. In one embodiment, the opioid is morphine. For example, the subject may experience chronic back pain for 3-68 months. In this example, the subject's pain may be treated with an opioid. In one embodiment, the subject has experienced chronic back pain for at least 6 months. In one embodiment, the subject has experienced chronic back pain for 6-12 months.

[0043] In certain embodiments, the present disclosure relates to methods and compositions for reducing pain, such as chronic low back pain. Pain reduction can be determined using various methods discussed herein (e.g., VAS, EQ-5D, ODI). The term "axial pain" is used in the context of the present disclosure to refer to localized pain that is confined to a particular site or area (e.g., neck pain or leg pain).

[0044] In one embodiment, the compositions of the present disclosure comprise mesenchymal precursor cell lines or stem cells that are not genetically modified. As used herein, the term "not genetically modified" refers to cells that have not been modified by transfection with a nucleic acid. For the avoidance of doubt, in the context of the present disclosure, mesenchymal precursor cells or stem cells that have been transfected with a nucleic acid encoding a protein are considered to be genetically modified.

[0045] Throughout this specification the term "comprising" or variations such as "comprises" or "comprising" will be understood to mean the inclusion of a stated element, integer or step, or group of elements, integers or steps, but not the exclusion of any other element, integer or step, or group of elements, integers or steps.

[0046] Throughout this specification, unless specifically stated otherwise or the context requires otherwise, a reference to a single step, composition of matter, group of steps or group of compositions of matter should be interpreted as encompassing one or more (i.e., one or more) of that step, composition of matter, group of steps or group of compositions of matter.

[0047] Those skilled in the art will understand that the disclosure described herein is susceptible to variations and improvements other than those specifically described. It is to be understood that the present disclosure includes all such variations and improvements. The present disclosure also includes all steps, features, compositions, and compounds referred to or shown herein, individually or collectively, and any and all combinations, or any two or more of said steps or features.

[0048] The present disclosure is not to be limited in scope by the specific embodiments described herein, which are for the purpose of illustration only. Functionally equivalent products, compositions, and methods are clearly within the scope of the present disclosure, as described herein.

[0049] Any example disclosed herein is intended to apply mutatis mutandis to any other example, unless expressly stated otherwise.

[0050] Opioid use The methods of the present disclosure are directed to a subject using opioids. In one embodiment, the subject is using opioids for pain. In one embodiment, the pain is chronic pain. For example, the pain may be lower back pain. Opioids are a group of analgesic drugs that exhibit opiate or morphine-like properties. In one embodiment, the opioids may be referred to as opioid receptor agonists.

[0051] Exemplary opioids include alfentanil, allylprodine, alphaprodine, anileridine, benzylmorphine, bezitramide, buprenorphine, butorphanol, clonitazene, codeine, desomorphine, dextromoramide, dezocine, diampromide, diamorphone, dihydrocodeine, dihydromorphine dimenoxadol, dimepheptanol, dimethylthiambutene, dioxaphetyl butyrate, dipipanone, eptazocine, ethoheptazine, ethylmethylthiambutene, ethylmorphine, etonitazene, fentanyl, heroin, hydrocodone, hydromorphone, hydroxypethidine, isomethadone. Examples of opioids include ketobemidone, levorphanol, levophenacylmorphan, lofentanil, meperidine, meptazinol, metazocine, methadone, metopon, morphine, myrophine, narceine, nicomorphine, norlevorphanol, normethadone, nalorphine, nalbufen, normorphine norpipanone, opium, oxycodone, oxymorphone, papaveretam, pentazocine, phenadoxone, phenomorphan, phenazocine, phenoperidine, piminodine, piritramide, propeptadine, promedol, properidine, propoxyphene, sufentanil, tilidine, tramadol, mixtures of any of the above, salts of any of the above, etc. In one embodiment, the opioid is morphine or an analog thereof that interacts with the morphine receptor.

[0052] In one embodiment, the subject has been using opioids for at least 1 month. In another embodiment, the subject has been using opioids for at least 3 months. In another embodiment, the subject has been using opioids for at least 6 months. In another embodiment, the subject has been using opioids for at least 12 months. In another embodiment, the subject has been using opioids for at least 24 months. In another embodiment, the subject has been using opioids for at least 36 months. In another embodiment, the subject has been using opioids for at least 48 months. In another embodiment, the subject has been using opioids for at least 60 months. In another embodiment, the subject has been using opioids for 6-78 months. In another embodiment, the subject has been using opioids for 6-70 months. In another embodiment, the subject has been using opioids for 6-68 months. In another embodiment, the subject has been opioid-free for more than 68 months.

[0053] In one embodiment, the subject has a mean baseline morphine equivalent dose (MED) of less than 75 mg / day. In one embodiment, the MED is determined by electronic diary entries by the subject.

[0054] In another embodiment, the subject has been using opioids for chronic low back pain for at least 6 months. In another embodiment, the subject has failed conservative low back pain care for at least 2 months, 3 months, 4 months, 5 months, or 6 months. Examples of conservative treatment regimes may include any or all of the following: initial rest, medication such as anti-inflammatory drugs, analgesics, narcotics / opioids, muscle relaxants, or interventions such as massage, acupuncture, chiropractic care, activity modification, and home lumbar exercise programs.

[0055] In another embodiment, subjects using opioids receive supervised physical therapy including routine gait training, therapeutic exercises, and a back pain education program specific to the treatment of back pain.

[0056] In another embodiment, the subject using opioids has a modified Pfirrmann score of 3, 4, 5, or 6 on MRI at the index disc and / or Modic grade II changes or less on MRI at the index disc. In one embodiment, the subject using opioids may or may not have a disc protrusion at the index disc on MRI.

[0057] In one embodiment, subjects using opioids can have back pain of at least 40 mm and no more than 90 mm out of 100 mm on a back pain VAS (average pain over a 24 hour period).

[0058] In another embodiment, the subject using opioids and having low back pain is associated with disc degeneration. In another embodiment, the low back pain is associated with an intervertebral disc. In one embodiment, the disc has a disc height that is not substantially reduced compared to that of adjacent healthy discs in the subject. In another embodiment, the low back pain is non-nerve root in origin and / or is associated with one or more of a herniated disc up to 3mm protrusion, nerve ingrowth into the disc, or inflammation of the disc. In one embodiment, the nerve ingrowth or inflammation is within the disc space, or the nucleus pulposus, or the fibrous annulus of the disc.

[0059] In another embodiment, the pain is axial pain. Thus, in one embodiment, the disclosure relates to a method of treating axial pain in a subject, the method comprising administering a composition of the disclosure. In an embodiment, the subject is using opioids. In one embodiment, the composition comprises MLPSC and HA. In one embodiment, the axial pain is leg pain. In one embodiment, the axial pain is due to nerve root compression as defined by MRI. In one embodiment, the subject has not reported chronic pain for more than 68 months. In another embodiment, the subject has not used opioids for more than 68 months.

[0060] Reducing pain, reducing opioid use, or increasing mobility In one embodiment, the method of the present disclosure reduces pain in a subject using opioids. In one embodiment, administering a composition of the present disclosure reduces the subject's visual analog scale (VAS) pain response. The VAS is a commonly used measurement device for measuring pain because it is useful for measuring a characteristic or consciousness that is considered to be in a continuous range of values ​​that cannot be easily measured directly. In short, the pain VAS is a unidimensional measure of pain intensity. The patient marks a point on the line that they feel represents their perception of their current pain state. The VAS score is determined by measuring in millimeters from the left end of the line to the point marked by the patient. The VAS score can be compared over time to measure changes in pain level. Thus, it can be a useful indicator of pain reduction. In one embodiment, administering a composition of the present disclosure reduces the subject's visual analog scale (VAS) pain response by 10%. In another embodiment, administering a composition of the present disclosure reduces the subject's VAS by 20%. In another embodiment, administering a composition of the present disclosure reduces the subject's VAS by 30%. In another embodiment, administering the composition of the present disclosure reduces the subject's VAS by 50%. In these embodiments, the reduction in VAS can be determined by comparison with a baseline VAS score obtained before the treatment disclosed herein. In one embodiment, the reduction in VAS is observed 12 months after treatment. In another embodiment, the reduction in VAS is observed 24 months after treatment.

[0061] In one embodiment, the subject has no significant pain after administration of the composition of the present disclosure. In one embodiment, the subject has no significant pain 12 months after administration of the composition of the present disclosure. In another embodiment, the subject has no significant pain 24 months after administration of the composition of the present disclosure.

[0062] The inventors have identified that the compositions of the present disclosure can be used as opioid sparing agents. Thus, in another embodiment, the methods of the present disclosure reduce opioid use in a subject. In one embodiment, opioid use is reduced one month after administration of the composition. In another embodiment, opioid use is reduced three months after administration of the composition. In another embodiment, opioid use is reduced six months after administration of the composition. In another embodiment, opioid use is reduced 12 months after administration of the composition. In another embodiment, opioid use is reduced 18 months after administration of the composition. In another embodiment, opioid use is reduced 24 months after administration of the composition. In another embodiment, opioid use is reduced 36 months after administration of the composition. In one embodiment, the subject's opioid use is reduced relative to baseline opioid use prior to administration of the composition of the present disclosure. For example, a subject's opioid use can be reduced relative to the subject's average baseline morphine equivalents prior to administration of the composition.

[0063] In one embodiment, the subject's opioid use is reduced by about 20% relative to baseline opioid use prior to administration of the composition. In another embodiment, the subject's opioid use is reduced by about 30% relative to baseline opioid use prior to administration of the composition. In another embodiment, the subject's opioid use is reduced by about 40% relative to baseline opioid use prior to administration of the composition. In one embodiment, the opioid is morphine and the reduction is relative to the subject's average baseline morphine equivalents prior to administration of the composition.

[0064] In one embodiment, the subject discontinues opioid use after administration of the composition of the present disclosure. In one embodiment, the subject discontinues opioid use 12 months after administration of the composition of the present disclosure. In another embodiment, the subject discontinues opioid use 18 months after administration of the composition of the present disclosure. In another embodiment, the subject discontinues opioid use 24 months after administration of the composition of the present disclosure. In another embodiment, the subject discontinues opioid use 36 months after administration of the composition of the present disclosure. In another embodiment, the subject discontinues opioid use 18-36 months after administration of the composition of the present disclosure.

[0065] In one embodiment, the disclosed method increases mobility and / or function in a subject using opioids. In one embodiment, mobility and / or function is described as the subject's function according to well-established measures of this standard, such as ODI and / or EQ-5D. In one embodiment, administration of the disclosed composition increases the subject's EuroQol-5 Dimension (EQ-5D) score from baseline. Thus, in one embodiment, the disclosed method increases the EQ-5D score in a subject using opioids. The EQ-5D provides a simple descriptive profile of health status and a single index value. The EQ-5D self-report questionnaire includes a visual analog scale (VAS) that records the respondent's self-assessed health status on a graded (0-100) scale, with higher scores indicating a better health-related quality of life. In certain embodiments, the EQ-5D also includes an EQ-5D descriptive system, which includes five dimensions of health: mobility, self-care, usual activities, pain / discomfort, and anxiety / depression. This descriptive system can be used as a health profile or converted into an index score representing the von Neumann-Mogenstern utility score for current health (EQ-5D index).

[0066] In one embodiment, the EQ-5D is increased for at least 1-6 months. In one embodiment, the EQ-5D is increased for at least 6-12 months. In one embodiment, the EQ-5D is increased by at least 0.01. In one embodiment, the EQ-5D is increased by at least 0.02. In one embodiment, the EQ-5D is increased by at least 0.03. In one embodiment, the EQ-5D is increased by 0.01-0.04. In one embodiment, the increase is determined based on the EQ-5D VAS.

[0067] In another embodiment, administering a composition of the present disclosure may reduce a subject's ODI score. In one embodiment, the ODI is reduced by at least 10 or at least 15 points for at least 1-6 months. In one embodiment, the ODI is reduced by at least 10 or at least 15 points for at least 6-12 months. In another embodiment, the ODI is reduced by at least 10 or at least 15 points for at least 24 months.

[0068] In another embodiment, the method of the present disclosure relates to treating a subject, the method comprising administering a composition of the present disclosure and an opioid, wherein multiple doses of the opioid are administered to the subject, and the dose of the opioid is decreased over the course of treatment, for example, the dose of the opioid can be decreased by about 20-50% over the course of treatment following administration of a composition of the present disclosure.

[0069] In another embodiment, the present disclosure relates to a method of reducing opioid use in a subject, the method comprising administering a composition of the present disclosure. For example, the method can comprise administering a composition comprising MLPSCs and HA. In one embodiment, the subject has chronic back pain. In one embodiment, the subject has been free of chronic back pain for 68 months or more. In one embodiment, opioid use is reduced 12-36 months after administration of the composition of the present disclosure. In one embodiment, the reduction in opioid use is sustained 36 months after administration of the composition of the present disclosure. In one embodiment, opioid use is discontinued 18-36 months after administration of the composition of the present disclosure.

[0070] Mesenchymal progenitor cells The term "mesenchymal precursor or stem cell (MLPSC)" as used herein refers to an undifferentiated multipotent cell that has the ability to self-renew while maintaining pluripotency and to differentiate into several cell types of mesenchymal origin, such as osteoblasts, chondrocytes, adipocytes, stromal cells, fibroblasts and tendons, or non-mesodermal origin, such as hepatocytes, neural cells and epithelial cells. For the avoidance of doubt, "mesenchymal precursor cell" refers to a cell that can differentiate into mesenchymal cells such as bone, cartilage, muscle and adipocytes, and fibrous connective tissue.

[0071] The term "mesenchymal precursor or stem cells" includes both parent cells and their undifferentiated progeny. The term also includes mesenchymal precursor cells, multipotent stromal cells, mesenchymal stem cells (MSCs), perivascular mesenchymal precursor cells, and their undifferentiated progeny.

[0072] Mesenchymal precursor or stem cells can be autologous, allogeneic, xenogeneic, syngeneic, or homogeneous. Autologous cells are isolated from the same individual into whom they will be reimplanted. Allogeneic cells are isolated from a donor of the same species. Xenogeneic cells are isolated from a donor of another species. Syngeneic or homogeneous cells are isolated from genetically identical organisms, such as twins, clones, or highly inbred research animal models.

[0073] In one embodiment, the mesenchymal precursor or stem cells are allogeneic. In one embodiment, the allogeneic mesenchymal precursor or stem cells are culture-expanded and cryopreserved.

[0074] Mesenchymal progenitor or stem cells are primarily found in bone marrow, but have also been shown to be present in a variety of host tissues, including, for example, umbilical cord blood and umbilical cord, adult peripheral blood, adipose tissue, trabecular bone, and dental pulp. They are also found in the skin, spleen, pancreas, brain, kidney, liver, heart, retina, brain, hair follicles, intestine, lung, lymph nodes, thymus, ligaments, tendons, skeletal muscle, dermis, and periosteum, and can differentiate into germ lineages such as mesoderm and / or endoderm and / or ectoderm. Thus, progenitor or stem cells of the mesenchymal lineage can differentiate into a number of cell types, including, but not limited to, adipose tissue, bone tissue, cartilage tissue, elastic tissue, muscle tissue, and fibrous connective tissue. The specific lineage commitment and differentiation pathway that these cells enter depends on various influences from mechanical influences and / or endogenous bioactive factors such as growth factors, cytokines, and / or local microenvironmental conditions established by the host tissue.

[0075] The terms "enriched", "enriched", or variations thereof, are used herein to describe a cell population in which the percentage of one particular cell type or the percentage of multiple particular cell types is increased when compared to an untreated population of cells (e.g., the cells in their natural environment). In one example, a population enriched for mesenchymal progenitor or stem cells comprises at least about 0.1%, 0.5%, 1%, 2%, 5%, 10%, 15%, 20%, 25%, 30%, 50%, or 75% mesenchymal progenitor or stem cells. In this regard, the term "a population of cells enriched for mesenchymal progenitor or stem cells" is used to give explicit support to the term "a population of cells comprising X% mesenchymal progenitor or stem cells", where X% is a percentage described herein. Mesenchymal progenitor or stem cells, in some embodiments, can form clonogenic colonies, e.g., CFU-F (fibroblasts) or a subset thereof (e.g., 50% or 60% or 70% or 70% or 90% or 95%) can have this activity.

[0076] In one embodiment of the present disclosure, the mesenchymal lineage precursors or stem cells are mesenchymal stem cells (MSCs). The MSCs may be a homogenous composition or a mixed cell population enriched in MSCs. The homogenous MSC composition may be obtained by culturing adherent bone marrow or periosteal cells, and the MSCs may be identified by specific cell surface markers identified with unique monoclonal antibodies. Methods for obtaining cell populations enriched in MSCs are described, for example, in U.S. Pat. No. 5,486,359. Alternative sources of MSCs include, but are not limited to, blood, skin, umbilical cord blood, muscle, fat, bone, and perichondrium. In one embodiment, the MSCs are allogeneic. In one embodiment, the MSCs are cryopreserved. In one embodiment, the MSCs are culture-expanded and cryopreserved.

[0077] In another embodiment, the mesenchymal progenitor or stem cells are CD29+, CD54+, CD73+, CD90+, CD102+, CD105+, CD106+, CD166+, MHC1+ MSCs.

[0078] The isolated or enriched mesenchymal progenitor or stem cells can be expanded in vitro by culture. The isolated or enriched mesenchymal progenitor or stem cells can be cryopreserved, thawed, and then expanded in vitro by culture.

[0079] In one example, isolated or enriched mesenchymal progenitor or stem cells are cultured in culture medium (serum-free or serum-supplemented), for example, alpha minimum essential medium (αMEM) supplemented with 5% fetal bovine serum (FBS) and glutamine at a concentration of 50,000 viable cells / cm. 2 Cells are seeded at 37 °C and allowed to attach to the culture vessel overnight at 37 °C and 20% O. The culture medium is then exchanged and / or changed as necessary, and the cells are cultured for an additional 68-72 h at 37 °C and 5% O.

[0080] As will be appreciated by those skilled in the art, cultured mesenchymal precursor or stem cells are phenotypically distinct from in vivo cells. For example, in one embodiment, they express one or more of the following markers: CD44, NG2, DC146, and CD140b. Cultured mesenchymal precursor or stem cells are also biologically distinct from in vivo cells, having a higher proliferation rate compared to most non-cycling (quiescent) cells in vivo.

[0081] In one example, a population of cells is enriched from a cell preparation that contains STRO-1+ cells in a selectable morphology. In this context, the term "selectable morphology" is understood to mean that the cells express a marker (e.g., a cell surface marker) that allows for the selection of STRO-1+ cells. The marker may be, but does not necessarily have to be, STRO-1. For example, as described and / or exemplified herein, cells (e.g., mesenchymal precursor cells) that express STRO-2 and / or STRO-3 (TNAP) and / or STRO-4 and / or VCAM-1 and / or CD146 and / or 3G5 also express STRO-1 (and may be STRO-1 bright). Thus, indicating that a cell is STRO-1+ does not mean that the cell is selected solely by STRO-1 expression. In one example, the cell is selected based on at least STRO-3 expression, e.g., STRO-3+ (TNAP+).

[0082] Reference to the selection of cells or populations thereof does not necessarily require selection from a particular tissue source. As described herein, STRO-1+ cells may be selected, isolated, or enriched from a wide variety of sources. That said, in some examples, these terms indicate support for selection from any tissue comprising STRO-1+ cells (e.g., mesenchymal progenitor cells) or vascular tissue or pericytes (e.g., STRO-1+ pericytes), or any one or more of the tissues described herein.

[0083] In one example, the cells used in the present disclosure express one or more markers individually or collectively selected from the group consisting of TNAP+, VCAM-1+, THY-1+, STRO-2+, STRO-4+(HSP-90β), CD45+, CD146+, 3G5+, or any combination thereof.

[0084] "Individually" means that the present disclosure encompasses each listed marker or group of markers individually, and notwithstanding that each marker or group of markers may not be individually listed herein, the appended claims may define such markers or groups of markers individually and divisibly from one another.

[0085] "Collectively" means that the disclosure encompasses any number or combination of the listed markers or groups of markers, and notwithstanding that such number or combination of markers or groups of markers may not be specifically recited herein, the appended claims may define such combinations or subcombinations separately and divisible from any other combinations of markers or groups of markers.

[0086] As used herein, the term "TNAP" is intended to encompass all isoforms of tissue non-specific alkaline phosphatase. For example, the term encompasses the liver isoform (LAP), the bone isoform (BAP), and the kidney isoform (KAP). In one embodiment, TNAP is BAP. In one embodiment, as used herein, TNAP refers to a molecule capable of binding to STRO-3 antibody produced by the hybridoma cell line deposited with ATCC on December 19, 2005 under the provisions of the Budapest Treaty (deposit accession number PTA-7282).

[0087] Furthermore, in one embodiment, STRO-1+ cells are capable of giving rise to clonogenic CFU-F.

[0088] In one embodiment, a significant proportion of STRO-1+ cells are capable of differentiation into at least two different germ lineages. Non-limiting examples of lineages into which STRO-1+ cells may commit include bone progenitor cells, hepatocyte progenitors that are multipotent for bile duct epithelial cells and hepatocytes, neural restricted cells that can generate glial progenitors that progress to oligodendrocytes and astrocytes, neuronal progenitors that progress to neurons, cardiac and cardiac progenitors, glucose-responsive insulin-secreting pancreatic beta cell lines, etc. Other lineages include, but are not limited to, odontoblasts, dentin-producing cells and chondrocytes, as well as the following progenitor cells: retinal pigment epithelial cells, fibroblasts, skin cells such as keratinocytes, dendritic cells, hair follicle cells, renal ductal epithelial cells, smooth and skeletal muscle cells, testicular progenitor cells, vascular endothelial cells, tendons, ligaments, cartilage, adipocytes, fibroblasts, bone marrow stroma, cardiac muscle, smooth muscle, skeletal muscle, pericytes, blood vessels, epithelium, glia, neurons, astrocytes and oligodendrocytes.

[0089] In one embodiment, mesenchymal precursor or stem cells are obtained from a single donor or multiple donors, and the donor samples or mesenchymal precursor or stem cells are subsequently pooled and then expanded in culture.

[0090] The mesenchymal precursor or stem cells encompassed by the present disclosure may also be cryopreserved prior to administration to a subject, hi one example, the mesenchymal precursor or stem cells are culture-expanded and cryopreserved prior to administration to a subject.

[0091] In one embodiment, the present disclosure encompasses mesenchymal precursor or stem cells, as well as their progeny, soluble factors derived therefrom, and / or extracellular vesicles isolated therefrom. In another embodiment, the present disclosure encompasses mesenchymal precursor or stem cells, as well as extracellular vesicles isolated therefrom. For example, the mesenchymal precursor or stem cells of the present disclosure can be expanded for a period of time and under conditions suitable for secretion of the extracellular vesicles into the cell culture medium. The secreted extracellular vesicles can then be obtained from the culture medium for use in therapy.

[0092] As used herein, the term "extracellular vesicles" refers to lipid particles that are naturally released from cells and range in size from about 30 nm to 10 microns, but usually they are less than 200 nm. They may contain proteins, nucleic acids, lipids, metabolites, or organelles from the releasing cells (e.g., mesenchymal stem cells, STRO-1+ cells).

[0093] As used herein, the term "exosome" refers to a type of extracellular vesicle, generally about 30 nm to about 150 nm in size, derived from endosomal vesicle compartments that are transported to and released from the plasma membrane of mammalian cells. They contain nucleic acids (e.g., RNA, microRNA), proteins, lipids, and metabolites, and function in intercellular communication by being secreted from one cell and taken up by other cells to carry cargo.

[0094] In one embodiment, the compositions of the present disclosure include cells that induce new blood vessel formation in a target tissue.

[0095] Cell culture growth In one embodiment, the mesenchymal progenitor or stem cells are cultured and expanded. "Cultured and expanded" mesenchymal progenitor or stem cell cultures are distinct from freshly isolated cells in that they have been cultured and subcultured (i.e., recultured) in cell culture medium. In one embodiment, the cultured and expanded mesenchymal progenitor or stem cells are cultured and expanded for about 4-10 passages. In one embodiment, the mesenchymal progenitor or stem cells are cultured and expanded for at least 5, at least 6, at least 7, at least 8, at least 9, at least 10 passages. For example, the mesenchymal progenitor or stem cells can be cultured and expanded for at least 5 passages. In one embodiment, the mesenchymal progenitor or stem cells can be cultured and expanded for at least 5-10 passages. In one embodiment, the mesenchymal progenitor or stem cells can be cultured and expanded for at least 5-8 passages. In one embodiment, the mesenchymal progenitor or stem cells can be cultured and expanded for at least 5-7 passages. In one example, the mesenchymal progenitor or stem cells can be expanded in culture for more than 10 passages. In another example, the mesenchymal progenitor or stem cells can be expanded in culture for more than 7 passages. In these examples, the stem cells can be expanded in culture before being cryopreserved, providing an intermediate cryopreserved MLPSC population. In one example, the compositions of the present disclosure are produced by culturing cells from an intermediate cryopreserved MLPSC population, or stated alternatively, a cryopreservation intermediate.

[0096] In one embodiment, the composition of the present disclosure includes mesenchymal precursor or stem cells that are cultured and expanded from a cryopreserved intermediate. In one embodiment, the cell culture expanded from a cryopreserved intermediate is cultured and expanded for at least 5, at least 6, at least 7, at least 8, at least 9, at least 10 passages. For example, the mesenchymal precursor or stem cells can be cultured and expanded for at least 5 passages. In one embodiment, the mesenchymal precursor or stem cells can be cultured and expanded for at least 5-10 passages. In one embodiment, the mesenchymal precursor or stem cells can be cultured and expanded for at least 5-8 passages. In one embodiment, the mesenchymal precursor or stem cells can be cultured and expanded for at least 5-7 passages. In one embodiment, the mesenchymal precursor or stem cells can be cultured and expanded for more than 10 passages. In another embodiment, the mesenchymal precursor or stem cells can be cultured and expanded for more than 7 passages.

[0097] In one embodiment, mesenchymal precursor or stem cell cultures expanded from cryopreserved intermediates can be grown in culture in medium that is free of animal proteins. In one embodiment, mesenchymal precursor or stem cell cultures expanded from cryopreserved intermediates can be grown in xeno-free medium. In one embodiment, mesenchymal precursor or stem cell cultures expanded from cryopreserved intermediates can be grown in medium that is free of fetal bovine serum.

[0098] In one embodiment, the mesenchymal precursor or stem cells can be obtained from a single donor or multiple donors, and the donor samples or the mesenchymal precursor or stem cells are subsequently pooled and then culture expanded. In one example, the culture expansion process comprises: i. expanding the number of viable cells by serial expansion to provide a preparation of at least about 1 billion viable cells, which serial expansion includes establishing a primary culture of the isolated mesenchymal progenitor or stem cells and then serially establishing a first non-primary (P1) culture of the isolated mesenchymal progenitor or stem cells from the previous culture; ii. expanding the P1 culture of isolated mesenchymal progenitor or stem cells by passage expansion into a second, non-primary (P2) culture of mesenchymal progenitor or stem cells; iii. Preparing and cryopreserving in-process mesenchymal progenitor or stem cell preparations obtained from P2 cultures of mesenchymal progenitor or stem cells; iv. thawing the cryopreserved in-process intermediate mesenchymal precursor or stem cell preparation and expanding the in-process mesenchymal precursor or stem cell preparation by sub-expansion.

[0099] In one example, the expanded mesenchymal precursor or stem cell preparation has an antigenic and activity profile comprising: i. less than about 0.75% CD45+ cells; ii. at least about 95% CD105+ cells; iii. At least about 95% CD166+ cells.

[0100] In one example, the expanded mesenchymal precursor or stem cell preparation is capable of inhibiting IL2-Rα expression by CD3 / CD28-activated PBMCs by at least about 30% compared to a control.

[0101] In one embodiment, the cultured expanded mesenchymal progenitor or stem cells are cultured and expanded for about 4-10 passages, where the mesenchymal progenitor or stem cells are cryopreserved after at least 2 or 3 passages before being further cultured and expanded. In one embodiment, the mesenchymal progenitor or stem cells are cultured and expanded at least once, at least twice, at least three times, at least four times, at least five times, cryopreserved, and then cultured at least once, at least twice, at least three times, at least four times, at least five times, before being cultured according to the disclosed method.

[0102] The process of mesenchymal precursor or stem cell isolation and ex vivo expansion can be carried out using any device and cell handling method known in the art. Various culture expansion embodiments of the present disclosure use steps that require cell manipulation, such as seeding, feeding, dissociation of adherent cultures, or washing steps. Steps that manipulate cells can damage the cells. Although mesenchymal precursor or stem cells can generally tolerate some damage during preparation, it is preferable to manipulate the cells by handling procedures and / or devices that properly perform a given step while minimizing damage to the cells.

[0103] In one example, the mesenchymal precursor or stem cells are washed in an apparatus including a cell source bag, a wash solution bag, a recirculating wash bag, a spun membrane filter with inlet and outlet ports, a filtrate bag, a mixing zone, a final product bag for the washed cells, and appropriate tubing, for example as described in U.S. Pat. No. 6,251,295, which is incorporated herein by reference.

[0104] In one example, mesenchymal progenitor or stem cell compositions cultured according to the present disclosure are 95% homogeneous with respect to being CD105 positive, CD166 positive, and CD45 negative, and in one example, this homogeneity persists through ex vivo expansion, i.e., doubling of multiple populations.

[0105] In one embodiment, the mesenchymal precursor or stem cells of the present disclosure are grown in 3D culture. For example, the mesenchymal precursor or stem cells of the present disclosure can be grown in a bioreactor. In one embodiment, the mesenchymal precursor or stem cells of the present disclosure are first grown in 2D culture and then further grown in 3D culture. In one embodiment, the mesenchymal precursor or stem cells of the present disclosure are grown from a master cell bank. In one embodiment, the mesenchymal precursor or stem cells of the present disclosure are grown from a master cell bank in 2D culture before seeding in 3D culture. In one embodiment, the mesenchymal precursor or stem cells of the present disclosure are grown from a master cell bank in 2D culture for at least 3 days before seeding in 3D culture in a bioreactor. In one embodiment, the mesenchymal precursor or stem cells of the present disclosure are grown from a master cell bank in 2D culture for at least 4 days before seeding in 3D culture in a bioreactor. In one embodiment, mesenchymal progenitor or stem cells of the present disclosure are culture expanded from a master cell bank in 2D culture for 3-5 days and then seeded into 3D culture in a bioreactor. In these embodiments, the 2D culture may be performed in a cell factory. Various cell factory products are commercially available (e.g., Thermofisher, Sigma).

[0106] Cell culture media The mesenchymal precursor or stem cells disclosed herein can be cultured and grown in a variety of suitable growth media.

[0107] As used in the context of this disclosure, the term "medium" or "media" includes components of the environment surrounding cells. A medium contributes and / or provides suitable conditions to allow cells to grow. A medium can be a solid, liquid, gas, or a mixture of phases and materials. A medium can include liquid growth media as well as liquid media that do not support cell growth. Media also include gelatinous media such as agar, agarose, gelatin, and collagen matrices. Exemplary gaseous media include the gaseous phase to which cells growing on a Petri dish or other solid or semi-solid support are exposed.

[0108] The cell culture medium used for culture growth contains all essential and may also contain non-essential amino acids. Generally, amino acids are classified as essential (Thr, Met, Val, Leu, Ile, Phe, Trp, Lys, His) and non-essential (Gly, Ala, Ser, Cys, Gln, Asn, Asp, Tyr, Arg, Pro).

[0109] Those skilled in the art will understand that for optimal results, the basal medium must be appropriate for the cell line of interest. For example, it may be necessary to increase the level of glucose (or other energy source) in the basal medium, or to add glucose (or other energy source) during the course of the culture if it is found to be depleted and thus limiting growth. In one embodiment, dissolved oxygen (DO) levels may also be controlled.

[0110] In one embodiment, the cell culture medium contains additives of human origin, for example, human serum and human platelet cell lysate can be added to the cell culture medium.

[0111] In one embodiment, the cell culture medium contains only human-derived additives. Thus, in the embodiment, the cell culture medium is xeno-free. For the avoidance of doubt, in these embodiments, the culture medium does not contain animal protein. In one embodiment, the cell culture medium used in the methods of the present disclosure does not contain animal components.

[0112] In one embodiment, the medium comprises serum. In another embodiment, the culture medium is a fetal bovine serum-free culture medium that comprises growth factors that promote mesenchymal progenitor or stem cell proliferation. In one embodiment, the medium is a serum-free stem cell medium. In one embodiment, the cell culture medium comprises: A basal medium; Platelet-derived growth factor (PDGF) and and fibroblast growth factor 2 (FGF2).

[0113] In one embodiment, the medium includes platelet derived growth factor (PDGF) and fibroblast growth factor 2 (FGF2), and the level of FGF2 is less than about 6 ng / ml. For example, the FGF2 level can be less than about 5 ng / ml, less than about 4 ng / ml, less than about 3 ng / ml, less than about 2 ng / ml, or less than about 1 ng / ml. In other embodiments, the FGF2 level is less than about 0.9 ng / ml, less than about 0.8 ng / ml, less than about 0.7 ng / ml, less than about 0.6 ng / ml, less than about 0.5 ng / ml, less than about 0.4 ng / ml, less than about 0.3 ng / ml, or less than about 0.2 ng / ml.

[0114] In another embodiment, the level of FGF2 is about 1 pg / ml to 100 pg / ml, hi another embodiment, the level of FGF2 is about 5 pg / ml to 80 pg / ml.

[0115] In one embodiment, the PDGF is PDGF-BB. In one embodiment, the level of PDGF-BB is about 1 ng / ml to 150 ng / ml. In another embodiment, the level of PDGF-BB is about 7.5 ng / ml to 120 ng / ml. In another embodiment, the level of PDGF-BB is about 15 ng / ml to 60 ng / ml. In another embodiment, the level of PDGF-BB is at least about 10 ng / ml. In another embodiment, the level of PDGF-BB is at least about 15 ng / ml. In another embodiment, the level of PDGF-BB is at least about 20 ng / ml. In another embodiment, the level of PDGF-BB is at least about 21 ng / ml. In another embodiment, the level of PDGF-BB is at least about 22 ng / ml. In another embodiment, the level of PDGF-BB is at least about 23 ng / ml. In another embodiment, the level of PDGF-BB is at least about 24 ng / ml. In another embodiment, the level of PDGF-BB is at least about 25 ng / ml.

[0116] In another embodiment, the PDGF is PDGF-AB. In one embodiment, the level of PDGF-AB is about 1 ng / ml to 150 ng / ml. In another embodiment, the level of PDGF-AB is about 7.5 ng / ml to 120 ng / ml. In another embodiment, the level of PDGF-AB is about 15 ng / ml to 60 ng / ml. In another embodiment, the level of PDGF-AB is at least about 10 ng / ml. In another embodiment, the level of PDGF-AB is at least about 15 ng / ml. In another embodiment, the level of PDGF-AB is at least about 20 ng / ml. In another embodiment, the level of PDGF-AB is at least about 21 ng / ml. In another embodiment, the level of PDGF-AB is at least about 22 ng / ml. In another embodiment, the level of PDGF-AB is at least about 23 ng / ml. In another embodiment, the level of PDGF-AB is at least about 24 ng / ml. In another embodiment, the level of PDGF-AB is at least about 25 ng / ml.

[0117] In other embodiments, additional factors can be added to the cell culture medium. In one embodiment, the medium further comprises EGF. EGF is a growth factor that stimulates cell proliferation by binding to its receptor EGFR. In one embodiment, the method of the disclosure comprises culturing a population of stem cells in a cell culture medium that does not contain fetal bovine serum and further comprises EGF. In one embodiment, the level of EGF is about 0.1-7 ng / ml. For example, the level of EGF can be at least about 5 ng / ml.

[0118] In another embodiment, the level of EGF is between about 0.2 ng / ml and 3.2 ng / ml. In another embodiment, the level of EGF is between about 0.4 ng / ml and 1.6 ng / ml. In another embodiment, the level of EGF is between about 0.2 ng / ml. In another embodiment, the level of EGF is at least about 0.3 ng / ml. In another embodiment, the level of EGF is at least about 0.4 ng / ml. In another embodiment, the level of EGF is at least about 0.5 ng / ml. In another embodiment, the level of EGF is at least about 0.6 ng / ml. In another embodiment, the level of EGF is at least about 0.7 ng / ml. In another embodiment, the level of EGF is at least about 0.8 ng / ml. In another embodiment, the level of EGF is at least about 0.9 ng / ml. In another embodiment, the level of EGF is at least about 1.0 ng / ml.

[0119] In the above examples, a basal medium such as alphaMEM or StemSpan™ may be supplemented with the growth factors in the amounts referenced. In one example, the medium comprises alphaMEM or StemSpan™ supplemented with 32 ng / ml PDGF-BB, 0.8 ng / ml EGF, and 0.02 ng / ml FGF.

[0120] In other examples, additional factors may be added to the cell culture medium. For example, the cell culture medium may be supplemented with one or more stimulatory factors selected from the group consisting of epidermal growth factor (EGF), lα, 25-dihydroxyvitamin D3 (1.25D), tumor necrosis factor alpha (TNF-α), interleukin-1β (IL-1β), and stromal cell-derived factor lα (SDF-lα). In another embodiment, the cells may be cultured in the presence of at least one cytokine in an amount sufficient to support the growth of the cells. In another embodiment, the cells may be cultured in the presence of heparin or a derivative thereof. For example, the cell culture medium may contain about 50 ng / ml of heparin. In other examples, the cell culture medium comprises about 60 ng / ml heparin, about 70 ng / ml heparin, about 80 ng / ml heparin, about 90 ng / ml heparin, about 100 ng / ml heparin, about 110 ng / ml heparin, about 120 ng / ml heparin, about 130 ng / ml heparin, about 140 ng / ml heparin, about 150 ng / ml heparin or a derivative thereof. In one example, the heparin derivative is a sulfate. Various forms of heparin sulfate are known in the art, including heparin sulfate 2 (HS2). HS2 can be derived from a variety of sources, including, for example, the liver of male and / or female mammals. Thus, exemplary heparin sulfates include male liver heparin sulfate (MML HS) and female liver heparin sulfate (FML HS).

[0121] In another embodiment, the cell culture medium of the present disclosure promotes the proliferation of stem cells while maintaining them in an undifferentiated state. Stem cells are considered undifferentiated if they are not committed to a specific differentiation lineage. As discussed above, stem cells exhibit morphological characteristics that distinguish them from differentiated cells. Furthermore, undifferentiated stem cells express genes that can be used as markers to detect the differentiation state. The polypeptide products can also be used as markers to detect the differentiation state. Thus, one skilled in the art can easily determine whether the method of the present disclosure maintains stem cells in an undifferentiated state using routine morphological, genetic, and / or proteomic analysis.

[0122] Cellular modification The mesenchymal precursor or stem cells disclosed herein can be modified in such a way that lysis of the cells is inhibited upon administration. Alteration of the antigen can induce immunological unresponsiveness or tolerance, thereby preventing induction of the effector phase of the immune response (e.g., cytotoxic T cell production, antibody production, etc.) that ultimately leads to rejection of foreign cells in normal immune responses. Antigens that can be modified to achieve this goal include, for example, MHC class I antigens, MHC class II antigens, LFA-3, and ICAM-1.

[0123] Mesenchymal progenitor or stem cells may also be genetically modified to express proteins important for the differentiation and / or maintenance of linear skeletal muscle cells. Exemplary proteins include growth factors (TGF-β, insulin-like growth factor 1 (IGF-1), FGF), myogenic factors (e.g., myoD, myogenin, myogenic factor 5 (Myf5), myogenic regulatory factors (MRF)), transcription factors (e.g., GATA-4), cytokines (e.g., cardiotropin-1), members of the neuregulin family (e.g., neuregulin 1, 2, and 3), and homeobox genes (e.g., Csx, Suzman, and NKx families).

[0124] composition In one embodiment, the disclosure encompasses an opioid-sparing composition comprising mesenchymal precursor or stem cells (MLPSCs) and hyaluronic acid (HA). In one embodiment, the composition is administered and then the opioid is sparing after administration. For example, the opioid may be sparing after 3 months. In another embodiment, the opioid may be sparing after 6 months. In another embodiment, the opioid may be sparing after 12 months. In another embodiment, the opioid may be sparing after 18 months. In another embodiment, the opioid may be sparing after 24 months. In another embodiment, the opioid may be sparing at 36 months. In another embodiment, the opioid may be stopped at 18 months. In another embodiment, the opioid may be stopped at 36 months.

[0125] In one embodiment, the opioid-sparing composition comprises 1% HA. In another embodiment, the opioid-sparing composition is administered to a subject who is using opioids. For example, the subject may be using an opioid for the treatment of pain.

[0126] The mesenchymal or stem cells disclosed herein may be culture expanded from a cryopreserved intermediate to generate a preparation containing at least one therapeutic dose. In one embodiment, the disclosed method involves administration of one dose. In other embodiments, two or more doses are administered.

[0127] In one embodiment, the composition of the present disclosure is 10×10 6 ~35×10 6 In another embodiment, the composition comprises 20×10 6 pieces~30×10 6 In another embodiment, the composition comprises at least 5 million cells. In another embodiment, the composition comprises at least 6 million cells.

[0128] In one embodiment, the compositions of the present disclosure include a pharma- ceutically acceptable carrier and / or excipient. The terms "carrier" and "excipient" refer to a composition of matter conventionally used in the art to facilitate the storage, administration, and / or biological activity of an active compound (see, e.g., Remington's Pharmaceutical Sciences, 16th Ed., Mac Publishing Company (1980)). A carrier may also reduce any undesirable side effects of an active compound. A suitable carrier is, for example, stable, e.g., incapable of reacting with other components within the carrier. In one embodiment, a carrier does not cause significant local or systemic adverse effects in a recipient at the dosages and concentrations used in therapy.

[0129] Suitable carriers for the present disclosure include those conventionally used, such as water, saline, aqueous dextrose, lactose, Ringer's solution, buffer solutions, hyaluronan and glycols are exemplary liquid carriers for solutions, particularly (when isotonic). Suitable pharmaceutical carriers and excipients include starch, cellulose, glucose, lactose, sucrose, gelatin, malt, rice, flour, chalk, silica gel, magnesium stearate, sodium stearate, glycerol monostearate, sodium chloride, glycerol, propylene glycol, water, ethanol, and the like.

[0130] In another example, the carrier is, for example, a media composition in which the cells are grown or suspended. Such a media composition does not induce any adverse effects in the subject to which it is administered. Exemplary carriers and excipients do not adversely affect the viability of the cells and / or the ability of the cells to treat or prevent a disease.

[0131] In one example, the carrier or excipient provides buffering activity to maintain the cells and / or soluble factors at a suitable pH, thereby exerting biological activity, for example, the carrier or excipient is phosphate buffered saline (PBS). PBS represents an attractive carrier or excipient since it minimizes cell and factor interaction, allowing for rapid release of cells and factors; in such cases, the compositions of the present disclosure can be prepared as a liquid for application directly to the bloodstream or to tissues or areas surrounding or adjacent to the tissue, for example, by injection.

[0132] The compositions of the present disclosure may be cryopreserved. Cryopreservation of mesenchymal progenitor or stem cells may be performed using slow cooling methods or "fast" freezing protocols known in the art. Preferably, the cryopreservation method maintains similar phenotype, cell surface markers, and growth rate of the cryopreserved cells compared to unfrozen cells.

[0133] The cryopreserved composition may contain a cryopreservation solution, the pH of which is usually 6.5 to 8, preferably 7.4.

[0134] The silo storage solution may comprise a sterile, non-pyrogenic, isotonic solution, such as, for example, PlasmaLyte ATM. 100 mL of PlasmaLyte ATM contains 526 mg Sodium Chloride, USP (NaCl); 502 mg Sodium Gluconate (C6H11NaO7); 368 mg Sodium Acetate, USP (C2H3NaO2·3H2O); 37 mg Potassium Chloride, USP (KCl); and 30 mg Magnesium Chloride, USP (MgCl2·6H2O). No antimicrobial agents are included. The pH is adjusted with sodium hydroxide. The pH is 7.4 (6.5-8.0).

[0135] The cryopreservation solution may include Profreze™. The cryopreservation solution may additionally or alternatively include culture medium, such as αMEM.

[0136] To facilitate freezing, cryoprotectants such as dimethyl sulfoxide (DMSO) are usually added to the cryopreservation solution. Ideally, the cryoprotectant should be non-toxic to cells and patients, non-antigenic, chemically inert, provide high post-thaw survival rates, and allow transplantation without washing. However, the most commonly used cryoprotectant, DMSO, exhibits some cytotoxicity. Hydroxyethyl starch (HES) can be used as an alternative to or in combination with DMSO to reduce the cytotoxicity of the cryopreservation solution.

[0137] The cryopreservation solution may include one or more of DMSO, hydroxyethyl starch, human serum components, and other protein bulking agents. In one example, the cryopreserved solution includes a Plasma Digest A (70%), DMSO (10%), HSA (25%) solution, where the HSA solution includes 5% HSA and 15% buffer.

[0138] In one embodiment, the cryopreservation solution may further comprise one or more of methylcellulose, polyvinylpyrrolidone (PVP), and trehalose.

[0139] The cryopreserved composition may be thawed and administered directly to a subject or may be added to another solution that contains, for example, hyaluronic acid. Alternatively, the cryopreserved composition may be thawed and the mesenchymal precursor or stem cells resuspended in an alternative carrier prior to administration.

[0140] The compositions disclosed herein can be administered alone or as a mixture with other cells. Different types of cells can be mixed with the compositions of the present disclosure immediately before or after administration, or can be co-cultured prior to administration.

[0141] The exact amount of cells to be administered will depend on a variety of factors, including the age, weight, and sex of the subject, as well as the extent and severity of the disorder being treated.

[0142] Regardless of the number of cells provided in the composition, in one embodiment, 50×10 6 ~200×10 7 In another embodiment, 60×10 cells are administered. 6 ~200×10 6 Cells or 75 x 10 6 ~150×10 6 In one embodiment, 75×10 cells are administered. 6 In another embodiment, 150×10 cells are administered. 6 In these embodiments, the cells may be administered as a single dose or multiple doses.

[0143] In one embodiment, the composition comprises 5.00×10 6 In another embodiment, the composition comprises more than 5.50×10 viable cells / mL. 6 In another embodiment, the composition comprises more than 6.00×10 viable cells / mL. 6 In another embodiment, the composition comprises more than 6.50×10 viable cells / mL. 6 In another embodiment, the composition comprises more than 6.68×10 viable cells / mL. 6 Contains more than 10 viable cells / mL.

[0144] In one embodiment, the mesenchymal precursor or stem cells comprise at least about 5%, at least about 10%, at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, at least about 55%, at least about 60%, at least about 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, at least about 95%, at least about 99% of the cell population of the composition.

[0145] In one example, the composition may be optionally packaged in a suitable container with written instructions for a desired purpose.

[0146] The compositions of the present disclosure may be administered systemically, for example, by intravenous administration. In one embodiment, the composition is administered to the painful disc. In one embodiment, the compositions of the present disclosure are administered into the nucleus pulposus or into the annulus fibrosus of the disc.

[0147] It will be appreciated by those skilled in the art that numerous variations and / or modifications may be made to the invention as illustrated in the specific embodiments without departing from the spirit or scope of the invention as broadly described, and the present embodiments are therefore to be considered in all respects as illustrative and not restrictive.

[0148] All publications discussed and / or referenced herein are incorporated herein in their entirety.

[0149] This application claims priority to AU2021900147, filed January 22, 2021, AU2021900250, filed February 4, 2021, and US63 / 298,391, filed January 11, 2022, the disclosures of which are incorporated herein in their entireties.

[0150] Any discussion of documents, acts, materials, devices, articles or the like which has been included in the present specification is solely for the purpose of providing a context for the present invention and should not be construed as an admission that any or all of those matters formed part of the prior art base or were common general knowledge in the fields relevant to the present invention prior to the priority date of each claim in this application. EXAMPLES

[0151] composition The therapeutic composition contains allogeneic MPC derived from human bone marrow, expanded ex vivo and cryopreserved. The cells are either alone (MPC) or with 1% hyaluronic acid (HA) (MPC+HA).

[0152] patient Subjects with chronic low back pain (greater than 6 months) associated with moderate radiographic degenerative changes of the intervertebral disc. [Table 1] [Table 2] [Table 3]

[0153] Both MPC and MPC+HA treatments reduced mean VAS back pain in all patients using opioids relative to baseline. The most significant reductions were observed in subjects receiving MPC+HA. Indeed, MPC+HA had a significantly greater mean pain reduction from baseline at all time points over 36 months compared to placebo (Figures 1 and 28). More broadly (Figure 29), treatment with MPC+HA reduced mean VAS back pain in all patients relative to baseline at 12 months (p=0.0162) and 24 months (p=0.0426).

[0154] Despite instructions not to change their treatment regimen, patients who were using opioids and were treated with MPC+HA demonstrated a reduction in opioid use of approximately 40% over 24 months. In these patients, MPC+HA was significantly -mean VAS score was reduced (Figure 1); -The proportion of VAS responders increased by 50% and 30% (Figure 2); The proportion of patients with minimal / no pain at 12 and 24 months increased (Figure 3). Pain responders, defined as subjects who had a 50% reduction in low back pain VAS score from baseline and had not received any post-treatment intervention by the time of evaluation, were: - Mean EQ-5D score increased (Figures 4 and 5), The proportion of patients who achieved a composite of treatment success in pain and function by 24 months increased (Figures 6-8). For LBP-ODI treatment success, overall success is defined as a 50% reduction in LBPVAS score from baseline and a 15-point improvement in ODI score from baseline at both 12 and 24 months, and no post-treatment interventions by 24 months. For MIC, success is defined as a 30% reduction in LBPVAS score from baseline and a 10-point improvement in ODI score from baseline at both 12 and 24 months, and no post-treatment interventions by 24 months. For LBP-EQ5D, treatment success is defined as a 0.03 improvement in EQ5D at both 12 and 24 months, and a 50% reduction in VAS (overall) or a 30% reduction in VAS (MIC), and no interventions.

[0155] Notably, both MPC and MPC+HA reduced morphine milligram equivalents over 24 months in opioid users (FIGS. 9 and 10), with a significant reduction observed with MPC+HA (p=0.01).

[0156] Further analysis of treatment response in patients receiving MPC+HA - Over 24 months, the proportion of opioid users who achieved both VAS 30% and VAS 50% pain responses increased while reducing daily opioid use (Figures 11 and 12). Over 24 months, there was an increase in the proportion of opioid users achieving both an ODI 10 functional response (Figure 13), a 15 functional response (Figure 14), a VAS 30% + ODI 10 functional response (Figure 15), and a VAS 50% + ODI 15 functional response (Figure 16) while reducing daily opioid use. - The proportion of opioid users achieving a combined pain / functional response increased at both 12 and 24 months while opioid use also decreased (Figures 17 and 18).

[0157] Combined with the above findings, these data indicate that compositions comprising MLPSCs may be useful as opioid-sparing agents, particularly in the context of subjects with chronic pain, such as back pain. Given the persistent use of opioids in this patient population, and their ongoing side effects, this is an important finding. Analysis of opioid use followed for 24 months after administration of cell therapy provided further evidence that compositions comprising MLPSCs may be useful as opioid-sparing agents. 73.7% and 63.4% of patients receiving MPC+HA and MPC, respectively, reduced their use of pain medications. In contrast, only 50% of placebo patients reduced their use of pain medications (Figure 30). Notably, a significant increase in patients achieving opioid independence was observed at 18 months (p=0.0121) and 36 months (p=0.0075) after administration of MPC+HA (Figure 31). The sustained elimination of opioid use is remarkable and represents a particularly surprising result given the chronic nature of the pathology in these patients.

[0158] early intervention Single dose MPC treatment reduced pain in all patients through 36 months (Figures 19 and 32). The median duration of chronic low back pain (CLBP) in these patients was 68 months. Further analysis of data from patients with CLBP less than 68 months revealed that the MPC treatment effect (both MPC and MPC+HA) on pain was most pronounced in these patients (Figures 20, 21). In particular, the treatment effect on ODI function scores was most pronounced in patients with CLBP duration less than 68 months (Figure 21), especially in patients who were also opioid users (Figure 33). Furthermore, MPC treatment (both MPC and MPC+HA) reduced morphine equivalents over 36 months in opioid users (Figure 34). It is also noteworthy that administration of MPC+HA significantly increased the number of combined responders (30% VAS / 0.03 EQ5D) at 12 months (Figure 22, a trend towards an increase in the number of combined responders at 12 months was also observed in the MPC treatment group). Improvement in EQ5D was observed in patients with CLBP duration less than 68 months after both MPC and MPC+HA treatment (Figures 23-26, RHS indicates CLBP less than 68 months). These data are particularly promising as EQ5D may more effectively assess treatment response in the early stages of CLBP. In addition, MPC+HA administration increased the composite treatment success of pain / function (VAS / ODI) and pain / quality of life (VAS / EQ5D index) at both 12 and 24 months (Figure 27).

[0159] The most significant improvement in CLBP patients aged <68 months was observed after administration of MPC+HA. - Significantly reduce the mean VAS score, Significantly increased the proportion of VAS responders by 50% and 30%, Significantly increased the proportion of patients with minimal / no pain at 12 and 24 months - Significantly increase the mean EQ-5D score, Significantly increased the proportion of patients who achieved combined pain and function treatment success by 24 months.

[0160] Taken together, the above reference data indicate improved treatment outcomes for early intervention with cell therapy in CLBP patients, especially intervention before 68 months of CLBP.

[0161] Reduction of axial pain Both MPC (n=15) and MPC+HA (n=14) treatments reduced axial pain in patients with MRI-defined nerve root compression (Tables 1 and 2). These data support a method of reducing axial pain in subjects by administering MLPSCs, particularly in subjects with MRI-defined nerve root compression. [Table 4] [Table 5]

Claims

1. A pharmaceutical composition for reducing opioid use in a subject, comprising mesenchymal precursor or stem cells (MLPSCs), wherein the subject is using opioids.

2. The pharmaceutical composition of claim 1, comprising hyaluronic acid (HA).

3. The pharmaceutical composition of claim 1 or claim 2, wherein the subject is using an opioid for pain.

4. The pharmaceutical composition according to any one of claims 1 to 3, wherein the pain is chronic pain.

5. The pharmaceutical composition according to any one of claims 1 to 3, wherein the pain is lower back pain, preferably said lower back pain being associated with intervertebral disc degeneration.

6. The lower back pain is of non-radicular origin and / or is - Herniated disc with a maximum protrusion of 3 mm, - nerve ingrowth into the disc, - Intradiscal inflammation, The pharmaceutical composition of claim 5, wherein the composition is associated with one or more of the following:

7. 7. The pharmaceutical composition of claim 6, wherein the nerve ingrowth or inflammation is within the intervertebral disc space, or the nucleus pulposus, or the annulus fibrosus of the intervertebral disc.

8. The pharmaceutical composition of any one of claims 1 to 7, wherein opioid use is reduced 1 to 3 months after administration of the composition.

9. The pharmaceutical composition of any one of claims 1 to 7, wherein opioid use is reduced for at least 12 months following administration of the composition.

10. 9. The pharmaceutical composition of any one of claims 1 to 8, wherein opioid use is reduced relative to the subject's average baseline morphine equivalents prior to administration of the composition.

11. The pharmaceutical composition of any one of claims 1 to 10, wherein the subject has been using opioids for at least 1 month to 6 months prior to administration of the composition.

12. The pharmaceutical composition of any one of claims 1 to 11, wherein the opioid is morphine.

13. 13. The pharmaceutical composition of any one of claims 1-12, wherein the subject's opioid use is reduced by 20% to 40% relative to the subject's baseline opioid use prior to administration of the composition.

14. 14. The pharmaceutical composition of any one of claims 1 to 13, wherein the subject is opioid abstinent 12 to 24 months after administration of the composition.

15. The pharmaceutical composition of any one of claims 1 to 14, wherein the MLPSCs are culture expanded from a population of STRO-1+ cells.

16. The pharmaceutical composition of any one of claims 1 to 14, wherein the MLPSCs are allogeneic and / or culture-expanded, preferably the MLPSCs are culture expanded from a TNAP+ cell population.

17. The pharmaceutical composition of any one of claims 1 to 14, wherein the MLPSCs are mesenchymal stem cells (MSCs).

18. A pharmaceutical composition described in any one of claims 3 to 16, wherein the subject's average EQ-5D score is increased from the baseline value after administration of the composition.

19. A pharmaceutical composition described in any one of claims 3 to 17, wherein the subject achieves an ODI functional response of 10, preferably an ODI functional response of 15.

20. A pharmaceutical composition for reducing pain in a subject comprising mesenchymal precursor or stem cells (MLPSCs), wherein the subject is using an opioid.

21. A pharmaceutical composition comprising mesenchymal progenitor or stem cells (MLPSCs) for reducing pain and / or increasing EQ-5D score in a subject, wherein the subject is using opioids.

22. An opioid-sparing composition comprising mesenchymal progenitor or stem cells (MLPSCs) and 1% hyaluronic acid (HA).

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