New Method

Abstract

The present invention relates to certain substituted heterocyclic-fused gamma-carbolines, as described herein, in free form, solid form, pharma- ceutically acceptable salt form and / or substantially pure form, and pharmaceutical compositions thereof, for use in methods for the treatment and / or prevention of fentanyl analogue-induced overdose and related complications.

Description

[Technical field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This international application claims priority to and the benefit of U.S. Provisional Application No. 63 / 262,732, filed October 19, 2021, the entire contents of which are incorporated herein by reference.

[0002] FIELD OF THEINVENTION The present invention relates to the use of certain substituted heterocyclic-fused gamma-carbolines, as described herein, in free form or in pharma- ceutically acceptable salt form and / or in substantially pure form, and pharmaceutical compositions thereof, for the treatment and / or prevention of fentanyl analogue-induced overdose and related events. [Background technology]

[0003] Substituted heterocycle-fused gamma-carbolines have been shown to mediate the activity of 5-HT2 receptors, particularly 5-HT 2A These compounds are known to be agonists or antagonists of the 5-HT receptor. These compounds are described, for example, in U.S. Pat. Nos. 6,552,017; 7,183,282; and Reissue Pat. No. 39680, for the treatment of anxiety, depression, and psychosis. 2A It has been disclosed as a novel compound useful for the treatment of disorders related to receptor modulation. U.S. Patent No. 7,081,455 discloses other gamma-carbolines as serotonin agonists and antagonists useful for the control and prevention of central nervous system disorders such as addictive behaviors and sleep disorders. U.S. Patent No. 8,598,119 discloses the use of certain substituted heterocyclic fused gamma-carbolines for the treatment of co-occurring psychotic and depressive disorders, as well as sleep disorders, depressive disorders and / or mood disorders in psychiatric or Parkinson's disease patients. U.S. Patent No. 8,309,722 discloses a method for preparing substituted heterocyclic fused gamma-carbolines. U.S. Patent No. 8,648,077 also discloses a method for preparing crystalline toluenesulfonic acid addition salts of these substituted heterocyclic fused gamma-carbolines.

[0004] Furthermore, US Patent Application Publication No. 2021 / 00600009 (hereby incorporated by reference) discloses that some of the above substituted fused heterocyclic gamma-carbolines may act, in part, through NMDA receptor antagonism via mTOR1 signaling, similar to ketamine. Ketamine is a selective NMDA receptor antagonist. Ketamine acts through a system independent of common psychogenic monoamines (serotonin, norepinephrine and dopamine), which is the main reason for its more rapid action. Ketamine directly antagonizes extrasynaptic glutamatergic NMDA receptors and also indirectly results in activation of AMPA-type glutamate receptors. Downstream actions involve brain-derived neurotrophic factor (BDNF) and mTORC1 kinase pathways. Similar to ketamine, recent evidence suggests that compounds related to the disclosed compounds enhance both NMDA- and AMPA-evoked currents in rat medial prefrontal cortex pyramidal neurons via activation of D1 receptors, and that this is associated with increased mTORC1 signaling.

[0005] US Patent No. 10,245,260 and US Patent No. 10,799,500 disclose further novel fused heterocyclic gamma carbolines that, in addition to providing serotonin receptor inhibition, SERT inhibition and dopamine receptor modulation, have also been unexpectedly found to exhibit significant activity at μ-opioid receptors. Analogues of these novel compounds are also disclosed, for example, in US Patent No. 10,961,245 and US Patent No. 10,906,906, US Patent No. 11,376,249 and US Patent No. 11,427,587, and US Patent Application Publication No. 2021 / 0163481, the contents of each of which are incorporated herein by reference in their entirety. Among the indications disclosed in these publications are generally the treatment of pain, neuropathic pain and chronic pain. Further therapeutic applications of these compounds are disclosed in U.S. Patent Application Publication No. 2021 / 0145829, U.S. Patent Application Publication No. 2021 / 0093634, and WO 2021 / 206391 (U.S. Patent Application Publication No. 2022 / 0184072), the contents of each of which are incorporated herein by reference in their entirety. Methods for the synthesis of such compounds are also disclosed in WO 2020 / 131895 (U.S. Patent Application Publication No. 2022 / 0041600), the contents of which are incorporated herein by reference in their entirety.

[0006] For example, the compound of formula A shown below is a potent serotonin 5-HT 2A It is a receptor antagonist and a μ-opioid receptor partial biased agonist. The compound also interacts with dopamine receptors, specifically the dopamine D1 receptor. [ka]

[0007] It is also believed that the compound of formula A can enhance NMDA and AMPA-mediated signal transduction through the mTOR pathway through its D1 receptor activity.Therefore, the compound of formula A is useful for treating or preventing central nervous system disorders, including opioid addiction, such as opioid use disorder, and treating pain disorders, such as chronic pain and neuropathic pain.

[0008] The compounds of formula A and related compounds are particularly useful due to their properties of biased μ-opioid receptor activity. Depending on the cell type, or even within the same cell type, the intracellular domain of the activated μ-opioid receptor can interact with inhibitory G proteins or β-arrestins. Binding of an unbiased agonist to the μ-opioid receptor results in roughly equal activation of both G protein signaling and β-arrestin signaling.

[0009] In contrast, when biased agonists bind to the μ opioid receptor, they do so in a way that biases the intracellular domain of the receptor to interact with G protein rather than β-arrestin. Thus, the compounds of formula A and related compounds act as partial or full agonists of the G protein-coupled signaling of the μ opioid receptor, but as antagonists of the β-arrestin signaling of the receptor. This is in contrast to traditional opioid agonists such as morphine and fentanyl, which tend to strongly activate both the G protein signaling pathway and the β-arrestin signaling pathway. Activation of β-arrestin signaling by such drugs is believed to mediate the gastrointestinal disorders, addictive and respiratory depressant effects typically mediated by opioid drugs, whereas the analgesic and anesthetic effects of μ opioid receptor agonists are mediated by the G protein signaling pathway.

[0010] This same effect was also demonstrated in full-blind studies and in Phase II and III clinical trials of the biased μ-receptor agonist oliceridine. Oliceridine has been shown to provide biased μ-opioid receptor agonism via G protein-coupled signaling with reduced β-arrestin signaling compared to morphine, which is associated with its ability to provide analgesia with reduced respiratory side effects compared to morphine.

[0011] Furthermore, biased agonists are known to be generally useful in the treatment of opioid overdose by reversing the respiratory depression caused by opioids, since they antagonize β-arrestin pathway.However, beneficially, they do so while relieving pain.Biased β-arrestin antagonists are expected to be useful in the treatment of opioid overdose, since they alleviate pain while inhibiting the most severe opioid adverse effects.

[0012] The United States is currently suffering from widespread opioid abuse that began in the late 1990s and has been fueled by a combination of overprescribed prescription opioids (e.g., oxycodone, sold as OxyContin by Purdue Pharma), cheap imported illegal heroin, and a combination of legal and illegal fentanyl. While heroin and oxycodone (as well as codeine, hydrocodone, hydromorphone, oxymorphone and several other drugs) are natural or semi-synthetic analogs of morphine, fentanyl was the first and most prominent of a new class of synthetic opioids. Unlike natural and semi-synthetic opioids, fentanyl and fentanyl analogs do not possess the complete classical pentacyclic core skeleton of morphine. Instead, fentanyl and fentanyl analogs share a common 4-aminophenyl (piperidine) core. The most common fentanyl analogs are sufentanil, alfentanil, remifentanil and carfentanil: [ka]

[0013] Fentanyl and its analogs are substantially more potent than both morphine and heroin, due to stronger mu-opioid receptor binding or greater lipophilicity, or both. Because of their greater lipophilicity compared to morphine and heroin, these drugs cross the blood-brain barrier much faster and are more potent, even with comparable receptor binding. Fentanyl is generally considered to be about 50 times more potent than heroin and 100 times more potent than morphine (some sources indicate 150 times more potent than morphine). Sufentanil is 5-10 times more potent than fentanyl, and carfentanil is considered to be about 100 times more potent than fentanyl (and therefore 10,000 times more potent than morphine).

[0014] Due to its extremely high potency and widespread, inexpensive availability, it is becoming increasingly common for amphetamines, heroin, and other street drugs to be adulterated with variable and unpredictable amounts of fentanyl. As a result of these trends, fentanyl has become the leading cause of opioid overdoses, especially opioid-related deaths, in the United States. Fentanyl was responsible for at least 50% of opioid deaths by 2016, rising to over 70% of deaths in 2017 and 2018. See Torralva & Janowsky, J. Pharmacol. Exp. Ther. 371:453-475 (2019). In fact, the rate of amphetamine overdoses has increased substantially in recent years, primarily due to fentanyl adulteration of amphetamines. In just five years, there has been a four-fold increase in amphetamine deaths, primarily related to fentanyl adulteration.

[0015] Of the fentanyl analogues, only three have been approved for human use (sufentanil, alfentanil, and remifentanil) and one has only been approved for veterinary use (carfentanil). Nevertheless, these and many other newly synthetic fentanyl analogues have been found as adulterants in numerous street drugs, including amphetamines, heroin, cocaine, alprazolam (Xanax), and hydrocodone / paracetamol (Norco). See Armenian et al., Neuropharmacology (2017). Until 2013, there had been only sporadic outbreaks of fentanyl or fentanyl analogue contamination of U.S. heroin supplies, but since then, such compounds have become widespread in North America and are found in both heroin and cocaine. Deaths from fentanyl-laced heroin and cocaine doubled from 2012 to 2014. In 2015-2016, street-bought counterfeit Xanax and Norco caused two outbreaks in California. The adulteration of non-opioid drugs with fentanyl and fentanyl analogues is of particular concern because users of such drugs are more likely to be opioid naive (and therefore have little or no established drug tolerance) and therefore have significantly worse clinical outcomes. As standard fentanyl analogue testing (in both medical and forensic settings) has become more widely available, illicit manufacturers have begun to switch to novel synthetic fentanyl derivatives to evade detection, and today, numerous such illicit compounds are known and available on the black market from manufacturers in China and other countries. At least 21 synthetic opioid compounds are currently scheduled by the U.S. Drug Enforcement Administration.

[0016] Due to its high potency and high lipophilicity, fentanyl-induced overdoses are much more difficult to treat than morphine, heroin, or oxycodone overdoses. Fentanyl has a very rapid onset of action, making reversal with μ-receptor antagonist (e.g., naloxone or naltrexone) treatment difficult in an outpatient setting (EMS or police response times are often longer than the time it takes for severe respiratory depression to develop). Larger doses of μ-receptor antagonists are also required to reverse a fentanyl overdose, and there are limits to the rate and dose of μ-opioid antagonists that can be safely administered. Whereas morphine takes an average of 19 minutes to reach 80% of its peak effect, fentanyl causes severe respiratory depression much more rapidly.

[0017] Even more alarming, however, is that fentanyl and its analogs have an additional mechanism of action that has become crucial in the ongoing opioid epidemic. While all opioids cause respiratory depression through μ-opioid receptor activation of the β-arrestin signaling pathway in the brain for reasons that are not yet entirely clear, fentanyl and its analogs can also rapidly cause vocal cord closure (laryngospasm) and severe muscular rigidity of the chest wall and diaphragm. This can occur following intravenous, transdermal or inhalation administration of fentanyl and its analogs. Neither morphine, nor heroin, nor any other opioid with the classical morphine structure, possess this property. This severe chest wall rigidity has been termed fentanyl-induced respiratory muscle rigidity (FIRMR) (or simply, fentanyl-induced muscle rigidity (FIMR)), and the combination of FIRMR and laryngospasm is known clinically as wooden chest syndrome (WCS). WCS can develop within as little as 1-2 minutes of injection of fentanyl, fentanyl analogues, or heroin or other drugs laced with fentanyl or its analogues. WCS has been demonstrated after administration of as little as 50 μg of intravenous fentanyl.

[0018] The main cause of death in WCS appears to be due to mechanical ventilation obstruction caused by closure of the glottic structures and upper airway. Laryngospasm is defined as the involuntary closure or obstruction of the glottic opening, which is controlled by the intrinsic muscles of the larynx. These muscles are innervated by both sympathetic (adrenergic) and parasympathetic (cholinergic) nerve fibers, and therefore the ultimate activity of these muscles is determined by the balance of sympathetic and parasympathetic inputs.

[0019] While FIRMR and WCS have long been known in the surgical anesthesia community (as they occur frequently within the therapeutic range for surgical anesthesia), these conditions are not well known in the first responder or emergency medical community. This often leads to the sudden death of drug abusers because those treating them are unaware of these effects of fentanyl (often exacerbated by the patient not realizing that they have ingested something containing fentanyl). Numerous witness and survivor accounts of overdoses report a very rapid onset of cyanosis, loss of consciousness, severe muscle rigidity, and seizure-like behavior immediately following drug injection. This rapid onset of death is very different from the respiratory depression that typically accompanies morphine, heroin, and oxycodone overdoses. Indeed, mechanical failure of respiration in fentanyl or fentanyl analogue overdose typically occurs within less than 2 minutes of drug administration and precedes centrally mediated respiratory depression (a 50% decline in respiratory mechanics takes 7-9 minutes to develop).

[0020] Even more alarming, the standard first-line treatments for opioid overdoses, naloxone, naltrexone, and nalmefene, are not effective in reversing these fentanyl-induced effects. Severe chest wall stiffness also impairs the effectiveness of chest compressions in cardiopulmonary resuscitation. As a result, the emergency department visit to death ratio for heroin-related overdoses is reported to be approximately 10:1, whereas for fentanyl-related overdoses, the ratio is only 1:1.

[0021] The standard dose of intravenous naloxone administered for opioid overdose is 0.4–2 mg, with additional doses up to 10 mg given at 2–3 minute intervals. However, intranasal naloxone, widely used by first responders, has a maximum recommended total dose of only 4 mg. See, for example, Williams et al., Prehospital Emergency Care 23(6):749-63 (2019). However, one study found that the upper airway effects of morphine could be completely blocked with a dose of 0.1 mg / kg naloxone (e.g., 7 mg in a 70 kg person), whereas 0.8–1.6 mg / kg naloxone (56–112 mg in a 70 kg person) was required to completely block the upper airway effects of fentanyl. A study investigating a 2006 fentanyl overdose outbreak reported that when patients were given 0.4 to 12 mg of naloxone in a hospital emergency room, only 15% of patients responded to the 0.4 mg dose, and 6 of 26 patients required at least 6 mg to reverse respiratory depression. Another study investigating 18 patients who overdosed on counterfeit hydrocodone / paracetamol laced with fentanyl required an intravenous bolus injection of 0.4 to 8 mg of naloxone, with 4 of the patients requiring a naloxone infusion lasting 26 to 40 hours.

[0022] Unfortunately, however, high doses of naloxone are not practical for treatment because rapid injection of as little as 0.4 mg of naloxone (0.0057 mg / kg in a 70 kg adult) in real-world opioid users typically causes laryngospasm, pulmonary edema, hemodynamic instability, and cardiac arrhythmias (all resulting from catecholamine release). Thus, high-dose naloxone treatment is contraindicated, especially in the field. Thus, in the field, it is usually extremely difficult, if not impossible, to reverse a fentanyl-induced overdose using naloxone before it becomes fatal, without additional medical and pharmacological support.

[0023] It is clear that WCS is not simply the result of μ-opioid receptor agonism, because other strong μ-opioid agonists (e.g., morphine) do not cause WCS, and because strong μ-opioid antagonists (e.g., naloxone) do not reverse WCS in the usual dose range. Thus, fentanyl and its analogs must cause WCS by some other mechanism involving other neurotransmitter systems.

[0024] There is evidence from both in vitro studies and various animal models indicating that fentanyl exerts these actions through stimulation of noradrenergic and possibly cholinergic activity in the locus coeruleus (LC) region of the brain. Without being bound by theory, it is believed that in the LC, fentanyl acts as an agonist of μ-opioid receptors, and the resulting hyperpolarization of LC neurons leads to efferent noradrenergic neuronal activity, specifically in the coerulospinal fibers connected to spinal motor neurons that terminate in the chest wall and abdomen, and in laryngeal nerve fibers that contribute to the vagus nerve via the superior and middle cervical ganglia. These laryngeal nerve fibers directly innervate the intrinsic muscles of the larynx.

[0025] The role of α1 adrenergic receptors has been demonstrated, in particular, by animal studies demonstrating that the selective α1 adrenergic antagonist prazosin, administered intravenously 10 min before fentanyl, inhibits the development of FIMR, and ablation of the LC region of the brain produces the same results. Other studies have shown that intrathecal administration of prazosin at the L3 spinal cord level also inhibits FIMR, whereas administration of the α2 adrenergic antagonist yohimbine does not. There is also evidence from animal studies showing that fentanyl itself is an antagonist of α1 adrenergic receptors, albeit weakly, with selectivity for α1B and α1A (but not α1D) receptors. Unfortunately, these studies are not directly predictive of the beneficial use of α1 adrenergic antagonists in the treatment of opioid overdose, since the corresponding human doses used in animal studies cause lethal hypotension in humans.

[0026] There is also increasing evidence for an intermediate role of GABA interneurons in the pathogenesis of WCS. GABA interneurons are part of a brain-wide inhibitory network and are particularly abundant in the LC. The LC is responsible for maintaining basal skeletal muscle tone in the trunk via noradrenergic activation of spinal motor neurons, whereas norepinephrine release from LC presynaptic terminals is inhibited by GABA efferent signaling. Thus, inhibition of GABA interneurons leads to increased skeletal muscle tone via increased LC noradrenergic activity. Without being bound by theory, it is believed that fentanyl binds to μ-opioid receptors on GABA interneurons, which inhibits GABA interneuron afferents and, consequently, releases inhibition of LC sympathetic neurons.

[0027] There is also evidence that LC neurons are rich in muscarinic and nicotinic acetylcholine receptors. Because the LC receives cholinergic input from other brain regions, such as the pontine reticular formation, it is believed that fentanyl-induced μ-receptor agonism in these adjacent regions may stimulate acetylcholine release, which in turn further stimulates norepinephrine release by the LC. There is also evidence that fentanyl may act directly as an M3 muscarinic receptor antagonist, thereby inhibiting parasympathetic tone in the intrinsic laryngeal muscles, further increasing spasms produced by sympathetic activation of these muscles.

[0028] NMDA and non-NMDA glutamate receptor activity have also been implicated in the pathogenesis of WCS.

[0029] Because of the intermediate role of these other neurotransmitters (e.g., norepinephrine, acetylcholine, GABA, etc.) in the pathogenesis of WCS, another reason why WCS is unresponsive to μ-opioid antagonist treatment may be that once these effects indirectly stimulated by fentanyl are initiated (by μ-receptor agonism), μ-receptor antagonism alone cannot reverse the effects already in place.

[0030] Finally, there is evidence that fentanyl, but not morphine, has some activity as a norepinephrine reuptake inhibitor. This effect has been shown to be not antagonized by naloxone in various neuronal cell lines, indicating that this is not an indirect effect of μ receptor agonism. Thus, it is possible that fentanyl acts directly on neurons in the LC to stimulate hyperactivity in muscles involved in the FIMR and WCS.

[0031] Thus, there remains a need for therapeutic agents specifically suited to reversing the effects of acute fentanyl overdose. Summary of the Invention

[0032] The present disclosure relates to the treatment of disorders associated with the abuse and overdose of fentanyl and fentanyl analogs. Fentanyl analogs include, but are not limited to, the compounds sufentanil, alfentanil, remifentanil, carfentanil, and derivatives of these compounds, as further described herein. Fentanyl and fentanyl analogs are collectively referred to herein as "F / FA."

[0033] The present disclosure relates to (a) Treatment or reversal of F / FA excess; (b) treatment or reversal of F / FA-induced respiratory depression; (c) treatment or reversal of F / FA-induced muscle stiffness; (d) treatment or reversal of F / A-induced laryngospasm; (e) reversal or inhibition of F / FA binding to μ-opioid receptors in the central nervous system (e.g., in the locus coeruleus); (f) inhibition of F / FA-induced β-arrestin signaling in the central nervous system (e.g., in the locus coeruleus); (g) Prevention of deaths due to excess F / FA intake; and (h) Anesthesia recovery (e.g., after surgery) A method for one or more of the following: The method includes administering to a patient in need thereof an effective amount of a compound of formula I or a pharmaceutical composition thereof, wherein the compound of formula I is in free form or in salt form (e.g., a pharma- ceutically acceptable salt form), e.g., isolated or purified free form or in salt form (e.g., a pharma- ceutically acceptable salt form), [ka] [In the formula, R 1 , H, C 1-6 Alkyl, -C(O)-OC(R a )(R b )(R c ), -C(O)-O-CH2-OC(R a )(R b )(R c ) or -C(R6 )(R 7 )-OC(O)-R 8 and; R 2 and R 3 are independently H, D, and C 1-6 Alkyl (e.g., methyl), C 1-6 selected from alkoxy (e.g., methoxy), halo (e.g., F), cyano, or hydroxy; L is for C 1-6 Alkylene (e.g., ethylene, propylene or butylene), C 1-6 Alkoxy (e.g., propoxy or butoxy), C 2-3 Alkoxy C 1-3 Alkylene (e.g., CH2CH2OCH2), C 1-6 Alkylamino or NC 1-6 Alkyl C 1-6 Alkylamino (e.g., propylamino or N-methylpropylamino), C 1-6 Alkylthio (e.g., -CH2CH2CH2S-), C 1-6 alkylsulfonyl (e.g., -CHCHCHS(O)-), each of which may be selected from one or more R 4 may be substituted with a moiety; Each R 4 is independently 1-6 Alkyl (e.g., methyl), C 1-6 selected from alkoxy (e.g., methoxy), halo (e.g., F), cyano, or hydroxy; Z is selected from aryl (e.g., phenyl) and heteroaryl (e.g., pyridyl, indazolyl, benzimidazolyl, benzisoxazolyl), where the aryl or heteroaryl is selected from one or more R 4 may be substituted with a moiety; R 8 is -C(R a )(R b )(R c ), -OC(R a )(R b )(R c ) or -N(R d )(R e) and; R a , R b and R c are each independently H and C 1-24 alkyl; R d and R e are each independently H and C 1-24 alkyl; R 6 and R 7 are each independently H, C 1-6 Alkyl, carboxy and C 1-6 alkoxycarbonyl] The method according to the present invention further comprises the steps of:

[0034] In a further aspect, the disclosure also provides the use of a compound of the disclosure, e.g., a compound of formula I, in the manufacture of a medicament for the methods disclosed herein. The disclosure also provides a compound of the disclosure, e.g., a compound of formula I, for use in the methods disclosed herein. [Brief description of the drawings]

[0035] [Figure 1] FIG. 1 is a dose-response curve for inhibition of fentanyl-induced β-arrestin signaling at the μ-opioid receptor by the compound of Example 1. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0036] Detailed Description of the Invention In a first aspect, the present disclosure provides a method for producing a method for treating a cancer cell comprising: (a) Treatment or reversal of F / FA excess; (b) treatment or reversal of F / FA-induced respiratory depression; (c) treatment or reversal of F / FA-induced muscle stiffness; (d) treatment or reversal of F / A-induced laryngospasm; (e) inhibition of F / FA-induced β-arrestin signaling in the central nervous system (e.g., in the locus coeruleus); (f) inhibition of F / FA-induced β-arrestin signaling in the central nervous system (e.g., in the locus coeruleus); (g) Prevention of deaths due to excess F / FA intake; and (h) Anesthesia recovery (e.g., after surgery) A method for one or more of the following: The method includes administering to a patient in need thereof an effective amount of a compound of formula I or a pharmaceutical composition comprising the compound of formula I, wherein the compound of formula I is in free form or in salt form (e.g., a pharma- ceutically acceptable salt form), e.g., isolated or purified free form or in salt form (e.g., a pharma- ceutically acceptable salt form), [ka] [In the formula, R 1 , H, C 1-6 Alkyl, -C(O)-OC(R a )(R b )(R c ), -C(O)-O-CH2-OC(R a )(R b )(R c ) or -C(R 6 )(R 7 )-OC(O)-R 8 and; R 2 and R 3 are independently H, D, and C 1-6 Alkyl (e.g., methyl), C 1-6 selected from alkoxy (e.g., methoxy), halo (e.g., F), cyano, or hydroxy; L is for C 1-6 Alkylene (e.g., ethylene, propylene or butylene), C 1-6 Alkoxy (e.g., propoxy or butoxy), C 2-3 Alkoxy C 1-3 Alkylene (e.g., CH2CH2OCH2), C 1-6 Alkylamino or NC 1-6 Alkyl C 1-6 Alkylamino (e.g., propylamino or N-methylpropylamino), C 1-6Alkylthio (e.g., -CH2CH2CH2S-), C 1-6 alkylsulfonyl (e.g., -CHCHCHS(O)-), each of which may be selected from one or more R 4 may be substituted with a moiety; Each R 4 is independently 1-6 Alkyl (e.g., methyl), C 1-6 selected from alkoxy (e.g., methoxy), halo (e.g., F), cyano, or hydroxy; Z is selected from aryl (e.g., phenyl) and heteroaryl (e.g., pyridyl, indazolyl, benzimidazolyl, benzisoxazolyl), where the aryl or heteroaryl is selected from one or more R 4 may be substituted with a moiety; R 8 is -C(R a )(R b )(R c ), -OC(R a )(R b )(R c ) or -N(R d )(R e ) and; R a , R b and R c are each independently H and C 1-24 alkyl; R d and R e are each independently H and C 1-24 alkyl; R 6 and R 7 are each independently H, C 1-6 Alkyl, carboxy and C 1-6 alkoxycarbonyl] The method according to the present invention further comprises the steps of:

[0037] The present disclosure provides a further exemplary embodiment Method 1, which includes:

[0038] 1.1 In the compounds of formula I, R1 Method 1 where is H;

[0039] 1.2 In the compounds of formula I, R 1 C 1-6 alkyl, e.g., methyl, method 1;

[0040] 1.3 In the compounds of formula I, R 1 -C(O)-OC(R a )(R b )(R c ), Method 1;

[0041] 1.4 In the compounds of formula I, R a is H and R b and R c However, each independently, C 1-24 Alkyl, e.g., C 1-20 Alkyl, C 5-20 Alkyl, C 9-18 Alkyl, C 10-16 Alkyl, or C 11 Alkyl, C 12 Alkyl, C 13 Alkyl, C 14 Alkyl, C 15 Alkyl or C 16 alkyl, method 1.3;

[0042] 1.5 In the compounds of formula I, R a and R b is H and R c C 1-24 Alkyl, e.g., C 1-20 Alkyl, C 5-20 Alkyl, C 9-18 Alkyl, C 10-16 Alkyl, or C 11 Alkyl, C 12 Alkyl, C 13 Alkyl, C 14 Alkyl, C 15 Alkyl or C 16 Method 1.3, which is alkyl;

[0043] 1.6 In the compounds of formula I, R a, R b and R c However, each independently, C 1-24 Alkyl, e.g., C 1-20 Alkyl, C 5-20 Alkyl, C 9-18 Alkyl, C 10-16 Alkyl, or C 11 Alkyl, C 12 Alkyl, C 13 Alkyl, C 14 Alkyl, C 15 Alkyl or C 16 alkyl, method 1.3;

[0044] 1.7 In the compounds of formula I, R a , R b and R c each is H; Method 1.3;

[0045] 1.8 In compounds of formula I, R a and R b is H and R c C 10-14 is alkyl (e.g., R c CH3(CH2) 10 or CH3(CH2) 14 ), Method 1.3;

[0046] 1.9 In compounds of formula I, R 1 -C(O)-O-CH2-OC(R a )(R b )(R c ), Method 1;

[0047] 1.10 In the compounds of formula I, R a is H and R b and R c However, each independently, C 1-24 Alkyl, e.g., C 1-20 Alkyl, C 5-20 Alkyl, C 9-18 Alkyl, C 10-16 Alkyl, or C 11 Alkyl, C 12 Alkyl, C 13Alkyl, C 14 Alkyl, C 15 Alkyl or C 16 alkyl, method 1.9;

[0048] 1.11 In compounds of formula I, R a and R b is H and R c But, C 1-24 Alkyl, e.g., C 1-20 Alkyl, C 5-20 Alkyl, C 9-18 Alkyl, C 10-16 Alkyl, or C 11 Alkyl, C 12 Alkyl, C 13 Alkyl, C 14 Alkyl, C 15 Alkyl or C 16 alkyl, method 1.9;

[0049] 1.12 In compounds of formula I, R a , R b and R c However, each independently, C 1-24 Alkyl, e.g., C 1-20 Alkyl, C 5-20 Alkyl, C 9-18 Alkyl, C 10-16 Alkyl, or C 11 Alkyl, C 12 Alkyl, C 13 Alkyl, C 14 Alkyl, C 15 Alkyl or C 16 alkyl, method 1.9;

[0050] 1.13 In compounds of formula I, R a , R b and R c are H, respectively; Method 1.9;

[0051] 1.14 In compounds of formula I, R 1 -C(R 6 )(R 7 )-OC(O)-R 8and R 8 -C(R a )(R b )(R c ), Method 1;

[0052] 1.15 In compounds of formula I, R 1 -C(R 6 )(R 7 )-OC(O)-R 8 and R 8 -OC(R a )(R b )(R c ), Method 1;

[0053] 1.16 In compounds of formula I, R a is H and R b and R c However, each independently, C 1-24 Alkyl, e.g., C 1-20 Alkyl, C 5-20 Alkyl, C 9-18 Alkyl, C 10-16 Alkyl, or C 11 Alkyl, C 12 Alkyl, C 13 Alkyl, C 14 Alkyl, C 15 Alkyl or C 16 alkyl, method 1.14 or 1.15;

[0054] 1.17 In compounds of formula I, R a and R b is H and R c But, C 1-24 Alkyl, e.g., C 1-20 Alkyl, C 5-20 Alkyl, C 9-18 Alkyl, C 10-16 Alkyl, or C 11 Alkyl, C 12 Alkyl, C 13 Alkyl, C 14 Alkyl, C 15 Alkyl or C 16 alkyl, method 1.14 or 1.15;

[0055] 1.18 In compounds of formula I, R a , R b and R c However, each independently, C 1-24 Alkyl, e.g., C 1-20 Alkyl, C 5-20 Alkyl, C 9-18 Alkyl, C 10-16 Alkyl, or C 11 Alkyl, C 12 Alkyl, C 13 Alkyl, C 14 Alkyl, C 15 Alkyl or C 16 alkyl, method 1.14 or 1.15;

[0056] 1.19 In compounds of formula I, R a , R b and R c Method 1.14 or 1.15, wherein each is H;

[0057] 1.20 In compounds of formula I, R 6 is H and R 7 C 1-3 is alkyl (e.g., R 7 is methyl or isopropyl), R 8 C 10-14 is alkyl (e.g., R 8 CH3(CH2) 10 or CH3(CH2) 14 ), any of methods 1.14 to 1.19;

[0058] 1.21 In compounds of formula I, R 1 -C(R 6 )(R 7 )-OC(O)-R 8 and R 8 -N(R d )(R e ), Method 1;

[0059] 1.22 In compounds of formula I, R d is H and Re But independently, C 1-24 Alkyl, e.g., C 1-20 Alkyl, C 5-20 Alkyl, C 9-18 Alkyl, C 10-16 Alkyl, or C 11 Alkyl, C 12 Alkyl, C 13 Alkyl, C 14 Alkyl, C 15 Alkyl or C 16 alkyl, method 1.21;

[0060] 1.23 In compounds of formula I, R d and R e However, each independently, C 1-24 Alkyl, e.g., C 1-20 Alkyl, C 5-20 Alkyl, C 9-18 Alkyl, C 10-16 Alkyl, or C 11 Alkyl, C 12 Alkyl, C 13 Alkyl, C 14 Alkyl, C 15 Alkyl or C 16 alkyl, method 1.21;

[0061] 1.24 In compounds of formula I, R d and R e are H, respectively; Method 1.21;

[0062] 1.25 In compounds of formula I, R 6 is H and R 7 any of methods 1.14 to 1.24, wherein

[0063] 1.26 In compounds of formula I, R 6 C 1-6 is alkyl, R 7 C 1-6 any of methods 1.14 to 1.24, wherein the alkyl group is an alkyl group;

[0064] 1.27 In compounds of formula I, R6 is H and R 7 C 1-6 any of methods 1.14 to 1.24, wherein the alkyl group is an alkyl group;

[0065] 1.28 In compounds of formula I, R 6 is H and R 7 any of methods 1.14-1.24, wherein is carboxy;

[0066] 1.29 In compounds of formula I, R 6 is H and R 7 C 1-6 any of methods 1.14-1.24, wherein the alkoxycarbonyl is, for example, ethoxycarbonyl or methoxycarbonyl;

[0067] 1.30 In compounds of formula I, R 2 and R 3 is H;

[0068] 1.31 In compounds of formula I, R 2 is H and R 3 is D, either Method 1 or Methods 1.1-1.29;

[0069] 1.32 In compounds of formula I, R 2 and R 3 is D, either Method 1 or Methods 1.1-1.29;

[0070] 1.33 In the compounds of formula I, L is one or more R 4 optionally substituted with a moiety, C 1-6 Alkylene (e.g., ethylene, propylene or butylene), C 1-6 Alkoxy (e.g., propoxy), C 2-3 Alkoxy C 1-3 Alkylene (e.g., CH2CH2OCH2)C 1-6 alkylamino (e.g., propylamino or N-methylpropylamino), or C 1-6alkylthio (e.g., -CHCHCHS-), any of Method 1 or Methods 1.1-1.32;

[0071] 1.34 In the compound of formula I, L is unsubstituted C 1-6 alkylene (e.g., ethylene, propylene, or butylene), method 1.33;

[0072] 1.35 In the compounds of formula I, L is one or more R 4 is substituted with a moiety, C 1-6 alkylene (e.g., ethylene, propylene, or butylene), method 1.33;

[0073] 1.36 In the compound of formula I, L is unsubstituted C 1-6 alkoxy (e.g., propoxy or butoxy), method 1.33;

[0074] 1.37 In the compounds of formula I, L is one or more R 4 is substituted with a moiety, C 1-6 alkoxy (e.g., propoxy or butoxy), method 1.33;

[0075] 1.38 In the compound of formula I, L is unsubstituted C 2-3 Alkoxy C 1-3 alkylene (e.g., CH2CH2OCH2), Method 1.33;

[0076] 1.39 In the compounds of formula I, L is one or more R 4 is substituted with a moiety, C 2-3 Alkoxy C 1-3 alkylene (e.g., CH2CH2OCH2), Method 1.33;

[0077] 1.40 In compounds of formula I, R 1 , R 2 and R 3 and any of Method 1 or Methods 1.1-1.39, wherein each of

[0078] 1.41 In the compound of formula I, L is (CH2) n -X-, where n is an integer selected from 2, 3 and 4, and X is -O-, -S-, -NH-, -N(C 1-6 any of Methods 1 or 1.1-1.40, wherein the alkyl group is selected from the group consisting of aryl, arylalkyl, arylsulfonyl, arylsulfur ...

[0079] 1.42 In the compound of formula I, L is -(CH2) n -X-, where n is an integer selected from 2, 3 and 4, and X is -O-;

[0080] 1.43 In the compound of formula I, L is -(CH2) n -X-, where n is 3 and X is -O-, -S-, -NH-, or -N(C 1-6 alkyl)-(e.g., -N(CH3)-), method 1.41;

[0081] 1.44 In the compound of formula I, L is -(CH2) n -X-, where n is 3 and X is CH2, Method 1.41;

[0082] 1.45 In the compound of formula I, Z is one or more R 4 any of Method 1 or Methods 1.1-1.44, wherein R is an aryl (e.g., phenyl) optionally substituted with a moiety;

[0083] 1.46 In the compound of formula I, Z is one or more R 4 Method 1.45, which is substituted with a moiety, which is aryl (e.g., phenyl);

[0084] 1.47 In the compound of formula I, Z is one, two, three or four R 4 Method 1.46, which is a phenyl substituted with a moiety;

[0085] 1.48 In the compound of formula I, the one, two, three or four R 4Method 1.47, wherein the moieties are independently selected from halo (e.g., fluoro, chloro, bromo, or iodo) and cyano;

[0086] 1.49 In the compounds of formula I, Z is one R selected from halo (e.g., fluoro, chloro, bromo or iodo) and cyano. 4 phenyl substituted with a moiety (e.g., Z is 4-fluorophenyl, or 4-chlorophenyl, or 4-cyanophenyl), Method 1.46;

[0087] 1.50 Method 1.46, wherein in the compound of formula I, Z is phenyl substituted with one fluoro (e.g., 2-fluorophenyl, 3-fluorophenyl, or 4-fluorophenyl);

[0088] 1.51 Method 1.46, wherein in the compound of formula I, Z is 4-fluorophenyl;

[0089] 1.52 In the compound of formula I, Z is one or more R 4 any of Method 1 or Methods 1.1-1.44, wherein the moiety is heteroaryl (e.g., pyridyl, indazolyl, benzimidazolyl, benzisoxazolyl);

[0090] 1.53 Method 1.52, in which in the compound of formula I, the heteroaryl is a monocyclic 5- or 6-membered heteroaryl (e.g., pyridyl, pyrimidyl, pyrazinyl, thiophenyl, pyrrolyl, furanyl, imidazolyl, oxazolyl, isoxazolyl, thiazolyl);

[0091] 1.54 Method 1.53, wherein in the compound of formula I, said heteroaryl is selected from pyridyl, pyrimidinyl, pyrazinyl, and thiophenyl;

[0092] 1.55 Method 1.52, in which in the compound of formula I, the heteroaryl is a bicyclic 9- or 10-membered heteroaryl (e.g., indolyl, isoindolyl, benzofuranyl, benzothiophenyl, indazolyl, benzimidazolyl, benzoxazolyl, benzisoxazolyl, benzothiazolyl, quinolinyl, isoquinolinyl, quinoxalinyl, quinazolinyl, benzodioxolyl, 2-oxo-tetrahydroquinolinyl);

[0093] 1.56 Method 1.55, wherein in the compound of formula I, said heteroaryl is selected from indazolyl, benzoisoxazolyl, quinolinyl, benzodioxolyl, and 2-oxo-tetrahydroquinolinyl;

[0094] 1.57 Method 1.55, wherein in the compound of formula I, said heteroaryl is selected from indazolyl, benzisoxazolyl, and quinolinyl;

[0095] 1.58 In the compound of formula I, the heteroaryl is selected from the group consisting of 1, 2, 3 or 4 R 4 any of methods 1.52 to 1.57, substituted with moiety;

[0096] 1.59 In the compound of formula I, the one, two, three or four R 4 The moieties are independently halo (e.g., fluoro, chloro, bromo, or iodo), cyano, hydroxy, or C 1-6 alkoxy (e.g., methoxy), method 1.58;

[0097] 1.60 In the compound of formula I, the heteroaryl has one R selected from halo (e.g., fluoro, chloro, bromo, or iodo) and cyano. 4 Method 1.58 or 1.59, wherein the heteroaryl is substituted with a moiety (e.g., the heteroaryl is 6-fluoro-3-indazolyl, 6-chloro-3-indazolyl, 6-fluoro-3-benzisoxazolyl, or 5-chloro-3-benzisoxazolyl);

[0098] 1.61 Compounds of formula I each independently in free form or in pharma- ceutically acceptable salt form: [ka] any of Method 1 or Methods 1.1-1.60 selected from the group consisting of:

[0099] 1.62 The compound of formula I is, each independently, in free form or in pharma- ceutically acceptable salt form: [ka] any of Method 1 or Methods 1.1-1.60 selected from the group consisting of:

[0100] 1.63 Compounds of formula I each independently in free form or in pharma- ceutically acceptable salt form: [ka] any of Method 1 or Methods 1.1-1.60 selected from the group consisting of:

[0101] 1.64 The compound of formula I, in free form or in the form of a pharma- ceutically acceptable salt, [ka] any of Method 1 or Methods 1.1 to 1.61;

[0102] 1.65 Method 1 or any of Methods 1.1-1.64, wherein the compound of formula I is in free form;

[0103] 1.66 Method 1 or any of Methods 1.1-1.64, wherein the compound of formula I is in the form of a salt, e.g., a pharma- ceutically acceptable salt;

[0104] 1.67 Method 1 or any of Methods 1.1-1.64, wherein the compound of formula I is in the form of an acid addition salt, e.g., the acid is hydrochloric acid, toluenesulfonic acid, glutamic acid, tartaric acid, malic acid, or ascorbic acid;

[0105] 1.68 Method 1 or any of Methods 1.1-1.67, wherein the compound of formula I is in substantially pure diastereomeric form (i.e., substantially free of other diastereomers);

[0106] 1.69 Method 1 or any of methods 1.1-1.67, wherein the compound of formula I has a diastereomeric excess of greater than 70%, preferably greater than 80%, more preferably greater than 90%, and most preferably greater than 95%;

[0107] 1.70 Method 1 or any of Methods 1.1-1.69, wherein the compound of formula I is in a solid form, e.g., a crystalline form;

[0108] 1.71 Method 1 or any of Methods 1.1-1.70, wherein the compound of formula I is in isolated or purified form (e.g., at least 90% pure, or at least 95% or at least 98% or at least 99% pure);

[0109] 1.72 Method 1, or any of Methods 1.1-1.71, wherein the compound of formula I is administered in the form of a pharmaceutical composition comprising the compound of formula I in admixture with a pharma- ceutically acceptable diluent or carrier;

[0110] 1.73 Method 1.72, wherein the compound of formula I is in a pharma- ceutically acceptable salt form admixed with a pharma- ceutically acceptable diluent or carrier;

[0111] 1.74 Method 1.72 or 1.73, wherein the pharmaceutical composition is an immediate release formulation;

[0112] 1.75 Any of methods 1.72-1.74, wherein the pharmaceutical composition is formulated for single dose administration (e.g., a tablet, capsule, wafer, single-use injection, single-use intranasal ampoule or vial, single-use injection ampoule or vial, single-use intranasal spray);

[0113] 1.76 Any of methods 1.72-1.75, wherein the pharmaceutical composition is in the form of a tablet, capsule, or wafer (e.g., an oral, sublingual, or buccal tablet, capsule, or wafer);

[0114] 1.77 Method 1.76, wherein the pharmaceutical composition is a fast dissolving oral tablet (e.g., a fast dissolving sublingual tablet);

[0115] 1.78 Any of Methods 1.72-1.75, wherein the pharmaceutical composition is formulated for intranasal or pulmonary administration (e.g., as an aerosol, mist, or powder for inhalation);

[0116] 1.79 Any of methods 1.72-1.75, wherein the pharmaceutical composition is formulated for administration by injection, e.g., as a sterile aqueous solution, e.g., for intravenous, subcutaneous or intramuscular injection;

[0117] 1.80 Method 1.79, wherein the pharmaceutical composition is formulated for intravenous, intrathecal, intramuscular, subcutaneous or intraperitoneal injection.

[0118] 1.81 Any of methods 1.72-1.80, wherein the pharmaceutical composition is formulated and / or packaged as a prefilled injection syringe, as an autoinjector, or as a sterile solution in a vial for injection or intranasal administration.

[0119] 1.82 Any of methods 1.72-1.81, wherein the pharmaceutical composition is packaged as a kit for administration by a nurse, emergency medical technician, or paramedic.

[0120] 1.83 Any of methods 1.72-1.81, wherein the pharmaceutical composition is packaged as a kit for administration by a non-medical first responder (e.g., a police or firefighter).

[0121] 1.84 Any of methods 1.72-1.81, wherein the pharmaceutical composition is packaged as a kit for administration by the general public (e.g., a single-use take-home kit for drug abusers, for family and friends of drug abusers, and for public places such as places of worship, community centers, sporting event venues, etc.).

[0122] As used herein, the term "compounds of the disclosure" refers to any of the compounds described in Method 1 or any of the embodiments of Methods 1.1-1.71.

[0123] Fentanyl and fentanyl analogs are collectively referred to herein as "F / FA". Fentanyl analogs include all compounds recognized as such by the US Drug Enforcement Administration and / or the United Nations Office on Drugs and Crime (UNODC). F / FA compounds include fentanyl, α-methylfentanyl, 3-methylfentanyl, acetylfentanyl (also known as desmethylfentanyl), acetyl-α-methylfentanyl, thiofentanyl, α-methylthiofentanyl, β-hydroxyfentanyl, parafluorofentanyl, β-hydroxy-3-methylthiofentanyl, β-hydroxythiofentanyl, butyrylfentanyl, furanylfentanyl, 4-fluoroisobutyrylfentanyl, 4-fluorobutyrylfentanyl, 4-methoxybutyrylfentanyl, 4-methylbutyrylfentanyl, acrylfentanyl, 4- These include, but are not limited to, chloroisobutyryl fentanyl, tetrahydrofuranyl fentanyl, cyclopentyl fentanyl, valeryl fentanyl, methoxyacetyl fentanyl, 3-carbomethoxy fentanyl, sufentanil, alfentanil, remifentanil, carfentanil, thiafentanil, lofentanil, ocfentanil, trefantinil, brifentanil, AH-7921, U-47700, MT-45, and other compounds that are "substantially similar" to fentanyl, sufentanil, alfentanil, remifentanil, or carfentanil. F / FA also includes any drug composition or mixture containing an F / FA compound, such as morphine, heroin, codeine, hydrocodone, oxycodone, hydromorphone, marijuana or cannabis products, tetrahydrocannabinol, cocaine, amphetamine, methamphetamine, methylenedioxymethamphetamine, alprazolam, or other illegal or legal drugs that are contaminated or mixed with the F / FA compounds described herein.

[0124] In further embodiments of the first aspect, the present disclosure provides further embodiments of Method 1, as follows:

[0125] 1.85 The patient is unconscious, method 1 or any of methods 1.1-1.84;

[0126] 1.86 The patient is suspected of suffering from acute F / FA overdose, method 1 or any of methods 1.1-1.84;

[0127] 1.87 The patient exhibits chest wall stiffness, method 1 or any of methods 1.1-1.86;

[0128] 1.88 The patient exhibits laryngospasm, method 1 or any of methods 1.1-1.87;

[0129] 1.89 The patient has been diagnosed with, is suspected of having, or is suffering from wooden chest syndrome (WCS), method 1 or any of methods 1.1 to 1.88;

[0130] 1.90 Method 1, or any of Methods 1.1-1.88, wherein the patient has been diagnosed with, is suspected of, or is suffering from, fentanyl-induced muscle rigidity (FIMR) or fentanyl-induced respiratory muscle rigidity (FIRMR), wherein the FIMR or FIRMR is caused by fentanyl or caused by a fentanyl analog;

[0131] 1.91 The patient is admitted to a non-hospital or non-emergency clinic setting, either method 1 or methods 1.1–1.90;

[0132] 1.92 The patient is suspected of having or has an opioid use disorder or has a history of opioid use disorder, Method 1 or any of Methods 1.1-1.91;

[0133] 1.93 The patient is suspected of being a naive opioid user, method 1 or any of methods 1.1-1.92;

[0134] 1.94 The patient has or is suspected of having overdosed on a legal or illegal drug (e.g., morphine, heroin, codeine, hydrocodone, oxycodone, hydromorphone, marijuana or cannabis products, tetrahydrocannabinol, cocaine, amphetamine, methamphetamine, methylenedioxymethamphetamine, alprazolam, or other illegal or legal drug) that is contaminated or mixed with F / FA, method 1, or any of methods 1.1-1.93;

[0135] 1.95 Method 1, or any of Methods 1.1-1.94, in which F / FA is or was administered as general anesthesia (e.g., surgical anesthesia);

[0136] 1.96 Method 1.95, in which the general anesthesia further comprises or included one or more of an inhaled anesthetic (e.g., isoflurane, cefoflurane, desflurane, nitrous oxide, halothane, methoxyflurane), another opioid agonist (e.g., morphine, oxycodone), a sedative or hypnotic (e.g., propofol, midazolam, ketamine, etomidate), or a muscle relaxant (e.g., atracurium, mivacurium, pancuronium, rocuronium, vecuronium, cistracurium, succinylcholine);

[0137] 1.97 Method 1.95 or 1.96, where the patient has difficulty coming out of anesthesia, e.g. due to persistent respiratory depression;

[0138] 1.98 Method 1, or any of Methods 1.1-1.97, where the patient has not responded or has responded inadequately (e.g., with respect to signs or symptoms of respiratory depression) to a single dose of a μ-opioid antagonist (e.g., naloxone or naltrexone, e.g., 0.1-4 mg) administered by any route (e.g., intranasally, intravenously, subcutaneously, or intramuscularly);

[0139] 1.99 The patient has not responded or has responded inadequately (e.g., in terms of signs or symptoms of respiratory depression) to multiple doses of a μ-opioid antagonist (e.g., naloxone or naltrexone, e.g., 0.4-20 mg total) administered by any route (e.g., intranasally, intravenously, subcutaneously, or intramuscularly), Method 1, or any of Methods 1.1-1.97;

[0140] 1.100 The patient has experienced a recurrence of respiratory depression after single or multiple doses of a μ-opioid antagonist (e.g., naloxone or naltrexone, e.g., intranasal, intravenous, subcutaneous, or intramuscular) administered by any route, Method 1, or any of Methods 1.1-1.99;

[0141] 1.101 The patient has experienced one or more opioid withdrawal symptoms or other adverse events (e.g., agitation, combativeness, laryngospasm, pulmonary edema, hemodynamic instability, or cardiac arrhythmias) after single or multiple doses of a μ-opioid antagonist (e.g., naloxone or naltrexone, e.g., intranasal, intravenous, subcutaneous, or intramuscular) administered by any route, Method 1, or any of Methods 1.1-1.100;

[0142] 1.102 Any of methods 1.98-1.101, wherein the μ-opioid antagonist is naloxone, naltrexone, or nalmefene;

[0143] 1.103 Any of methods 1.98-1.101, wherein the μ opioid antagonist is naloxone;

[0144] 1.104 Method 1, or any of methods 1.1-1.103, in which the patient has received at least one dose of naloxone and is experiencing one or more opioid withdrawal symptoms or adverse events that contraindicate further administration of naloxone;

[0145] 1.105 The use of naloxone is contraindicated for any reason, either method 1 or methods 1.1 to 1.104;

[0146] 1.106 The patient has previously suffered an opioid overdose, either method 1 or methods 1.1-1.105;

[0147] 1.107 Method 1, or any of Methods 1.1 to 1.106, where the patient has been confirmed to have an F / FA overdose by toxicological or forensic methods (e.g., by confirming the presence of F / FA in the patient's blood, or in the patient's drugs or drug paraphernalia);

[0148] 1.108 Method 1, or any of Methods 1.1-1.107, wherein the effective amount of the compound of Formula I is an amount effective to reverse one or more of respiratory arrest, respiratory depression, skeletal muscle spasms, chest wall rigidity, laryngospasm, pupillary constriction, cardiac arrest, bradycardia, or unconsciousness;

[0149] 1.109 Method 1, or any of Methods 1.1-1.108, wherein the effective amount of the compound of formula I is from 0.1 mg to 200 mg, e.g., from 1 to 200 mg, or from 10 to 150 mg, or from 25 to 100 mg, or from 50 to 100 mg, or from 75 to 100 mg, or from 25 to 75 mg, or from 25 to 50 mg, or from 1 to 50 mg, or from 1 to 25 mg, 0.1 to 50 mg, 2.5 mg to 50 mg, or for long acting formulations, from 25 mg to 1500 mg, e.g., from 50 mg to 500 mg, or from 250 mg to 1000 mg, or from 250 mg to 750 mg, or from 75 mg to 300 mg;

[0150] 1.110 Method 1.109, in which the effective amount is administered as a single dose;

[0151] 1.111 Method 1.109, wherein an effective amount is administered two or more times within less than 30 minutes (e.g., less than 20 minutes, or less than 15 minutes, or less than 10 minutes);

[0152] 1.112 Method 1, or any of Methods 1.1-1.111, wherein an effective amount of a compound of Formula I is administered by intranasal administration (e.g., as an aerosol, mist, or powder for inhalation);

[0153] 1.113 Method 1, or any of Methods 1.1-1.111, wherein an effective amount of a compound of Formula I is administered via the oral mucosa, for example, by a fast dissolving oral tablet (e.g., a fast dissolving sublingual tablet);

[0154] 1.114 Method 1, or any of Methods 1.1-1.111, wherein an effective amount of a compound of Formula I is administered by injection (e.g., intravenous, intramuscular, intrathecal, intraperitoneal or subcutaneous injection);

[0155] 1.115 Any of the above methods, wherein the method does not include co-administration of another opioid antagonist (e.g., naloxone, naltrexone, nalmefene, methadone, nalorphine, levallorphan, samidorphan, nalodeine, cyprodim, or nor-binaltorphimine);

[0156] 1.116 The method is 1 is H and prodrugs of the compounds of formula I (i.e., R 1 is as described above, -C(O)-OC(R a )(R b )(R c ), -C(O)-O-CH2-OC(R a )(R b )(R c ) or -C(R 6 )(R 7 )-OC(O)-R 8any of the above methods, comprising administering a pharmaceutical composition comprising both

[0157] 1.117 Any of the above methods, wherein the compound of formula I is the only pharmacological treatment for the overdose (e.g., other than supportive interventions such as administration of oxygen, cardiopulmonary resuscitation, chest compressions and fluids);

[0158] 1.118 Any of the above methods, wherein the method is for the treatment or reversal of F / FA overconsumption;

[0159] 1.119 Any of the above methods, wherein the method is for the treatment or reversal of F / FA-induced respiratory depression;

[0160] 1.120 Any of the above methods, wherein the method is for the treatment or reversal of F / FA-induced muscle stiffness;

[0161] 1.121 Any of the above methods, wherein the method is for the treatment or reversal of F / A induced laryngospasm;

[0162] 1.122 Any of the above methods, wherein the method is for inhibition of F / FA-induced β-arrestin signaling in the central nervous system (e.g., in the locus coeruleus);

[0163] 1.123 Any of the above methods, wherein the method is for inhibition of F / FA-induced β-arrestin signaling in the central nervous system (e.g., in the locus coeruleus);

[0164] 1.124 Any of the above methods, wherein the method is for the prevention of death from F / FA overdose;

[0165] 1.125 Any of the above methods, wherein the method is a method for anesthesia recovery (e.g., emergence from anesthesia, such as after surgery).

[0166] 1.126 Any of the above methods, wherein the F / FA is a F / FA disclosed throughout this specification;

[0167] 1.127 Any of the above methods wherein F / FA is selected from fentanyl, sufentanil, alfentanil, remifentanil, carfentanil, thiafentanil, lofentanil, ocfentanil, trefentanil, and briffentanil;

[0168] 1.128 Any of the above methods, wherein F / FA is selected from fentanyl, sufentanil, alfentanil, and carfentanil;

[0169] 1.129 Any of the above methods, wherein the F / FA is fentanyl;

[0170] 1.130 Any of the above methods, wherein the method does not cause in the patient induced withdrawal, e.g., withdrawal symptoms selected from tachycardia, nausea, vomiting, diarrhea, extreme anxiety, restless legs, muscle pain, and profuse sweating;

[0171] 1.131 Any of methods 1 or 1.1-1.130, where the source of the F / FA is another illicit drug with which the F / FA is mixed, such as cocaine, heroin, oxycodone, amphetamine, methamphetamine, or marijuana;

[0172] 1.132 The method is (a) Treatment or reversal of drug overdose; (b) treatment or reversal of drug-induced respiratory depression; (c) treatment or reversal of drug-induced muscle rigidity; (d) Treating or reversing drug-induced laryngospasm; or (e) Preventing drug overdose deaths The method of claim 1, Any of methods 1 or 1.1 to 1.130, wherein the drug is an illicit drug that is a F / FA mixture;

[0173] 1.133 Method 1.132, in which the illegal drug is heroin, cocaine, amphetamine, methamphetamine, oxycodone, or marijuana;

[0174] 1.134 Method 1.132 or 1.133, where the risk of overdose, respiratory depression, muscle rigidity, laryngospasm, and / or death is primarily or exclusively attributable to F / FA contamination in the illicit drug (e.g., without the F / FA contamination, the illicit drug would not have caused the risk of overdose, respiratory depression, muscle rigidity, laryngospasm, and / or death).

[0175] In any of the embodiments of Method 1 and subsequent embodiments in which a compound of the present disclosure is administered with one or more second therapeutic agents, the one or more second therapeutic agents may be administered as part of a pharmaceutical composition comprising a compound of the present disclosure. Alternatively, the one or more second therapeutic agents may be administered in a separate pharmaceutical composition (such as a pill, tablet, capsule, and injection) that is administered simultaneously, sequentially, or separately from the administration of the compound of the present disclosure.

[0176] In a second aspect, the disclosure provides the use of a compound of the disclosure, e.g., any of the compounds of Formula I, or described in any of the embodiments of Methods 1.1-1.71, in the manufacture of a medicament for use by Method 1 or any of Methods 1.1-1.134.

[0177] In a third aspect, the disclosure provides a compound of the disclosure, e.g., any of the compounds of formula I, or described in any of the embodiments of Methods 1.1-1.71, for use according to Method 1 or any of Methods 1.1-1.134.

[0178] Without being bound by theory, compounds of the present disclosure, such as the compound of formula A, are known to inhibit 5-HT 2ADue to their D1 and μ opioid modulating activity, and especially due to their biased μ opioid receptor activity, they are unexpectedly effective in reversing symptoms of F / FA overdose, particularly respiratory depression, chest wall rigidity and laryngospasm. This may be due in particular to the activity of these compounds as μ receptor antagonists via β-arrestin signaling. It is believed that this may be due to their activity as α1 adrenergic antagonists, indirect NMDA and AMPA antagonists, and potentially indirect actions on GABA expressing neurons. These properties are highly unique and are not shared with conventional μ opioid receptor antagonists, such as naloxone, used both for opioid overdose treatment and surgical reversal of opioid agonism.

[0179] The compounds disclosed herein are also highly beneficial in the treatment of acute overdose and chronic opioid addiction because they do not induce opioid withdrawal symptoms as opioid cessation or opioid antagonist treatment can induce. Opioid withdrawal syndrome can be very intense in addicted patients and can include symptoms such as tachycardia, nausea, vomiting, diarrhea, extreme anxiety, restless legs, muscle pain, and profuse sweating. These withdrawal symptoms are the result of the body's adaptation to the presence of opioids, resulting in tolerance and physical dependence. In severe cases, abrupt cessation of opioid abuse or treatment with opioid antagonists can result in withdrawal symptoms lasting for weeks or months. Administration of opioid antagonists such as naloxone or naltrexone, especially at high doses, can hasten the acute withdrawal effect, especially in patients suffering from acute overdose of F / FA. In patients suffering from an overdose of a weak opioid agonist such as heroin, antagonist treatment can be used with small repeated doses to avoid or minimize such withdrawal syndromes. However, in acute F / FA overdoses, such low doses of antagonists are ineffective, and therefore it is often not possible to avoid severe withdrawal with traditional antagonist treatments in order to have any chance of reversing the overdose.

[0180] In some embodiments of the present disclosure, the compounds of formula I have one or more biologically labile functional groups disposed within the compound such that natural metabolic activity removes the labile functional groups to yield another compound of formula I. For example, a group R 1 C(O)-OC(R a )(R b )(R c ), -C(O)-O-CH2-OC(R a )(R b )(R c ) or -C(R 6 )(R 7 )-OC(O)-R 8 Under biological conditions, this substituent undergoes hydrolysis to give R 1 gives the same compound where R 1 is H. Some of these prodrugs have little or no or only moderate biological activity, but 1 When hydrolyzed to a compound where R is H, the compound may have strong biological activity. Thus, depending on the compound selected, administration of the compounds of the present disclosure to a patient in need thereof may result in immediate biological and therapeutic effects, or immediate and delayed biological and therapeutic effects, or only delayed biological and therapeutic effects. Such prodrug compounds are therefore suitable for use in treating conditions where R 1 is H. In certain embodiments, the group R 1 The nature of the compound of formula I obtained is such that R 1 is substantially more lipophilic than the corresponding compound of formula I where is H, such that the prodrug compound crosses the blood-brain barrier and accumulates in central nervous system (CNS) tissue much more rapidly, followed by rapid hydrolysis of the labile group that acquires the CNS. Overall, this may result in a more rapid action of the compound to reverse the effects of μ receptor activation.

[0181] In another embodiment, the methods of the present disclosure provide for the administration of a pharmaceutical composition comprising both a compound of formula I and a prodrug of the same. Thus, the composition comprises R 1 Certain compounds of formula I, wherein R 1 -C(O)-OC(R a )(R b )(R c ), -C(O)-O-CH2-OC(R a )(R b )(R c ) or -C(R 6 )(R 7 )-OC(O)-R 8 In such an embodiment, the prodrug group R 1 Depending on the nature of R, the composition may 1 The instant release effect due to the rapid absorption and action of the compounds of formula I where R is H can be combined with a sustained or delayed release effect due to the slow hydrolysis of the prodrug versions of the compounds, over a period of time (e.g., 1-3 hours, 6-12 hours, 12-48 hours, 2-3 days). 1 is H. Thus, in certain embodiments, the present disclosure also provides compounds of formula I, 1 a first compound of formula I, wherein R 1 -C(O)-OC(R a )(R b )(R c ), -C(O)-O-CH2-OC(R a )(R b )(R c ) or -C(R 6 )(R 7 )-OC(O)-R 8 In a further embodiment of this aspect, R 1 Both the compound of Formula I, where is H, and the prodrug compound of Formula I can be as described in any of Embodiments 1.1-1.70, and the pharmaceutical compositions containing same can be as described in other pharmaceutical composition embodiments described herein.

[0182] As used herein, unless otherwise specified, "alkyl" refers to a saturated or unsaturated hydrocarbon moiety, e.g., from 1 to 21 carbon atoms in length; such alkyl may be straight or branched chain (e.g., n-butyl or tert-butyl), and is preferably straight chain, unless otherwise specified. For example, "C 1-21 "Alkyl" refers to an alkyl having 1 to 21 carbon atoms. In one embodiment, the alkyl is selected from the group consisting of one or more hydroxyl or C 1-22 In another embodiment, the alkyl group contains 1 to 21 carbon atoms, is preferably straight chained, and may be saturated or unsaturated, e.g., in some embodiments, R 1 is an alkyl chain containing 1 to 21 carbon atoms, preferably 6 to 15 carbon atoms, 16 to 21 carbon atoms, e.g., such that, when cleaved from a compound of formula I, it forms, together with the -C(O)- to which it is attached, the residue of a natural or unnatural, saturated or unsaturated fatty acid.

[0183] The term "pharmaceutical acceptable diluent or carrier" is intended to mean diluents and carriers that are useful in pharmaceutical formulations and do not contain any substances that are known to be allergenic, pyrogenic or pathogenic and potentially cause or promote disease. Thus, pharmaceutical acceptable diluents or carriers exclude body fluids such as blood, urine, cerebrospinal fluid and saliva, and their components such as blood cells and circulating proteins. Suitable pharmaceutical acceptable diluents and carriers can be found in any of several well-known treatises on pharmaceutical formulations, such as Goodman and Gilman, eds., The Pharmacological Basis of Therapeutics, Tenth Edition, McGraw Hill, 2001; Remington's Pharmaceutical Sciences, 20th Ed., Lippincott Williams & Wilkins., 2000; and Martindale, The Extra Pharmacopoeia, Thirty-Second Edition (The Pharmaceutical Press, London, 1999); all of which are incorporated herein by reference in their entirety.

[0184] The terms "purified," "in purified form," or "in isolated and purified form" with respect to a compound refer to the physical state of said compound after it has been isolated from a synthetic process (e.g., from a reaction mixture), or from a natural source, or from a combination thereof. Thus, the terms "purified," "in purified form," or "in isolated and purified form" with respect to a compound refer to the physical state of said compound after it has been obtained from a purification process described herein or known to those of skill in the art (e.g., chromatography, recrystallization, LC-MS and LC-MS / MS techniques, etc.) with sufficient purity to be characterized by standard analytical techniques described herein or known to those of skill in the art.

[0185] Unless otherwise specified, the compound of the present disclosure can be in free base form or in salt form, such as pharmaceutically acceptable salt form, for example, as an acid addition salt.The acid addition salt of the compound of the present disclosure that is sufficiently basic is, for example, an acid addition salt with inorganic acid or organic acid, for example, hydrochloric acid or toluenesulfonic acid.In addition, the salt of the compound of the present disclosure that is sufficiently acidic is an alkali metal salt, for example, sodium salt or potassium salt, or a salt with an organic base that provides physiologically acceptable cation.In certain embodiments, the salt of the compound of the present disclosure is a toluenesulfonic acid addition salt.

[0186] The compounds of the present disclosure are intended for use as pharmaceuticals, and therefore pharma- ceutically acceptable salts are preferred. Salts that are not suitable for pharmaceutical use may be useful, for example, for the isolation or purification of the free compounds of the present disclosure, and therefore are also included within the scope of the compounds of the present disclosure.

[0187] The compounds of the present disclosure may contain one or more asymmetric carbon atoms. Thus, the compounds exist as individual isomers, e.g., in enantiomeric or diastereomeric forms, or as mixtures of individual forms, e.g., racemic / diastereomeric mixtures. Isomers in which the asymmetric center is in the (R)-, (S)-, or (R,S)-configuration may exist. It is understood that the present invention encompasses both individual optically active isomers as well as mixtures thereof (e.g., racemic / diastereomeric mixtures). Thus, the compounds of the present disclosure may be racemic mixtures or may be primarily, e.g., in the form of pure or substantially pure isomers, e.g., greater than 70% enantiomeric / diastereomeric excess ("ee"), preferably greater than 80% ee, more preferably greater than 90% ee, and most preferably greater than 95% ee. Purification of said isomers and separation of said isomeric mixtures can be achieved by standard techniques known in the art, such as, for example, column chromatography, preparative TLC, preparative HPLC, and simulated moving bed.

[0188] Geometric isomers, by nature of substituents about a double bond or a ring, may exist in cis (Z) or trans (E) form and both isomeric forms are encompassed within the scope of the present invention.

[0189] The compounds of the present disclosure are also intended to include their stable and unstable isotopes. Stable isotopes are non-radioactive isotopes that contain one additional neutron compared to the abundant nuclide of the same species (i.e., element). The activity of compounds containing such isotopes is expected to be retained, and such compounds are also useful for measuring the pharmacokinetics of non-isotopic analogs. For example, hydrogen atoms at certain positions of the compounds of the present disclosure can be replaced with deuterium (a non-radioactive stable isotope). Examples of known stable isotopes include deuterium ( 2 H or D), 13 C. 15 N, 18 Alternatively, unstable isotopes, which are radioactive isotopes that contain additional neutrons compared to the abundant nuclide of the same species (i.e., element), such as: 123 I, 131 I, 125 I, 11 C. 18 F can be replaced by the corresponding abundant species of I, C, and F. Another example of a useful isotope of the compounds of the present disclosure is: 11 C isotopes. These radioisotopes are useful for radioimaging and / or pharmacokinetic studies of the compounds of the present disclosure. Additionally, substitution of atoms with heavier isotopes that have a natural isotopic distribution can result in desirable changes in pharmacokinetic rates if these substitutions are made at metabolically responsible sites. For example, deuterium ( 2 Incorporation of H) can slow metabolic degradation if the hydrogen position is a site of enzymatic or metabolic activity.

[0190] By "effective amount" is meant a "therapeutically effective amount," i.e., an amount of a compound of the disclosure (e.g., contained in a pharmaceutical composition or dosage form) that, when administered to a subject suffering from a disease or disorder, is effective to cause relief, remission, or regression of the disease or disorder over the period of time intended for treatment.

[0191] Dosages employed in the practice of the present invention will, of course, vary depending, for example, on the particular disease or condition being treated, the particular compound of the present disclosure being used, the mode of administration, and the desired therapy. Unless otherwise specified, amounts of compounds of the present disclosure for administration (whether administered as a free base or as a salt form) refer to or are based on the amount of the compound of the present disclosure in free base form (i.e., amount calculations are based on the amount of free base).

[0192] The compounds of the present disclosure can be administered by any suitable route, including oral, parenteral (intravenous, intramuscular or subcutaneous) or transdermal.In certain embodiments, the compounds of the present disclosure are preferably administered parenterally, for example, by injection, for example intramuscular or subcutaneous injection, for example in depot formulations.

[0193] The pharma- ceutically acceptable salts of the compounds of the present disclosure can be synthesized from the parent compound containing a basic or acidic moiety by conventional chemical methods.In general, such salts can be prepared by reacting the free base form of these compounds with a stoichiometric amount of an appropriate acid in water or in an organic solvent, or in a mixture thereof; generally, non-aqueous media such as ether, ethyl acetate, ethanol, isopropanol, or acetonitrile are preferred.

[0194] Pharmaceutical compositions containing the compounds of the present disclosure can be prepared using conventional diluents or excipients (including but not limited to sesame oil) and techniques known in the galenic art.Accordingly, oral dosage forms include tablets, capsules, liquids, and suspensions.

[0195] The term "co-administration" when referring to therapeutic use means administration of two or more active ingredients to a patient as part of a regimen for the treatment of a disease or disorder, whether the two or more active ingredients are administered at the same time or at different times, or whether they are administered by the same or different routes of administration. Co-administration of two or more active ingredients may be at different times on the same day, on different dates, or with different frequencies.

[0196] The term "concurrently" when referring to therapeutic use means that two or more active ingredients are administered at the same time or at about the same time and by the same route of administration.

[0197] The term "separately" when referring to therapeutic use means that two or more active ingredients are administered simultaneously or at about the same time by different routes of administration.

[0198] Methods for preparing the compounds of the present disclosure: Methods for the synthesis of compounds of formula A, including the synthesis of intermediates used in the synthetic schemes described below, are disclosed, for example, in U.S. Pat. Nos. 8,309,722 and 10,245,260, U.S. Patent Application Publication No. 2021 / 00009592, and WO 2020 / 131895. Synthesis of analogous fused gamma carbolines is disclosed, for example, in U.S. Pat. Nos. 8,309,722, 8,993,572, 10,077,267, 10,961,245, 10,906,906, U.S. Patent Application Publication No. 2021 / 0163481, and WO 2020 / 132605 (U.S. Patent Application Publication No. 2022 / 0048910) (each of which is incorporated herein by reference in its entirety). Compounds of the present disclosure can be prepared using similar procedures.

[0199] Isolation or purification of diastereomers of compounds of the present disclosure can be achieved by conventional methods known in the art, such as column purification, preparative thin layer chromatography, preparative HPLC, crystallization, trituration, chiral salt resolution, and simulated moving bed.

[0200] Salts of the compounds of the present disclosure can be prepared as described in U.S. Pat. Nos. 6,552,017; 7,183,282; 8,648,077; 10,654,854; and 11,014,925, each of which is incorporated herein by reference in its entirety.

[0201] The diastereomers of the compounds prepared can be separated, for example, by HPLC using, for example, a CHIRALPAK® AY-H, 5μ, 30×250 mm column operated at room temperature and eluted with an ethanol / hexane / dimethylethylamine solvent system. EXAMPLES

[0202] Example 1: Synthesis of (6bR,10aS)-8-(3-(4-fluorophenoxy)propyl)-6b,7,8,9,10,10a-hexahydro-1H-pyrido[3',4':4,5]pyrrolo[1,2,3-de]quinoxalin-2(3H)-one [ka] A mixture of (6bR,10aS)-6b,7,8,9,10,10a-hexahydro-1H-pyrido[3',4':4,5]pyrrolo[1,2,3-de]quinoxalin-2(3H)-one (100 mg, 0.436 mmol), 1-(3-chloroproxy)-4-fluorobenzene (100 μL, 0.65 mmol) and potassium iodide (KI) (144 mg, 0.87 mmol) in dimethylformamide (DMF) (2 mL) is degassed with argon for 3 minutes and N,N-diisopropylethylamine (DIPEA) (150 μL, 0.87 mmol) is added. The resulting mixture is heated to 78° C. and stirred at this temperature for 2 hours. The mixture is cooled to room temperature and then filtered. The filter cake is purified by silica gel column chromatography using a gradient of 0-100% ethyl acetate in methanol / 7N NH3 in methanol mixture (1:0.1 v / v) as eluent to give a partially purified product, which is further purified using a semi-preparative HPLC system using a gradient of 0-60% acetonitrile in water containing 0.1% formic acid over 16 min to give the title product as a solid (50 mg, 30% yield). MS (ESI) m / z 406.2 [M+1] + . 1 H NMR (500 MHz, DMSO-d6) δ 10.3 (s, 1H), 7.2-7.1 (m, 2H), 7.0-6.9 (m, 2H), 6.8 (dd, J=1.03, 7.25 Hz, 1H), 6.6 (t, J=7.55 Hz, 1H), 6.6 (dd, J=1.07, 7.79 Hz, 1H), 4.0 (t, J=6.35 Hz, 2H), 3.8 (d, J=14.74 Hz, 1H), 3.3-3.2 (m, 3H), 2.9 (dd, J=6.35, 11.13 Hz, 1H), 2.7-2.6 (m, 1H), 2.5-2.3 (m, 2H), 2.1 (t, J=11.66 Hz, 1H), 2.0 (d, J=14.50 Hz, 1H), 1.9-1.8 (m, 3H), 1.7 (t, J=11.04 Hz, 1H).

[0203] Example 2: Synthesis of (6bR,10aS)-8-(3-(6-fluoro-1H-indazol-3-yl)propyl)-6b,7,8,9,10,10a-hexahydro-1H-pyrido[3',4':4,5]pyrrolo[1,2,3-de]quinoxalin-2(3H)-one [ka]

[0204] Step 1: To a stirred solution of BCl3·MeS (10.8 g, 60 mmol) in toluene at 0-5 °C, 3-fluoroaniline (5.6 mL, 58 mmol) is added, followed by 4-chlorobutyronitrile (7.12 g, 68.73 mmol) and aluminum chloride (AlCl3) (8.0 g, 60.01 mmol). The mixture is stirred at 130 °C overnight and cooled to 50 °C. Hydrochloric acid (3N, 30 mL) is carefully added and the resulting solution is stirred at 90 °C overnight. The resulting brown solution is cooled to room temperature and evaporated to dryness. The residue is dissolved in dichloromethane (DCM) (20 mL) and basified to pH 7-8 with saturated Na2CO3. The organic phase is separated, dried over Na2CO3 and then concentrated. The residue is purified by silica gel column chromatography using a gradient of 0-20% ethyl acetate in hexane as eluent to give 2'-amino-4-chloro-4'-fluorobutyrophenone as a yellow solid (3.5 g, 28% yield). MS (ESI) m / z 216.1 [M+1] + .

[0205] Step 2: To a suspension of 2'-amino-4-chloro-4'-fluorobutyrophenone (680 mg, 3.2 mmol) in concentrated HCl (14 mL) at 0-5 °C, NaNO2 (248 mg, 3.5 mmol) in water (3 mL) is added. The resulting brown solution is stirred at 0-5 °C for 1 h, then SnCl2·2H2O (1.74 g, 7.7 mmol) in concentrated HCl (3 mL) is added. The mixture is stirred at 0-5 °C for an additional 1 h, then dichloromethane (30 mL) is added. The reaction mixture is filtered, the filter cake is dried over K2CO3 and evaporated to dryness. The residue is purified by silica gel column chromatography using a 0-35% ethyl acetate in hexane gradient as eluent to give 3-(3-chloropropyl)-6-fluoro-1H-indazole as a white solid (400 mg, 60% yield). MS (ESI) m / z 213.1 [M+1] + .

[0206] Step 3: (6bR,10aS)-6b,7,8,9,10,10a-hexahydro-1H-pyrido[3',4':4,5]pyrrolo[1,2,3-de]quinoxalin-2(3H)-one (100 mg, 0.436 mmol), 3-(3-chloropropyl)-6-fluoro-1H-indazole (124 mg, 0.65 mmol) and KI (144 mg, 0.87 mmol) are degassed with argon for 3 minutes and DIPEA (150 μL, 0.87 mmol) is added. The resulting mixture is stirred at 78 ° C for 2 hours and then cooled to room temperature. The resulting precipitate is filtered. The filter cake is purified on a semi-preparative HPLC system using a gradient of 0-60% acetonitrile in water containing 0.1% formic acid over 16 min to give (6bR,10aS)-8-(3-(6-fluoro-1H-indazol-3-yl)propyl)-6b,7,8,9,10,10a-hexahydro-1H-pyrido[3',4':4,5]pyrrolo[1,2,3-de]quinoxalin-2(3H)-one as an off-white solid (50 mg, 28% yield). MS (ESI) m / z 406.2 [M+1] + . 1H NMR (500 MHz, DMSO-d6) δ 12.7 (s, 1H), 10.3 (s, 1H), 7.8 (dd, J=5.24, 8.76 Hz, 1H), 7.2 (dd, J=2.19, 9.75 Hz, 1H), 6.9 (ddd, J=2.22, 8.69, 9.41 Hz, 1H), 6.8-6.7 (m, 1H), 6.6 (t, J=7.53 Hz, 1H), 6.6 (dd, J=1.07, 7.83 Hz, 1H), 3.8 (d, J=14.51 Hz, 1H), 3.3-3.2 (m, 1H), 3.2 (s, 2H), 2.9 (dt, J=6.35, 14.79 Hz, 3H), 2.7-2.6 (m, 1H), 2.4-2.2 (m, 2H), 2.1 (t, J=11.42 Hz, 1H), 2.0-1.8 (m, 3H), 1.8-1.7 (m, 1H), 1.7 (t, J=10.89 Hz, 1H).

[0207] Example 3: Synthesis of (6bR,10aS)-8-(3-(6-fluorobenzo[d]isoxazol-3-yl)propyl)-6b,7,8,9,10,10a-hexahydro-1H-pyrido[3',4':4,5]pyrrolo[1,2,3-de]quinoxalin-2(3H)-one [ka]

[0208] A mixture of (6bR,10aS)-6b,7,8,9,10,10a-hexahydro-1H-pyrido[3',4':4,5]pyrrolo[1,2,3-de]quinoxalin-2(3H)-one (148 mg, 0.65 mmol), 3-(3-chloropropyl)-6-fluorobenzo[d]isoxazole (276 mg, 1.3 mmol) and KI (210 mg, 1.3 mmol) is degassed with argon, then DIPEA (220 μL, 1.3 mmol) is added. The resulting mixture is stirred at 78° C. for 2 hours, then cooled to room temperature. The mixture is concentrated in vacuum. The residue is suspended in dichloromethane (50 mL) and then washed with water (20 mL). The organic phase is dried over K2CO3 and then concentrated in vacuum. The crude product is purified by silica gel column chromatography using a gradient of 0-10% methanol in ethyl acetate containing 1% 7N NH3 to give the title product as a solid (80 mg, 30% yield). MS (ESI) m / z 407.2 [M+1] + . 1 H NMR (500 MHz, DMSO-d6) δ 10.3 (s, 1H), 8.0-7.9 (m, 1H), 7.7 (dd, J=2.15, 9.19 Hz, 1H), 7.3 (td, J=2.20, 9.09 Hz, 1H), 6.8 (d, J=7.22 Hz, 1H), 6.6 (t, J=7.54 Hz, 1H), 6.6 (d, J=7.75 Hz, 1H), 3.8 (d, J=14.53 Hz, 1H), 3.3 (s, 1H), 3.2 (s, 1H), 3.2-3.1 (m, 1H), 3.0 (t, J=7.45 Hz, 2H), 2.9-2.8 (m, 1H), 2.7-2.5 (m, 1H), 2.4-2.2 (m, 2H), 2.2-2.0 (m, 1H), 2.0-1.8 (m, 3H), 1.8-1.6 (m, 2H).

[0209] Example 4: Synthesis of 4-(3-((6bR,10aS)-2-oxo-2,3,6b,7,10,10a-hexahydro-1H-pyrido[3',4':4,5]-pyrrolo[1,2,3-de]quinoxalin-8(9H)-yl)propoxy)benzonitrile [ka]

[0210] Step 1: A degassed suspension of ethyl (4aS,9bR)-6-bromo-3,4,4a,5-tetrahydro-1H-pyrido[4,3-b]indole-2(9bH)-carboxylate (21.5 g, 66.2 mmol), chloroacetamide (9.3 g, 100 mmol), and KI (17.7 g, 107 mmol) in dioxane (60 mL) is stirred for 48 h at 104° C. The solvent is removed and the residue is suspended in dichloromethane (200 mL) and extracted with water (100 mL). The separated dichloromethane phase is dried over potassium carbonate (K2CO3) for 1 h and then filtered. The filtrate is evaporated to give the crude product as a brown oil. Ethyl acetate (100 mL) is added to the brown oil and the mixture is then sonicated for 2 min. A yellow solid gradually precipitates from the mixture and becomes a gel after standing at room temperature for another 2 h. Additional ethyl acetate (10 mL) is added and the resulting solid is filtered. The filter cake is rinsed with ethyl acetate (2 mL) and further dried under high vacuum to give ethyl (4aS,9bR)-5-(2-amino-2-oxoethyl)-6-bromo-3,4,4a,5-tetrahydro-1H-pyrido[4,3-b]indole-2(9bH)-carboxylate as an off-white solid (19 g, 75% yield). The product is used directly in the next step without further purification. MS (ESI) m / z 382.0 [M+H] + .

[0211] Step 2: (4aS,9bR)-5-(2-amino-2-oxoethyl)-6-bromo-3,4,4a,5-tetrahydro-1H-pyrido[4,3-b]indole-2(9bH)-ethyl carboxylate (12.9 g, 33.7 mmol), KI (10.6 g, 63.8 mmol), CuI (1.34 g, 6.74 mmol) in dioxane (50 mL) is bubbled with argon for 5 minutes. N,N,N,N'-tetramethylethylenediamine (3 mL) is added to the mixture, and the resulting suspension is stirred at 100°C for 48 hours. The reaction mixture is cooled to room temperature and poured onto a silica gel pad and filtered. The filter cake is rinsed with ethyl acetate (1 L x 2). The combined filtrates are concentrated to dryness to give the product (6bR,10aS)-2-oxo-2,3,6b,9,10,10a-hexahydro-1H,7H-pyrido[3',4':4,5]pyrrolo[1,2,3-de]quinoxaline-8-carboxylic acid ethyl ester as a white solid (8 g, 79% yield). MS (ESI) m / z 302.1 [M+H] + .

[0212] Step 3: (6bR,10aS)-2-oxo-2,3,6b,9,10,10a-hexahydro-1H,7H-pyrido[3',4':4,5]pyrrolo[1,2,3-de]quinoxaline-8-carboxylic acid ethyl ester (6.4 g, 21.2 mmol) is suspended in HBr / acetic acid solution (64 mL, 33% w / w) at room temperature. The mixture is heated at 50° C. for 16 hours. After cooling and treatment with ethyl acetate (300 mL), the mixture is filtered. The filter cake is washed with ethyl acetate (300 mL) and then dried under vacuum. The obtained HBr salt is then suspended in methanol (200 mL) and cooled with dry ice in isopropanol. Under vigorous stirring, ammonia solution (10 mL, 7N in methanol) is slowly added to the suspension to adjust the pH of the mixture to 10. The resulting mixture was dried in vacuum without further purification to give crude (6bR,10aS)-2-oxo-2,3,6b,9,10,10a-hexahydro-1H,7H-pyrido[3',4':4,5]pyrrolo[1,2,3-de]quinoxaline (8.0 g), which was used directly in the next step. MS (ESI) m / z 230.2 [M+H]+ .

[0213] Step 4: (6bR,10aS)-6b,7,8,9,10,10a-hexahydro-1H-pyrido[3',4':4,5]pyrrolo[1,2,3-de]quinoxalin-2(3H)-one (100 mg, 0.436 mmol), 4-(3-bromopropoxy)benzonitrile (99 mg, 0.40 mmol) and KI (97 mg, 0.44 mmol) in DMF (2 mL) are bubbled with argon for 3 min and diisopropylethylamine (DIPEA) (80 μL, 0.44 mmol) is added. The resulting mixture is heated to 76 °C and stirred at this temperature for 2 h. The solvent is removed and the residue is purified by silica gel column chromatography using a gradient of 0-100% mixed solvent [ethyl acetate / methanol / 7N NH3 (10:1:0.1 v / v)] in ethyl acetate to give the title product as a white foam (35 mg, 45% yield). MS (ESI) m / z 389.1 [M+1] + . 1 H NMR (500 MHz, DMSO-d6) δ 10.3 (s, 1H), 7.8 (d, J=8.80 Hz, 2H), 7.1 (d, J=8.79 Hz, 2H), 6.8 (d, J=7.39 Hz, 1H), 6.6 (t, J=7.55 Hz, 1H), 6.6 (d, J=6.78 Hz, 1H), 4.1 (t, J=6.36 Hz, 2H), 3.8 (d, J=14.53 Hz, 1H), 3.3-3.2 (m, 3H), 3.0-2.8 (m, 1H), 2.7-2.6 (m, 1H), 2.5-2.3 (m, 2H), 2.2-2.0 (m, 1H), 2.0-1.8 (m, 3H), 1.8-1.7 (m, 1H), 1.7 (t, J=11.00 Hz, 1H).

[0214] Example 5: Synthesis of (6bR,10aS)-8-(3-(4-chlorophenoxy)propyl)-6b,7,8,9,10,10a-hexahydro-1H-pyrido[3',4':4,5]pyrrolo[1,2,3-de]quinoxalin-2(3H)-one [ka]

[0215] To a degassed mixture of (6bR,10aS)-6b,7,8,9,10,10a-hexahydro-1H-pyrido[3',4':4,5]pyrrolo-[1,2,3-de]quinoxalin-2(3H)-one (110 mg, 0.48 mmol), 1-(3-bromopropoxy)-4-chlorobenzene (122 mg, 0.49 mmol) and KI (120 mg, 0.72 mmol) in DMF (2.5 mL) is added DIPEA (100 μL, 0.57 mmol). The resulting mixture is heated to 76 °C and stirred at this temperature for 2 h. The solvent is removed and the residue is purified by silica gel column chromatography using a gradient of 0-100% mixed solvent [ethyl acetate / methanol / 7N NH3 (10:1:0.1 v / v)] in ethyl acetate. The title product is obtained as a white solid (41 mg, 43% yield). (ESI) m / z 398.1 [M+1] + . 1 H NMR (500 MHz, DMSO-d6) δ 10.3 (s, 1H), 7.4-7.2 (m, 2H), 6.9 (d, J=8.90 Hz, 2H), 6.8-6.7 (m, 1H), 6.6 (t, J=7.53 Hz, 1H), 6.6 (dd, J=1.04, 7.80 Hz, 1H), 4.0 (t, J=6.37 Hz, 2H), 3.8 (d, J=14.53 Hz, 1H), 3.3-3.2 (m, 3H), 2.9-2.8 (m, 1H), 2.7-2.6 (m, 1H), 2.4 (ddt, J=6.30, 12.61, 19.24 Hz, 2H), 2.1-2.0 (m, 1H), 2.0-1.9 (m, 1H), 1.9-1.7 (m, 3H), 1.7 (t, J=10.98 Hz, 1H).

[0216] Example 6: Synthesis of (6bR,10aS)-8-(3-(quinolin-8-yloxy)propyl)-6b,7,8,9,10,10a-hexahydro-1H-pyrido[3',4':4,5]pyrrolo[1,2,3-de]quinoxalin-2(3H)-one [ka]

[0217] A mixture of (6bR,10aS)-6b,7,8,9,10,10a-hexahydro-1H-pyrido[3',4':4,5]pyrrolo[1,2,3-de]quinoxalin-2(3H)-one (120 mg, 0.52 mmol), 8-(3-chloropropoxy)quinoline (110 mg, 0.50 mmol) and KI (120 mg, 0.72 mmol) in DMF (2.5 mL) is bubbled with argon for 3 min and DIPEA (100 μL, 0.57 mmol) is added. The resulting mixture is heated to 76 °C and stirred at this temperature for 2 h. The solvent is removed and the residue is suspended in dichloromethane (30 mL) and washed with water (10 mL). The dichloromethane phase is dried over K2CO3. The separated organic phase is evaporated to dryness. The residue is purified by silica gel column chromatography using a gradient of 0-100% mixed solvent [ethyl acetate / methanol / 7N NH3 (10:1:0.1 v / v)] in ethyl acetate to give the title product as a light brown solid (56 mg, 55% yield). (ESI) m / z 415.2 [M+1] + . 1H NMR (500 MHz, DMSO-d6) δ 10.1 (s, 1H), 8.9 (dd, J=1.68, 4.25 Hz, 1H), 8.3 (dd, J=1.71, 8.33 Hz, 1H), 7.7-7.5 (m, 3H), 7.3 (dd, J=1.50, 7.44 Hz, 1H), 7.0-6.8 (m, 1H), 6.8-6.5 (m, 2H), 4.4 (t, J=5.85 Hz, 2H), 3.9 (d, J=14.55 Hz, 1H), 3.8-3.6 (m, 2H), 3.5 (s, 1H), 3.4 (d, J=14.47 Hz, 1H), 2.9 (b, 1H), 2.3 (d, J=23.61 Hz, 5H), 1.3 (d, J=7.00 Hz, 3H).

[0218] Example 7: Receptor Binding Profile Receptor binding is determined for the compound of Example 1 (compound of formula A) and the compounds of Examples 2-6. The following literature procedures are used (each of which is incorporated herein by reference in its entirety): 5-HT 2A :Bryant, HU et al. (1996), Life Sci., 15:1259-1268;D2:Hall, DA and Strange, PG (1997), Brit. J. Pharmacol., 121:731-736;D1:Zhou, QY et al. (1990), Nature, 347:76-80;SERT:Park, YM et al. (1999), Anal. Biochem., 269:94-104; μ opioid receptor: Wang, JB et al. (1994), FEBS Lett., 338:217-222.

[0219] Generally, results are expressed as a percentage of control specific binding obtained in the presence of test compound:

number

number

[0220] I C 50 The values ​​(concentration causing half-maximal inhibition of control specific binding) and Hill coefficients (nH) are determined by nonlinear regression analysis of competition curves generated with mean replicate values ​​using Hill equation curve fitting:

number

number

[0221] The following receptor affinity results are obtained: [Table 1] Additional compounds of formula I are prepared by procedures similar to those described in Examples 1-6. Receptor affinity results for these compounds are shown in the table below: [Table 2]

[0222] Example 8: μ-Opioid Receptor Activity Assay The compound of Example 1 is tested in CHO-K1 cells expressing hOP3 (human μ opioid receptor μ1 subtype) using a HTRF-based cAMP assay kit (cAMP Dynamic2 Assay Kit, from Cisbio, #62AM4PEB). Frozen cells are thawed in a 37°C water bath and resuspended in 10mL of Ham's F-12 medium containing 10% FBS. Cells are harvested by centrifugation and resuspended in assay buffer (5mM KCl, 1.25mM MgSO4, 124mM NaCl, 25mM HEPES, 13.3mM glucose, 1.25mM KH2PO4, 1.45mM CaCl2, 0.5g / L protease-free BSA, supplemented with 1mM IBMX). Buprenorphine, a μ-opioid receptor partial agonist, and naloxone, a μ-opioid receptor antagonist, and DAMGO, a synthetic opioid peptide full agonist, are used as controls.

[0223] For the agonist assay, 12 μL of cell suspension (2500 cells / well) is mixed with 6 μL of forskolin (final assay concentration 10 μM) and 6 μL of increasing concentrations of test compound are combined in the wells of a 384-well white plate and the plate is incubated for 30 min at room temperature. Lysis buffer is added and after a further incubation for 1 h, cAMP concentrations are measured according to the kit instructions. All measurement points are measured in triplicate. Curve fitting is performed using XLfit software (IDBS) and EC 50 Values ​​are determined using a four parameter logistic fit. The agonist assay measures the ability of test compounds to inhibit forskolin-stimulated cAMP accumulation.

[0224] For antagonist assays, 12 μL of cell suspension (2500 cells / well) is mixed with 6 μL of increasing concentrations of test compound, combined in wells of a 384-well white plate, and the plate is incubated at room temperature for 10 min. 2-N-MePhe 4 Add 6 μL of a mixture of -Gly-ol-enkepherin (final assay concentration 10 nM) and forskolin (final assay concentration 10 μM) and incubate the plate for 30 min at room temperature. Add lysis buffer and incubate for a further hour before measuring cAMP concentrations according to the kit instructions. All measurement points are measured in triplicate. Curve fitting is performed using XLfit software (IDBS) to determine the IC 50 Values ​​are determined using a four-parameter logistic fit. B ) is calculated using the modified Cheng-Prusoff equation. The antagonist assay measures the ability of a test compound to reverse the inhibition of forskolin-induced cAMP accumulation caused by DAMGO.

[0225] The results are shown in the table below. The results show that the compound of Example 1 is a weak antagonist of the Mu receptor, with a much higher IC compared to naloxone. 50 It has been demonstrated that the compound of Example 1 has moderately strong partial agonist activity, and that it is a partial agonist with moderately high affinity, exhibiting only about 22% agonist activity compared to DAMGO (compared to about 79% activity of buprenorphine compared to DAMGO). The compound of Example 1 has also been shown to have moderately strong partial agonist activity. [Table 3]

[0226] Buprenorphine is a drug used in opioid withdrawal, but has the problem that users are prone to become addicted due to its high partial agonist activity. To counter this, a commercial combination of buprenorphine and naloxone is used (sold as Suboxone). Without being bound by theory, it is believed that the compounds of the present invention, which are weaker partial Mu agonists than buprenorphine and have some moderate antagonist activity, allow patients to be more effectively treated for opioid withdrawal with a lower risk of addiction.

[0227] These results show that the compounds of the present invention act as partial agonists of the GPCR signaling pathway of μ opioid receptors, but in the presence of full agonists (DAMGO), these compounds effectively compete for receptor binding and therefore act as antagonists of full agonists.In effect, this means that in the presence of opioid drugs such as fentanyl or fentanyl analogs, the compounds of the present invention competitively bind to μ opioid receptors and displace these full agonists from μ opioid receptors.Therefore, in practice, these compounds are effective as antagonists for the purpose of reversing overdose of fentanyl and fentanyl analogs.

[0228] Example 9: GPCR β-arrestin signaling assay The compound of Example 1 is studied using a β-arrestin assay. This assay uses a proprietary technology based on β-galactosidase as a functional reporter to monitor the activation of selected G protein-coupled receptors (GPCRs) in a homogeneous non-imaging assay format. The enzyme is split into two inactive complementary parts, EA and PK, and expressed as a fusion protein in cells. The EA part is fused to β-arrestin and the PK part is fused to the GPCR of interest, the human μ-opioid receptor. When the GPCR is activated and β-arrestin is recruited to the receptor, the two parts of the enzyme are complemented and the enzyme activity is restored, which is detected via a chemiluminescent reagent.

[0229] Proprietary cell lines are seeded in 384 cell microplates in a volume of 20 μL and incubated at 37°C. For agonist determination, cells are incubated with compound of Example 1 to induce a response. An intermediate dilution of compound stock is made to generate 5X compound in assay buffer. 5 μL of 5X compound solution is added to cells and incubated at 37°C for 1.5-3 hours. Vehicle concentration is 1%. For antagonist determination, cells are pre-incubated with compound of Example 1 and then challenged with agonist ([Met]-enkephalin) at an EC80 concentration of agonist. An intermediate dilution of compound stock is made to generate 5X compound in assay buffer. 5 μL of 5X compound solution is added to cells and incubated at 37°C or room temperature for 0.5 hours. Vehicle concentration is 1%. Then 5 μL of 6X EC80 agonist in assay buffer is added and cells are incubated at 37°C for 1.5-3 hours. In both formats, the assay signal is generated by a single addition of 12.5-15 μL of a proprietary detection reagent cocktail, followed by a 1-h incubation at room temperature. The microplate is then read to detect the chemiluminescent signal. Data are analyzed using the CBIS data analysis software suite (ChemInnovation, CA). Control dose-response curves are generated using [Met]-enkephalin as a positive control for the agonist format and naloxone hydrochloride as a positive control for the antagonist format.

[0230] The results are shown in the table below: [Table 4]

[0231] These results demonstrate that the compound of Example 1 does not stimulate β-arrestin signaling through the μ-opioid receptor at concentrations up to 10 μM, but has an IC 50 In contrast, the full opioid agonist [Met]-enkephalin has an EC 50 stimulates β-arrestin signaling.

[0232] Example 10: Alpha 1-adrenergic receptor activity

[0233] Example 10a: Receptor Binding Assay The compound of Example 1 is tested in the human α1A adrenergic receptor antagonist radioligand assay. Standard procedures according to Schwinn, DA et al., J. Biol. Chem. 265:8183-89 (1990) are followed. Human recombinant CHO cells are used in the assay. Assay incubation is carried out for 60 minutes at room temperature. Antagonist radioligands are 3 H]prazosin and the non-specific control is epinephrine (0.1 mM). The compound of Example 1 is used from a 0.01 M stock solution in DMSO.

[0234] The compound of formula 1 is found to be an antagonist of the α1A adrenergic receptor with a binding Ki of 28 nM.

[0235] Example 10b: Functional Assays Further studies are carried out in a functional alpha-1A adrenergic receptor assay that uses aequorin luminescence to measure intracellular calcium responses.

[0236] For the agonist assay, CHO-K1 cells expressing human α1A adrenergic receptors are suspended in Ham's F-12 medium containing 10% FBS. The cells are then harvested by centrifugation and diluted to 3×10 in Falcon tubes. 5Cells are resuspended in pre-warmed assay buffer (DMEM / HAM's F12 w / HEPES) at 1000 cells / mL. Coelenterazine h is added to a final concentration of 5 μM, the tube is wrapped in aluminum foil and placed on a rotating wheel at room temperature for 4 hours. The cells are then diluted 3-fold in assay buffer and transferred to an aluminum foil wrapped beaker. After stirring for 1 hour, 50 μL of cells (5,000 cells / well) are injected into 50 μL of increasing concentrations of the compound of Example 1 in a 96-well plate. Luminescence is immediately recorded for 20 seconds using a luminescence detector. Receptor-independent cellular calcium responses are measured using 50 μM digitonin in assay buffer as a positive control. Phenylephrine is used as a positive control for receptor activity. Agonist activity is measured as the degree of luminescence stimulated by the test compound.

[0237] For antagonist assay, 50 μL of cells (5,000 cells / well) are mixed with 50 μL of compound of Example 1 at increasing concentrations in a 96-well plate and incubated at room temperature for 15 minutes. Then, 50 μL of phenylephrine is added at a final concentration of 50 nM (corresponding to the EC80 of phenylephrine). Luminescence is immediately recorded for 20 seconds using a luminescence detector. Antagonist activity is measured by the decrease in luminescence caused by phenylephrine. Tamsulosin is used as a positive control.

[0238] The results show that the compound of formula 1 has no agonist activity at the receptor, but has an IC 50 It is shown that the antagonist has the following structure:

[0239] Example 11: Competitive inhibition of fentanyl binding The procedure described in Example 10 is used to examine the ability of the compound of Example 1 to functionally inhibit fentanyl-induced β-arrestin signaling.

[0240] Following the agonist protocol, the functional activity of fentanyl is tested in the absence and presence of 10 μM of the compound of Example 1. The results are shown in the table below and in FIG. [Table 5]

[0241] The results demonstrate that the example compounds completely inhibit fentanyl-induced agonism of the μ-opioid receptor β-arrestin signaling pathway.

[0242] Example 12: Pharmacokinetics The oral pharmacokinetics of the compound of Example 1 was studied in cynomolgus monkeys using standard procedures. Oral administration was performed with the compound of Example 1 in the tosylate salt form at a dose of 2.8 mg / kg formulated in PEG-400. Intravenous (IV) administration was performed with the compound of Example 1 in the tosylate salt form at a dose of 1 mg / kg in sterile water containing 45% trapsol (beta cyclodextrin) and 1% DMSO. The results are shown in the table below. [Table 6]

[0243] The compound of formula I is also found to have human plasma protein binding of 91.6%.

[0244] Example 13: Naloxone-induced oxycodone dependence withdrawal study in mice Adult male C57BL / 6J mice are administered oxycodone for 8 days at an escalating dose regimen of 9, 17.8, 23.7, and 33 mg / kg twice daily (7 hours between injections) on days 1-2, 3-4, 5-6, and 7-8, respectively. On the morning of day 9, mice are administered either 0.3, 1, or 3 mg / kg of the compound of Example 1 subcutaneously. This is followed 30 minutes later by an injection of vehicle or an injection of 3 mg / kg of naloxone. A separate cohort of mice serves as negative control, and these mice are administered saline instead of oxycodone on days 1-8. On day 9, these mice are administered either vehicle (followed by naloxone as above) or 3 mg / kg of the compound of Example 1 subcutaneously (followed by naloxone as above).

[0245] On day 9, immediately after injection of naloxone (or vehicle), mice are individually placed in clear plastic cages and observed continuously for 30 min. Mice are monitored for typical physical signs of opioid withdrawal, including jumping, wet dog shakes, paw tremors, backing, ptosis, and diarrhea. All such behaviors are recorded as new occurrences if they are separated by at least 1 s or are interrupted by normal behavior. Animal weights are also recorded immediately before and 30 min after naloxone (or vehicle) injection. Data are analyzed by ANOVA, if necessary, followed by Tukey's test for multiple comparisons. Significance levels are established at p<0.05.

[0246] The results are shown in the table below: [Table 7]

[0247] The total number of symptoms included paw tremors, jumping, and wet dog shakes. In oxycodone-treated mice, naloxone was found to induce significant total number of symptoms, paw tremors, jumping, and weight change (p≦0.0001 for each), indicating induced withdrawal. At all doses tested, the compound of Example 1 significantly reduces the total number of symptoms and paw tremors induced by naloxone. Furthermore, at 3.0 mg / kg, the compound also produces a significant reduction in jumping and attenuated weight loss.

[0248] These results demonstrate that the compound of Example 1 dose-dependently reduces signs and symptoms of opioid withdrawal following abrupt cessation of opioid administration in opioid-dependent rats and prevents the signs and symptoms of opioid withdrawal induced by naloxone.

[0249] Example 14: Lack of Oxycodone-Induced Withdrawal In a study design similar to that of Example 13, mice chronically treated with oxycodone or saline are challenged with ITI-333 or vehicle (Veh) and observed for the onset of physical signs of withdrawal, including jumping, wet dog shakes, paw tremors, backing, ptosis, and diarrhea.

[0250] Adult male C57Bl / 6 mice (Jackson Labs, Bar Harbor, ME) are administered oxycodone as described in Example 13. On the morning of the 9th day, mice are administered oxycodone (33 mg / kg, sc) and 2 hours later are injected with the compound of Example 1 (3, 10 or 17.8 mg / kg, sc; n=8 each) or vehicle (n=8). Another group of mice is chronically administered saline instead of oxycodone and challenged with the compound of Example 1 (17.8 mg / kg, sc; n=8) or vehicle (n=8) on the 9th day to evaluate the effect of the compound of Example 1 alone. Thirty minutes after vehicle or compound injection on the 9th day, mice are individually placed in plastic cages and observed for physical signs of withdrawal as described in Example 13. Data are analyzed by ANOVA followed by Tukey's test for multiple comparisons.

[0251] The results show that mice chronically administered oxycodone and given the compound of Example 1 (at a dose of <10 mg / kg) do not differ from mice administered vehicle in terms of paw tremors or number of jumps. The compound of Example 1 (<10 mg / kg) also does not induce additional weight loss in mice chronically receiving oxycodone. However, with increasing doses, the compound of Example 1 induced greater total withdrawal symptoms (p<0.0001). At 10 mg / kg, it induced significantly more total withdrawal symptoms compared to morphine alone (p<0.05), mainly due to an increase in wet dog shakes. After chronic treatment with saline, the compound of Example 1 does not produce a significant effect on physical signs or weight loss compared to mice administered vehicle on day 9 (p>0.05).

[0252] Example 15: Reversal of fentanyl-induced respiratory depression in rats The compound of Example 1 is administered intravenously in conscious rats and tested to determine its potential effect on fentanyl-induced respiratory depression.

[0253] The animals are acclimated to the housing environment and laboratory procedures for a minimum of 5 days before dosing begins. Animals are selected by weight and apparent health and randomly assigned to test groups. Crl:CD rats (weight 150-255 g at the start of dosing, 6-7 weeks old) from Charles River Laboratories are used in the study and are divided into 6 groups. In group (1), the negative control, animals are pretreated with 3 mL / kg vehicle (sc) and then treated with 5 mL / kg vehicle (iv). In group (2), the positive control, animals are pretreated with 0.15 mg / kg fentanyl (sc, 0.05 mg / mL) and then treated with vehicle (iv). In the first test group, group (3), animals are pretreated with 0.15 mg / kg fentanyl (sc, 0.05 mg / mL) and then treated with 1 mg / kg of the compound of Example 1 (iv). Groups (4) and (5) follow the same protocol as group (3), except that higher doses of 3.0 mg / kg and 5.0 mg / kg of the compound of Example 1 are used. In the final group, group (6), animals are pretreated with vehicle (iv) and then treated with 5.0 mg / kg (iv) of the compound of Example 1. All intravenous treatments are administered as an infusion over 5 minutes.

[0254] Animals are first trained in a head-out plethysmograph chamber for approximately 10-15 min each day for 2 days immediately prior to testing. On the day of dosing, each animal is weighed and placed in the plethysmograph chamber and allowed to stabilize for at least 5 min. After stabilization, respiratory parameters (respiratory rate, tidal volume, and minute ventilation) are measured continuously for 5 min to obtain pre-dose baseline values. Animals are then removed from the chamber and dosed according to group assignment. After dosing, each animal is returned to its designated plethysmograph chamber and respiratory parameters are measured at 5-min intervals for 15 min. After each reading, animals are removed from the plethysmograph chamber. Before the next scheduled reading, animals are returned to the plethysmograph chamber and allowed to stabilize for at least 5 min before the next reading is taken. Respiratory data are acquired and analyzed using the PONEMAH Physiology Platform (Ponemah v.5.20 pulmonary). Individual values ​​for tidal volume and minute ventilation for test substance dose groups are compared to vehicle controls and baseline using unpaired T-tests.

[0255] The results are shown in the table below (TV: tidal volume; MV: minute ventilation): [Table 8]

[0256] The results show that fentanyl rapidly induces respiratory depression as indicated by a decrease in minute ventilation (volume of air delivered in one minute) and a decrease in tidal volume (volume of air delivered in one breath). The compound of Example 1 clearly prevents this respiratory depression, maintaining animals with near normal tidal volumes and slightly reduced minute ventilation at both high doses, with partial efficacy at the lowest dose tested.

Claims

1. (a) Treatment or reversal of F / FA excess intake; (b) treatment or reversal of F / FA-induced respiratory depression; (c) treatment or reversal of F / FA-induced muscle stiffness; (d) treatment or reversal of F / A-induced laryngospasm; (e) reversal or inhibition of F / FA binding to μ-opioid receptors in the central nervous system (e.g., in the locus coeruleus); (f) inhibition of F / FA-induced β-arrestin signaling in the central nervous system (e.g., in the locus coeruleus); (g) Prevention of deaths due to F / FA overdose; and (h) recovery from anesthesia (e.g., after surgery) A pharmaceutical agent for one or more of the following: The pharmaceutical agent is a compound of Formula I: 【Chemical 1】 [In the formula, R 1 is H, C 1-6 Alkyl, -C(O)-OC(R a )(R b )(R c ), -C(O)-O-CH 2 -OC(R a )(R b )(R c ) or -C(R 6 )(R 7 )-OC(O)-R 8 and R 2 and R 3 are independently H, D, C 1-6 Alkyl (e.g., methyl), C 1-6 selected from alkoxy (e.g., methoxy), halo (e.g., F), cyano, or hydroxy; L is C 1-6 Alkylene (e.g., ethylene, propylene, or butylene), C 1-6 Alkoxy (e.g., propoxy or butoxy), C 2-3 Alkoxy C 1-3 Alkylene (e.g., -CH 2 CH 2 OCH 2 -), C 1-6 Alkylamino or NC 1-6 Alkyl C 1-6 alkylamino (e.g., propylamino or N-methylpropylamino), C 1-6 Alkylthio (e.g., -CH 2 CH 2 CH 2 S-), C 1-6 Alkylsulfonyl (e.g., -CH 2 CH 2 CH 2 S(O) 2 -), each of which is one or more R 4 optionally substituted with a moiety; Each R 4 independently, C 1-6 Alkyl (e.g., methyl), C 1-6 selected from alkoxy (e.g., methoxy), halo (e.g., F), cyano, or hydroxy; Z is selected from aryl (e.g., phenyl) and heteroaryl (e.g., pyridyl, indazolyl, benzimidazolyl, benzisoxazolyl), wherein the aryl or heteroaryl is selected from one or more R 4 optionally substituted with a moiety; R 8 is -C(R a )(R b )(R c ), -OC(R a )(R b )(R c ) or -N(R d )(R e ) and R a , R b and R c are each independently H and C 1-24 alkyl; R d and R e are each independently H and C 1-24 alkyl; R 6 and R 7 are each independently H, C 1-6 Alkyl, carboxy and C 1-6 alkoxycarbonyl] A pharmaceutical comprising the compound of formula (I).

2. In compounds of formula I, R 1 The pharmaceutical composition of claim 1, wherein is H.

3. In compounds of formula I, R 1 But -C(O)-OC(R a )(R b )(R c ), -C(O)-O-CH 2 -OC(R a )(R b )(R c ) or -C(R 6 )(R 7 )-OC(O)-R 8 The pharmaceutical composition according to claim 1,

4. In compounds of formula I, L each represents one or more R 4 C optionally substituted with a moiety 1-6 Alkylene (e.g., ethylene, propylene, or butylene) or C 1-6 The pharmaceutical of claim 1, which is alkoxy (e.g., propoxy or butoxy).

5. In compounds of formula I, R 2 and R 3 The pharmaceutical composition of claim 1, wherein each of

6. 2. The method of claim 1, wherein in the compound of formula I, Z is phenyl substituted with one fluoro (e.g., 2-fluorophenyl, 3-fluorophenyl, or 4-fluorophenyl).

7. In compounds of formula I, Z is one or more R 4 2. The pharmaceutical composition of claim 1, wherein the heteroaryl is an optionally substituted heteroaryl moiety (e.g., pyridyl, indazolyl, benzimidazolyl, benzisoxazolyl).

8. A pharmaceutical composition as described in claim 1, wherein in the compound of formula I, R 1 is H, R 2 and R 3 are each H, L is C 1-6 alkylene (e.g., ethylene, propylene or butylene) or C 1-6 alkoxy (e.g., propoxy or butoxy), each of which may be substituted with one or more R 4 moieties, and Z is selected from phenyl and heteroaryl (e.g., pyridyl, indazolyl, benzimidazolyl, benzisoxazolyl), each of which may be substituted with one or more R 4 moieties.

9. The compounds of formula I are each independently in free form or in pharmaceutically acceptable salt form: 【Chemistry 2】 The pharmaceutical composition of claim 1, wherein the pharmaceutical composition is selected from the group consisting of:

10. The compounds of formula I are each independently in free form or in pharmaceutically acceptable salt form: 【Chemistry 3】 The pharmaceutical composition of claim 1, wherein the pharmaceutical composition is selected from the group consisting of:

11. The compound of formula I, in free form or in pharmaceutically acceptable salt form, 【Chemistry 4】 The pharmaceutical composition according to claim 1,

12. 2. The method of claim 1, wherein the compound of formula I is in the form of a salt, such as a pharmaceutically acceptable salt.

13. 10. The method of claim 1, wherein the medicament comprises a compound of formula I in admixture with a pharmaceutically acceptable diluent or carrier.

14. 14. The medicament of claim 13, wherein the medicament is formulated for single-dose administration (e.g., a tablet, capsule, wafer, single-use injection, single-use intranasal ampoule or vial, single-use injection ampoule or vial, single-use intranasal spray).

15. 14. The medicament of claim 13, wherein the medicament is formulated for intranasal or pulmonary administration (e.g., as an aerosol, mist, or powder for inhalation).

16. 14. The medicament of claim 13, wherein the medicament is formulated for administration by injection, for example as a sterile aqueous solution, for example for intravenous, subcutaneous or intramuscular injection.

17. 17. The medicament of claim 16, wherein the medicament is formulated and / or packaged as a pre-filled injection syringe, as an autoinjector, or as a sterile solution in a vial for injection or intranasal administration.

18. The pharmaceutical composition according to any one of claims 1 to 17, wherein the patient is exhibiting chest wall stiffness.

19. The pharmaceutical composition according to any one of claims 1 to 17, wherein the patient is experiencing laryngospasm.

20. 18. The pharmaceutical composition of any one of claims 1 to 17, wherein the patient has been diagnosed with, is suspected of having, or is suffering from, wooden chest syndrome (WCS), fentanyl-induced muscle rigidity (FIMR) or fentanyl-induced muscle rigidity of the respiratory system (FIRMR).

21. 18. The medicament of any one of claims 1 to 17, wherein the patient has not responded or has not responded adequately (e.g., in terms of signs or symptoms of respiratory depression) to single or multiple doses of a μ-opioid antagonist such as naloxone (e.g., 0.1 to 4 mg), administered by any route (e.g., intranasally, intravenously, subcutaneously, or intramuscularly).

22. 18. The medicament of any one of claims 1 to 17, wherein the compound of formula I is in an amount effective to reverse one or more of respiratory arrest, respiratory depression, skeletal muscle spasms, chest wall rigidity, laryngospasm, pupillary constriction, cardiac arrest, bradycardia, or unconsciousness.

23. 18. The pharmaceutical composition of any one of claims 1 to 17, wherein the F / FA is selected from fentanyl, sufentanil, alfentanil, remifentanil, carfentanil, thiafentanil, lofentanil, ocfentanil, trefentanil, and briffentanil.

24. A pharmaceutical described in any one of claims 1 to 17, which does not cause induced withdrawal in the patient, for example, withdrawal symptoms selected from tachycardia, nausea, vomiting, diarrhea, extreme anxiety, restless legs, muscle pain, and profuse sweating.

25. 18. The method of claim 1, wherein the source of the F / FA is another illicit drug that is adulterated with F / FA, such as cocaine, amphetamine, methamphetamine, or marijuana.

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