Gelsolin and opioid tolerance

Abstract

The present invention relates to compositions and methods for treating opioid tolerance in subjects and methods for selecting a pain-reduction therapeutic regimen for a subject who has an opioid tolerance and / or a subject who is at risk of having an opioid tolerance. Embodiments of treatment methods of the invention include administering a gelsolin agent to produce a therapeutic effect against opioid tolerance in a subject.

Description

[0001] GEL SOLIN AND OPIOID TOLERANCE

[0002] Related Applications

[0003] This application claims benefit under 35 U.S.C. § 119(e) of U.S. Provisional application serial number 63 / 547,801 filed November 8, 2023, the disclosure of which is incorporated by reference herein in its entirety.

[0004] Government Interest

[0005] This invention was made with government support under NS 122855 awarded by the National Institutes of Health and N00014-22- 1-2818 awarded by the U.S. Office of Naval Research. The government has certain rights in the invention.

[0006] Field of the Invention

[0007] The invention, in some aspects, relates to compositions and methods for reducing opioid tolerance.

[0008] Background of the Invention

[0009] It is well established that opioid tolerance is a serious problem in health care. Effective methods to reduce and / or eliminate opioid tolerance are not available and there is a widespread need for such methods to assist in the treatment of moderate and severe pain.

[0010] Summary of Certain Elements of the Invention

[0011] According to an aspect of the invention, a method of treating opioid tolerance in a subject is provided, the method including: administering to a subject in need of such treatment, a composition including a gelsolin agent, in an amount effective to treat the opioid tolerance in the subject. In some embodiments, the opioid tolerance is morphine tolerance. In certain embodiments, the gelsolin agent includes a gelsolin molecule, a functional fragment thereof, or a functional derivative of the gelsolin molecule. In certain embodiments, the gelsolin molecule is a plasma gelsolin (pGSN). In some embodiments, the gelsolin molecule is a recombinant gelsolin molecule. In some embodiments, the administration of the composition including the gelsolin agent is oral, sublingual, buccal, intranasal, intravenous, intramuscular, intrathecal, intraperitoneal, subcutaneous, intradermal, topical, rectal, vaginal, intrasynovial, or intra-ocular administration, orally, sublingually, intravenously, subcutaneously, topically, intrathecally, or by inhalation. In some embodiments, administering the gelsolin agent has a greater therapeutic effect against the opioid tolerance in the subject compared to a control therapeutic effect against the opioid tolerance. In certain embodiments, the control therapeutic effect is equal to an effect against the opioid tolerance in a subject in the absence of administering the gelsolin agent. In certain embodiments, the administration of the gelsolin agent reduces the opioid tolerance in the subject by at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100% compared to the severity of the opioid tolerance of a control in which the gelsolin agent is not administered. In certain embodiments, the subject is a mammal. In some embodiments, the mammal is a human. In certain embodiments, the gelsolin agent is administered to the subject 1, 2, 3, 4, 5, 6, 7, 8, or more times. In certain embodiments, the administration of the gelsolin agent increases pain-relief efficacy of an opioid administered to the subject by at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100% compared to the pain-relief efficacy of the opioid of a control in which the gelsolin agent is not administered. In some embodiments, the method also includes administering an opioid to the subject administered the composition including the gelsolin agent. In certain embodiments, the administered gelsolin agent reduces a level of opioid tolerance in the subject. In certain embodiments, the administered gelsolin agent prevents opioid tolerance in the subject. In certain embodiments, the opioid includes: oxycodone, fentanyl, morphine, opium, hydromorphone, oxymorphone, methadone, or hydrocodone.

[0012] According to an aspect of the invention, a method of selecting a pain-reduction treatment for a subject having an opioid tolerance is provided, the method including: (a) selecting a gelsolin therapeutic regimen for the subject, including the administration of a composition including a gelsolin agent, in an amount effective to treat the opioid tolerance in the subject and; (b) selecting a pain-reducing therapeutic regimen for the subject, including the administration of one or more opioids and / or a different pain-relieving agent to the subject. In some embodiments, the method also includes determining the identity of the opioid, and optionally selecting the one or more opioids and / or the different pain-relieving agent based at least in part on the identity of the opioid. In some embodiments, the method also includes administering the selected painreducing therapeutic regimen to the subject 2, 3, 4, 5, 6, 7, 8, or more times. In some embodiments, the method also includes administering the selected gelsolin therapeutic regimen to the subject 2, 3, 4, 5, 6, 7, 8, or more times. In certain embodiments, administering the gelsolin therapeutic regimen and the pain-reducing therapeutic regimen comprise administering the gelsolin agent at one or more of: before, in conjunction, with, and after administering the one or more opioids and / or the different pain-relieving agent to the subject. In some embodiments, the gelsolin agent includes a gelsolin molecule, wherein the gelsolin molecule is optionally a recombinant gelsolin molecule, and optionally is a plasma gelsolin (pGSN). In some embodiments, administering the selected gelsolin therapeutic regimen and the selected painreducing therapeutic regimen has a greater therapeutic effect against the opioid tolerance in the subject compared to a control therapeutic effect against the opioid tolerance, optionally wherein the control therapeutic effect is an effect against the opioid tolerance in a subject administered the selected pain-reducing therapeutic regimen and not administered the selected gelsolin therapeutic regimen. In certain embodiments, the administration of the gelsolin agent reduces the opioid tolerance in the subject by at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100% compared to a control opioid tolerance in the absence of administration of the gelsolin agent. In certain embodiments, the opioid tolerance is measured based on one or more of the presence of one or more opioid-tolerance symptoms in the subject and the severity of the opioid tolerance in the subject. In some embodiments, the subject is a mammal, optionally, the subject is a human. In certain embodiments, the administration of the gelsolin agent increases pain-relief efficacy of the selected pain-reducing therapeutic regimen in the subject by at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, 100%, 125%, 150%, 175%, 200%, or more compared to the pain-relief efficacy of the selected pain-reducing therapeutic regimen of a control not administered the gelsolin agent. In certain embodiments, the opioid includes: oxycodone, fentanyl, morphine, hydromorphone, oxymorphone, methadone, or hydrocodone. According to another aspect of the invention, a method of selecting a pain-reduction treatment for a subject at risk of having an opioid tolerance is provided, the method including: (a) selecting a gelsolin therapeutic regimen for the subject, including the administration of a composition including a gelsolin agent, in an amount effective to reduce the risk of the opioid tolerance in the subject and; (b) selecting a pain-reducing therapeutic regimen for the subject, including the administration of one or more opioids and / or a different pain-relieving agent to the subject. In some embodiments, the method also includes administering the selected painreducing therapeutic regimen to the subject 2, 3, 4, 5, 6, 7, 8, or more times. In certain embodiments, the method also includes administering the selected gelsolin therapeutic regimen to the subject 2, 3, 4, 5, 6, 7, 8, or more times. In certain embodiments, administering the gelsolin therapeutic regimen and the pain-reducing therapeutic regimen comprise administering the gelsolin agent to the subject at one or more of before, in conjunction, with, and after administering the one or more opioids and / or the different pain-relieving agent to the subject. In some embodiments, the gelsolin agent includes a gelsolin molecule, wherein the gelsolin molecule is optionally a recombinant gelsolin molecule. In some embodiments, the gelsolin molecule is a plasma gelsolin (pGSN). In certain embodiments, administering the gelsolin therapeutic regimen and the pain-reducing therapeutic regimen reduces the risk of opioid tolerance in the subject compared to a control therapeutic effect against the risk of opioid tolerance, optionally wherein the control therapeutic effect is equal to an effect against the opioid tolerance in a subject administered the pain-reducing therapeutic regimen and not administered the gelsolin therapeutic regimen. In some embodiments, the administration of the gelsolin agent reduces the risk of opioid tolerance in the subject by at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100% compared to the opioid tolerance of a control that is not administered the gelsolin agent. In some embodiments, the subject is a mammal, optionally, the subject is a human. In certain embodiments, the administration of the gelsolin agent increases pain-relief efficacy of the selected pain-reducing therapeutic regimen in the subject by at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, 100%, 125%, 150%, 175%, 200%, or more compared to the pain-relief efficacy of the selected pain-reducing therapeutic regimen of a control not administered the gelsolin agent. In certain embodiments, the opioid includes: oxycodone, fentanyl, morphine, hydromorphone, oxymorphone, methadone, or hydrocodone.

[0013] According to another aspect of the invention, a pharmaceutical composition including a gelsolin agent and an opioid is provided. In certain embodiments, the gelsolin agent includes a gelsolin molecule, wherein the gelsolin molecule is optionally a recombinant gelsolin molecule, and optionally is a plasma gelsolin (pGSN). In some embodiments, the opioid is morphine, heroin, hydromorphone, oxymorphone, fentanyl, methadone, oxycodone, hydrocodone, codeine, buprenorphine, dextromethorphan, dextropropoxyphene, loperamide, meperidine, opium, carfentanyl / carfentanil, morphone, talpentadol, tramadol, or pethidine.

[0014] Brief Description of the Drawings

[0015] These and other features, aspects, and advantages of the embodiments of the present disclosure is better understood when the following detailed description is read with reference to the accompanying drawings in which like characters represent like parts throughout the drawing, wherein:

[0016] Figure 1 is a schematic image depicting an interpretation of data from morphine tolerance studies. The image illustrates the cyclic nature of inflammation triggered by various stimuli where astrocytes and microglia generate microparticles (MPs) that travel via the glymphatic system. The MPs pass from central nervous system perivascular channels to the deep cervical nodes and then to the systemic circulation. CNS-derived, thrombospondin- 1 expressing MPs from astrocytes cause neutrophil activation with production of additional MPs, some expressing filamentous (F-)actin. The F-actin MPs lead to neutrophil auto-activation exacerbating the inflammatory process and neutrophil adherence to the brain microvasculature triggers further astrocyte and microglial activation. The F-actin MPs can be destroyed by plasma gelsolin (pGSN) and as this occurs, the concentration of pGSN in the blood stream drops.

[0017] Figure 2A-B provides a schematic diagram and graph. Fig. 2A is a schematic diagram illustrating an interpretation of results of some studies and indicates that brain-derived MPs can initiate a cyclic neuroinflammatory cycle. This interpretation differs from Fig. 1 by showing more detail as to why F-actin MPs appear to be pro-inflammatory. In these other studies, it has now been shown that the F-actin positive particles contain high concentrations of nitric oxide synthase 2 (NOS2, the inflammatory form of nitric oxide synthase) as well as interleukin-10. Plasma gelsolin destroys these MPs and in the process of doing so, plasma gelsolin level decreases. Fig. 2B provides a graph of experimental results that showed reduction of plasma gelsolin in morphine tolerant mice and in mice that had been injected with F-actin positive MPs obtained from morphine tolerant mice.

[0018] Figure 3 A-B provides a schematic diagram and a list showing a withdrawal test regimen (Fig. 3 A) that includes inducing morphine tolerance in mice with three daily injections of morphine and testing on the 4thday. Fig. 3B is graphs showing the time required by mice to remove the tail from warm water when measured at base line (no morphine injection) and then after cumulative morphine dosing at 0.5, 1, 2, and 3 mg / kg intraperitoneal (IP) injection. The results indicated that the controls exhibit a slower response to remove their tail because they are injected with morphine at any dose (0.5 to 3 mg / kg) whereas the mice rendered tolerant to morphine respond to the warm water by removing their tail despite being injected with morphine (0.5, 1, or 2 mg / kg).

[0019] Figure 4 provides schematic diagrams and a graph illustrating in top panel the direction of CSF flow in the brain, lower left panel shows the lymphatic system in mouse brain, and the lower right panel is a graph of concentration of microparticles in control versus morphine-tolerant subject. The figure illustrates the brain glymphatic and traditional lymphatic systems. Fluid from both drain to the deep cervical lymph nodes. Studies were performed in which microparticles (MPs) were measured in the deep cervical nodes and results demonstrated a significant elevation of MPs in mice rendered morphine tolerant (shown in graph at lower right).

[0020] Figure 5 provides graphs showing number of microparticles found in the deep cervical lymph nodes of mice when rendered morphine tolerant and when subjected to the tolerance protocol (see Fig. 3) plus injections of various drugs to antagonize different inflammatory pathways. These included: PEG Telomer B (0.7 pl of a 0.3% solution [w / v] IV / gram) PEG Telomer B is an agent that will destroy most MPs when injected in the blood stream], anakinra (100 mg / kg TP) [anakinra is a drug that blocks the receptor for interleukin- 1 ], methylnaltrexone (1 mg / kg IP) [methyl naltrexone is an opiate receptor blocker that does not cross the blood brain barrier], or neutropenic animals [mice are treated with an antibody to selective remove the polymorphonuclear leukocytes (also known as neutrophils) from the blood stream]. Data shown are mean + SE, the numbers show the number of mice in each group. The lettering to the right lists the protein markers that were studied on the individual MPs and include Ly6 (mature neutrophils), CD45 (all leukocytes), P2Y12 and CD45 (microglia), CD41 (platelets), CD3 H7 CD41-dim (endothelium), glial fibrillary acidic protein, GFAP (astrocytes), myelin basic protein, MBP (oligodendroglia), or neuronal pentraxin receptor, NPR (neurons).

[0021] Figure 6 provides graphs demonstrating tolerance antagonism and showing anti-nociceptive tolerance (as shown in Fig. 1) can be prevented if mice are treated with agents that impede microparticles elevations (as shown in Fig. 3). Fig. 6 shows the time required by mice to remove the tail from warm water measured at base line and then after cumulative morphine dosing at 0.5, 1, 2, and 3 mg / kg IP. Studies were performed after receiving daily sterile saline (control) or morphine at 20 mg / kg for two days and 50 mg / kg on the third day. Where indicated, mice also received anakinra (100 mg / kg IP), methylnaltrexone (1 mg / kg IP) or PEG Telomer B (0.7 pl of a 0.3% solution [w / v] IV / gram). Data are mean + SE, p<0.05 by repeated measures, 2-way ANOVA.

[0022] Figure 7 provides an image of a Western blot probed for the pro-form of IL-10 as well as the mature protein. Plasma samples containing 100,000 MPs were centrifuged for 1 hour at 21,000 x g. Pellets were set aside for Western blotting and the supernatant centrifuged for 1 hour at 100,000g so that this pellet could also be subjected to Western blotting to assess relative content of pro- and mature IL- 10. Data beneath the figure show the concentration of IL- 10 as pg / 1 million MPs from whole plasma and post-21,000g centrifugation supernatant and pellet fractions. Data are mean + SE, n = 6. The results shown in the table demonstrate that IL- 10 is elevated in tolerant mice and virtually all the IL-10 is found within microparticles. Results showed there was no IL- 10 in 100,000g plasma supernatant (therefore packaged in a vesicle). Figure 8 provides a table showing results from a study in which blood was collected from patients who were just entering methadone treatment for opiate-use disorder and age-matched controls taking no medications. Data show mean + SD, n=40 for each group, *p<0.05, t-test. The results show elevated levels of blood-borne MPs in patients entering methadone treatment compared to control levels.

[0023] Figure 9A-C provides photos and graphs illustrating results of measurement of brain glymphatic flow assessment by gadolinium (Gd) contrast MRI. Fig. 9A highlights the signal near the Vein of Galan and at deep cervical nodes. Flow was quantified using 1 mm regions of interest at these sites and normalized the signal by including a 60 mM Gd vial beneath the mouse skull within the scanning field. Images of control and tolerant mice are shown in Fig. 9B. Graphs of glymphatic flow quantifications measured in 5 mice is shown in Fig. 9C. The ordinates show normalized Gd signals and abscissa shows the time following Gd injections in the mice. The MRI machine was programmed to collect images for 5 minutes and then report the value. Therefore, the abscissa is shown as sequential 5-minute intervals. The data demonstrated that mice rendered morphine tolerant exhibit elevations of glymphatic flow versus control mice that were injected with just sterile saline.

[0024] Figure 10 provides a schematic diagram, graphs, and Western blot images illustrating experiments performed by injecting F-actin positive MPs from morphine-tolerant mice into naive mice. Overall, the results indicated that glymphatic flow was increased by morphine injections and this contributed to the elevation of MPs found in the deep cervical nodes and blood. Results of PEG-telomer B injection studies indicated that blood-borne MPs are needed for morphine tolerance. Further studies indicated it was specifically the F-actin positive MPs that were triggering on-going inflammation. Fig. 10 illustrates that when mice were injected with F-actin MPs from tolerant mice they showed somewhat similar elevations of glymphatic flow (graphs on left) and show neuroinflammation (the Western blot to the right). The numbers below each band indicate mean + SD (n=3 brains per lane) band densities relative to -actin of control samples from replicate studies. Western blots were probed for IBA-1 (which indicates microglial activation), aquaporin-4 (AQP4, the protein in astrocytes that drives the glymphatic flow), myeloperoxidase (MPO, shows evidence for neutrophil adherence to brain vasculature) and the CD36 protein (which when elevated is associated with neuroinflammation).

[0025] Brief Description of Sequence

[0026] SEQ ID NO: 1 is an amino acid sequence of human plasma gelsolin having Gen Bank"

[0027] Accession No. X04412:

[0028] MAPHRPAPALLCALSLALCALSLPVRAATASRGASQAGAPQGRVPEARPNSMVVEHPE FLKAGKEPGLQIWRVEKFDLVPVPTNLYGDFFTGDAYVILKTVQLRNGNLQYDLHYWL GNECSQDESGAAAIFTVQLDDYLNGRAVQHREVQGFESATFLGYFKSGLKYKKGGVAS GFKHVVPNEVVVQRLFQVKGRRVVRATEVPVSWESFNNGDCFILDLGNNIHQWCGSNS NRYERLKATQVSKGIRDNERSGRARVHVSEEGTEPEAMLQVLGPKPALPAGTEDTAKE DAANRKLAKLYKVSNGAGTMSVSLVADENPFAQGALKSEDCFILDHGKDGKIFVWKG KQANTEERKAALKTASDFITKMDYPKQTQVSVLPEGGETPLFKQFFKNWRDPDQTDGL GLSYLSSHIANVERVPFDAATLHTSTAMAAQHGMDDDGTGQKQIWRIEGSNKVPVDPA TYGQFYGGDSYIILYNYRHGGRQGQIIYNWQGAQSTQDEVAASAILTAQLDEELGGTPV QSRVVQGKEPAHLMSLFGGKPMIIYKGGTSREGGQTAPASTRLFQVRANSAGATRAVE VLPKAGALNSNDAFVLKTPSAAYLWVGTGASEAEKTGAQELLRVLRAQPVQVAEGSEP DGF WEALGGKAAYRT SPRLKDKKMD AHPPRLF AC SNKIGRF VIEEVPGELMQEDL ATD DVMLLDTWDQVFVWVGKDSQEEEKTEALTSAKRYIETDPANRDRRTPITVVKQGFEPP SFVGWFLGWDDDYWSVDPLDRAMAELAA.

[0029] Detailed Description

[0030] The present invention is based, in part, on the surprising discovery that gelsolin can be administered to a subject to treat opioid tolerance in the subject. Certain embodiments of methods of the invention include a treatment regimen comprising administering to a subject identified as having, or at risk of having, opioid tolerance a therapeutic composition comprising a gelsolin agent. Certain aspects of the invention include selecting a pain-reducing treatment for a subject who is known to have, or is at risk of having opioid tolerance. Certain embodiments of methods of the invention can increase efficacy of pain-management in subjects by administering gelsolin. It has now been determined that increasing plasma gelsolin (pGSN) levels in a subject receiving opioid agents can reduce opioid tolerance in the subject.

[0031] Opioids and Opioid Tolerance

[0032] Opioids are analgesics that are widely used to provide relief of moderate to severe pain, but opioid use for chronic pain relief or other pain conditions can result in a reduction in the efficacy of the opioid. Opioid tolerance is a physical effect of repeated use of opioids and may result in opioid-induced hyperalgesia, which is also described as increased pain with escalating doses of opioids. Opioid-induced hyperalgesia is a condition of nociceptive sensitization that results from exposure to opioids. The condition is characterized by a paradoxical response whereby a patient receiving opioids for the treatment of pain could actually become more sensitive to certain painful stimuli. Hyperalgesia may manifest as opioid-induced tolerance because increased sensitivity to pain counteracts the pain-relieving effects of opioids. A subject may develop opioid tolerance in response to ongoing and / or repeated opioid use, and a subject with opioid tolerance may exhibit a reduction in pain-relief response to an opioid drug. Opioid tolerance may result from administration to the subject of illegal and / or legal opioid drugs.

[0033] There are various opioids used for analgesia in health care and used illegally. As used herein the term “opioid” may refer to a natural opioid or a synthetic opioid. Non-limiting examples of opioids to which tolerance may develop are morphine, heroin, hydromorphone, oxymorphone, fentanyl, methadone, oxycodone, hydrocodone, codeine, buprenorphine, dextromethorphan, dextropropoxyphene, loperamide, meperidine, opium, carfentanyl / carfentanil, morphone, talpentadol, tramadol, and pethidine.

[0034] Loss of therapeutic pain-relief benefits of opioids due to ongoing or prior opioid use is referred to as “opioid tolerance” and can result in a need for increased amounts of opioids administered and increased dosing of opioids in an opioid-tolerant subject to maintain a satisfactory level of pain relief. In addition, for a patient with opioid tolerance resulting from opioid treatment of a condition such as, but not limited to chronic pain or resulting from illegal opioid use, it can be extremely difficult to manage new moderate or severe pain, for example pain resulting from a surgical procedure or injury. Opioid tolerance in human subjects is defined by the FDA as resulting from a subject being administered, “for one week or longer, at least 60 mg oral morphine / day, 25 mcg transdermal fentanyl / hour, 30 mg oral oxycodone / day, 8 mg oral hydromorphone / day, 25 mg oral oxymorphone / day, or an equianalgesic dose of another opioid” (fda.gov / down1oad s / drugs / drugsafety / postmarketdrugsafetyinformationforpatientsandproviders / u cm311290.pdf). There are well-established animal models for assessing opioid tolerance.

[0035] Details and results of certain experimental studies provided herein have been interpreted in view of gelsolin reduction of opioid tolerance. For example, although not intended to be limiting, Figs. 1 and 2 depict interpretations of data from morphine tolerance studies that were performed. Although not wishing to be bound by a particular theory, the schematic image in Fig. 1 illustrates the cyclic nature of inflammation triggered by various stimuli where astrocytes and microglia generate microparticles (MPs) that travel via the glymphatic system. In the interpretation, the MPs pass from central nervous system perivascular channels to the deep cervical nodes and then to the systemic circulation. CNS-derived, thrombospondin- 1 expressing MPs from astrocytes cause neutrophil activation with production of additional MPs, some expressing fdamentous-actin (F-actin). The F-actin MPs lead to neutrophil auto-activation exacerbating the inflammatory process and neutrophil adherence to the brain microvasculature triggers further astrocyte and microglial activation. The F-actin MPs can be destroyed by plasma gelsolin (pGSN) and as this occurs, the concentration of pGSN in the blood stream drops. Fig. 2 provides a non-limiting interpretation of results of certain studies set forth herein. Fig. 2A illustrates an interpretation of results of certain studies and indicates that brain-derived MPs can initiate a cyclic neuroinflammatory cycle. This interpretation differs from Fig. 1 in that it shows more detail as to why F-actin MPs may be pro-inflammatory. In studies including those disclosed herein, it has now been shown that the F-actin positive particles contain high concentrations of NOS2 (the inflammatory form of nitric oxide synthase) as well as interleukin- ip. Plasma gelsolin destroys these MPs and in the process of doing so, plasma gelsolin level decreases. Fig. 2B provides a graph showing the reduction of plasma gelsolin seen in morphine tolerant mice and in mice that had been injected with F-actin positive MPs obtained from morphine-tolerant mice. Determining Risk of, and / or Presence of Opioid Tolerance

[0036] The invention, in part, includes methods of reducing a subject’s risk of developing opioid tolerance, a non-limiting example of which is morphine tolerance. Certain embodiments of risk reduction methods of the invention include administering a gelsolin agent to a subject identified as at risk of developing opioid tolerance, and the gelsolin agent is administered in an amount effective to reduce the subject’s risk of developing the opioid tolerance. Efficacy of a method of the invention to reduce a subject’s risk may be determined by comparing results of administering a gelsolin agent to a subject with control results. In some embodiments of the invention, a gelsolin agent administered to a subject reduces the subject’s risk of developing opioid tolerance compared to a control risk of developing the opioid tolerance, wherein the control risk is a risk of a subject in essentially identical circumstances developing the opioid tolerance in the absence of administering the gelsolin agent. In some embodiments of methods of the invention, determining efficacy of a method of the invention to reduce a subject’s risk of opioid tolerance may comprise observing characteristics of the subject, observing efficacy of pain management using an opioid, observing behavior of the subject, etc.

[0037] In some embodiments, a subject at risk of developing an opioid tolerance is a subject to whom the opioid will be administered. In some embodiments, the opioid is administered over a length of time. As a non-limiting example, an opioid may be administered to treat a subject over a length of time, during which one or more opioids may be repeatedly administered to a subject across a period of days, weeks, months or longer. As used herein the term “repeatedly” means more than once. It will be understood that repeated administrations to a subject may occur on a regular schedule, a non-limiting example of which is every 4-6 hours, and in certain instances, repeated administrations may occur at more irregular times. The amount of opioid, frequency of the opioid administration to a subject, and / or the duration of time over which the opioid is administered to the subject may result in the subject having opioid tolerance to the administered opioid.

[0038] In some embodiments of methods of the invention, a determination that a subject is at risk of developing opioid tolerance is based at least in part, on a current or an upcoming regimen of opioid administration to the subject. For example, if a subject is currently being administered an opioid regimen, the current dosing of the opioid administered to the subject, frequency of the opioid administration to the subject, and / or the duration of time over which the opioid has been administered to the subject, may be used to assess risk or presence of opioid tolerance in the subject. Based at least in part on such an assessment of risk, a determination that a subject is at risk of opioid tolerance or that a subject has opioid tolerance, embodiments of methods of the invention can be used to prevent, reduce, or eliminate opioid tolerance in the subject.

[0039] In a situation in which a subject will be treated with an opioid regimen, the dosing of the opioid that will be administered to the subject, the frequency at which the opioid will be administered to the subject, and / or the duration of time over which the opioid will be administered to the subject, may be used to assess risk of opioid tolerance in the subject. Based at least in part on an assessment of risk of opioid tolerance determined for a subject to be administered an opioid regimen, embodiments of methods of the invention can be used to reduce or eliminate opioid tolerance in the subject.

[0040] In an example, though not intended to be limiting, a subject who is currently being treated with a morphine treatment regimen comprising administration of oral morphine at an amount of at least 60 mg / day for 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 days or longer may be determined to be at risk of having, or as having morphine tolerance. In another non-limiting example, a subject who will be administered oral morphine at an amount of at least 60 mg / day for an expected 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 days or longer may be determined to be at risk of developing morphine tolerance, thus at risk of having morphine tolerance. In another nonlimiting example, a subject to whom at least 30 mg oral oxycodone per day is administered for at least 5, 6, 7, 8, 9 ,10, 11, 12, 13, 14, or more days, may be assessed and determined to be at risk of having, or as having oxycodone tolerance.

[0041] Other characteristics of a subject may also be used to determine whether the subject is at risk of or has opioid tolerance. Non-limiting examples of such characteristics include but are not limited to: a subject’s medical history, a subject’s description of their own behavior and drug use, a subject’s behavior (a non-limiting example of which is known drug use and / or abuse by the subject), a blood test to determine a level of opioids in a subject, presence of an adverse reaction in a subject when the subject is administered an opioid, a lack of analgesia in a subject following administration of an opioid to the subject, etc. Those skilled in arts relating to pain management and health care will be able to assess a subject’s risk of opioid tolerance and / or the presence of opioid tolerance in a subject using routine methods disclosed herein and / or known in the art.

[0042] In addition to characteristics that can be assessed in a subject, it will be understood that a risk of opioid tolerance in a subject may be determined based on a therapeutic regimen that will be administered to the subject. For example, if a subject will be administered an opioid pain management regimen, parameters of the regimen may be used to assess whether the subject is at risk for opioid tolerance. Thus, a current or upcoming opioid treatment of a subject may indicate a risk of a subject developing opioid tolerance.

[0043] Gelsolin Agents

[0044] As described elsewhere herein, it has now been determined that a gelsolin agent administered to a subject can treat opioid tolerance in the subject. Gelsolin is a highly conserved, multifunctional protein, initially described in the cytosol of macrophages and subsequently identified in many vertebrate cells [see for example Piktel E. et al., IntJMol Sci 2018;

[0045] 19:E2516; Silacci P. et al., Cell Mol Life Sci 2004; 61 :2614-23.) A unique property of gelsolin is that its gene expresses a splice variant coding for a distinct plasma isoform (pGSN), which is secreted into extracellular fluids and differs from its cytoplasmic counterpart (cGSN) by expressing an additional sequence of 25 amino acids. pGSN normally circulates in mammalian blood at concentrations of 200-300 pg / ml, placing it among the most abundant plasma proteins.

[0046] The term “gelsolin agent” as used herein means a composition that includes a gelsolin molecule. In some embodiments of methods of the invention, a gelsolin molecule may be a functional fragment or functional derivative of a full-length, natural, parent gelsolin molecule. In some embodiments of the invention, a gel solin agent only includes one or more of the gel solin molecule, a functional fragment thereof, or a functional derivative of the gelsolin molecule. In certain embodiments of the invention a gelsolin agent may include one of more additional components, non-limiting examples of which are detectable labels, carriers, delivery agents, etc. In certain aspects of the invention a gelsolin molecule is a plasma gelsolin (pGSN) and in certain instances, a gelsolin molecule is a cytoplasmic GSN. A gelsolin molecule included in compositions and methods of the invention may be a recombinant gel solin molecule. As used herein, the term “gelsolin agent” is a compound that includes an exogenous gelsolin molecule. The term “exogenous” as used herein in reference to a gelsolin molecule means a gelsolin molecule administered to a subject, even if the same gelsolin molecule is naturally present in the subject, which may be referred to as an endogenous gelsolin molecule. A gelsolin agent included in a method of the invention may be a wild-type gelsolin molecule, such as GenBank accession No.: X04412, the amino acid sequence of which is set forth herein as SEQ ID NO: 1, an isoform, an analog, a functional variant, a functional fragment, or a functional derivative of a gelsolin molecule. It will be understood that in some embodiments of the invention an administered gelsolin molecule is a gelsolin polypeptide and in certain embodiments of methods of the invention an administered gelsolin molecule is a gelsolin polypeptide-encoding polynucleotide.

[0047] Some embodiments of methods of the invention include administration of a “gelsolin analog,” which as used herein refers to a compound substantially similar in function to either the native gelsolin or to a fragment thereof. Gelsolin analogs include biologically active amino acid sequences substantially similar to the gelsolin sequences and may have substituted, deleted, elongated, replaced, or otherwise modified sequences that possess bioactivity substantially similar to that of gel solin. For example, an analog of gelsolin is one that does not have the same amino acid sequence as gelsolin but that is sufficiently homologous to gelsolin so as to retain the bioactivity of gelsolin. Bioactivity can be determined, for example, by determining the properties of the gel solin analog and / or by determining the ability of the gelsolin analog to reduce or prevent opioid tolerance in a subject, and in some embodiments, to reduce or prevent morphine tolerance in a subject. Gelsolin bioactivity assays known to those of ordinary skill in the art.

[0048] Certain embodiments of methods of the invention include fragments of a gelsolin molecule. The term “fragment” is meant to include any portion of a gelsolin molecule that provides a segment of gelsolin that maintains at least a portion or substantially all of a level of bioactivity of the “parent” gelsolin. The term gelsolin fragment is meant to include gelsolin fragments made from any source, such as, for example, from naturally occurring peptide sequences, synthetic or chemically synthesized peptide sequences, and genetically engineered peptide sequences. The term “parent” as used herein in reference to a gelsolin fragment or derivative molecule means the gelsolin molecule from which the sequence of the fragment or derivative originated.

[0049] In certain embodiments of methods of the invention, a gelsolin fragment is a functional fragment and retains at least some, up to all the function of its parent gelsolin molecule. Methods of the invention may in some embodiments include administration of a “variant” of gelsolin. As used herein a gelsolin variant may be a compound substantially similar in structure and bioactivity either to native gel solin, or to a fragment thereof. In certain aspects of the invention, a gelsolin variant is referred to as a functional variant and retains at least some up to all the function of its parent gelsolin molecule.

[0050] Gelsolin derivatives are also contemplated for inclusion in embodiments of methods of the invention. A “functional derivative” of gelsolin is a derivative that possesses a bioactivity that is substantially similar to the bioactivity of gelsolin. By “substantially similar” is meant activity which may be quantitatively different but qualitatively the same. For example, a functional derivative of gelsolin could contain the same amino acid backbone as gelsolin but also contains other modifications such as post-translational modifications such as, for example, bound phospholipids, or covalently linked carbohydrate, depending on the necessity of such modifications for the performance of a therapeutic method of the invention. As used herein, the term is also meant to include a chemical derivative of gelsolin. Such derivatives may improve gelsolin's solubility, absorption, biological half-life, etc. The derivatives may also decrease the toxicity of gelsolin, or eliminate or attenuate any undesirable side effect of gelsolin, etc. Derivatives and specifically, chemical moieties capable of mediating such effects are disclosed in Remington, The Science and Practice of Pharmacy, 2012, Editor: Allen, Loyd V., Jr, 22ndEdition). Procedures for coupling such moieties to a molecule such as gelsolin are well known in the art. The term “functional derivative” is intended to include the “fragments,” “variants,” “analogues,” or “chemical derivatives” of gelsolin.

[0051] Certain Treatment Strategies

[0052] Certain embodiments of methods of the invention include administering a gelsolin agent to a subject who has, or is identified as at risk of developing, opioid tolerance. In some embodiments of therapeutic methods of the invention a gelsolin agent includes a gelsolin molecule, a functional fragment of a gel solin molecule, or a functional derivative of a gel solin molecule. In some embodiments of the invention, the administered gelsolin agent comprises a plasma gelsolin (pGSN). An administered gelsolin agent may, in some embodiments of the invention, comprise a recombinant gelsolin molecule.

[0053] Certain embodiments of methods of the invention include administering the gelsolin agent to a subject in an amount effective to reduce the subject’s risk of developing opioid tolerance, to reduce the severity of opioid tolerance present in a subject, and / or to eliminate opioid tolerance present in a subject. In some embodiments, a therapeutically effective amount of a gel solin agent refers to the amount of the gel solin agent administered to a subject that is sufficient to prevent onset and / or progression of opioid tolerance in the subject. Administration of the gelsolin agent may reduce the risk of a subject developing opioid tolerance as a result of the a prior, current, or future opioid administration by at least 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, 11%, 12%, 13%, 14%, 15%, 16%, 17%, 18%, 19%, 20%, 21%, 22%, 23%, 24%, 25%, 26%, 27%, 28%, 29%, 30%, 31%, 32%, 33%, 34%, 35%, 36%, 37%, 38%, 39%, 40%, 41%, 42,%, 43%, 44%, 45%, 46%, 47%, 48%, 49%, 50%, 51%, 52%, 53%, 54%, 55%, 56%, 57%, 58%, 59%, 60%, 61%, 62,%, 63%, 64%, 65%, 66%, 67%, 68%, 69%, 70%, 71%, 72%, 73%, 74%, 75%, 76%, 77%, 78%, 79%, 80%, 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or 100%, compared to the percent control risk of the subject developing the opioid tolerance. For example, if a subject’s risk of developing opioid tolerance as a result of ongoing opioid administration to the subject is 50%, administering an effective amount of a gelsolin agent to the subject may reduce the subject’s 50% risk to less than 45%, 40%, 35%, 30%, 25%, 20%, 15%, 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, 1% risk, or to 0% risk.

[0054] In some embodiments of methods of the invention, a therapeutically effective amount of a gelsolin agent to treat opioid tolerance in a subject refers to that amount of the gelsolin agent administered to the subject that is sufficient reduce or eliminate opioid tolerance present in the subject. Administration of the gelsolin agent may reduce opioid tolerance in a subject with opioid tolerance by at least 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, 11%, 12%, 13%, 14%, 15%, 16%, 17%, 18%, 19%, 20%, 21%, 22%, 23%, 24%, 25%, 26%, 27%, 28%, 29%, 30%, 31%, 32%, 33%, 34%, 35%, 36%, 37%, 38%, 39%, 40%, 41%, 42,%, 43%, 44%, 45%, 46%, 47%, 48%, 49%, 50%, 51%, 52%, 53%, 54%, 55%, 56%, 57%, 58%, 59%, 60%, 61%, 62,%,

[0055] 63%, 64%, 65%, 66%, 67%, 68%, 69%, 70%, 71%, 72%, 73%, 74%, 75%, 76%, 77%, 78%,

[0056] 79%, 80%, 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%,

[0057] 95%, 96%, 97%, 98%, 99%, or 100%, compared to the a control level of opioid tolerance. In some embodiments, a control level is a level in a subject with opioid tolerance who is not administered a gelsolin agent. In some embodiments, a control level for a subject is the level of opioid tolerance in the subject prior to administration of a gelsolin agent.

[0058] The timing of administration of a gelsolin agent and amount of gelsolin administered to a subject may be determined based on the medical circumstances of the subject and need for pain relief for the subject. In some embodiments, a gelsolin agent is administered to a subject at one or more of prior to, during, and after the administration of an opioid to the subject. The gelsolin agent may be administered to a subject determined to be in need such treatment once, or multiple times. Multiple administrations of a gelsolin agent mean the gelsolin agent is administered to a subject 2, 3, 4, 5, 6, 7, 8, 9, 10, or more times. It will be understood that administration of a gelsolin agent may be done in combination with additional treatments for the subject, which in some embodiments are opioid administration to the subject and in certain embodiments, may comprise administering to the subject another opioid-tolerance-reducing treatment and / or another non-opioid pain relief agent.

[0059] Pain-reducing Treatment Selection

[0060] As described herein, certain embodiments of the invention include methods of selecting a pain-reducing treatment for a subject based at least in part on the presence of opioid tolerance in the subject or a risk of the subject developing opioid tolerance. In some embodiments of the invention, a selected treatment regimen is administered to a subject in need of such treatment, and includes administering an effective amount of a gelsolin agent to treat opioid tolerance in the subject. In some embodiments, the gelsolin agent is soluble gelsolin. In some embodiments the gelsolin agent is a recombinant gelsolin. In some embodiments of a pain-reducing treatment method of the invention, an opioid to which a subject has opioid tolerance, another opioid, or a non-opioid pain medication may also be administered to the subject, at one or more of before, essentially concurrently with, and after administration of a gelsolin agent. As a non-limiting example of an opioid In some embodiments of methods of the invention, the opioid is morphine or a morphine derivative or may be an opioid listed elsewhere herein, or a derivative thereof. In some embodiments of methods of the invention the opioid administered is a pharmaceutical opioid composition. In certain embodiments of methods of the invention, the opioid is administered under the direction of a health care professional. In certain embodiments of methods of the invention, the opioid is administered by the subject or by someone who is not a health care professional. In some embodiments of methods of the invention the opioid is not administered under the direction of a health care professional.

[0061] As a non-limiting example, in certain embodiments of methods of the invention the opioid is morphine. In some embodiments of methods of the invention, morphine administered to a subject is a pharmaceutical morphine composition and is administered under the direction of a health care professional. In certain embodiments of methods of the invention, the morphine is self-administered by a subject or is administered by someone who is not a health care professional. In some embodiments of methods of the invention the morphine is not administered under the direction of a health care professional.

[0062] Certain embodiment of methods of the invention include selecting a pain-reduction treatment for a subject who is known to have (also referred to herein as: as a subject “having” or a subject who “has”) an opioid tolerance. Embodiments of the method may, but need not, include determining which one or more opioids are the basis of the subject’s opioid tolerance. The term “basis” used herein in relation to a subject’s opioid tolerance means the one or more opioids administered to a subject that result in the presence of the opioid tolerance in the subject. In some embodiments, a health care professional or other person administered the one or more opioids that are a basis for the subject’s opioid tolerance. In certain embodiments, the subject may have self-administered one or more opioids that are the basis for the subject’s opioid tolerance.

[0063] Some embodiments of pain-reduction treatment selection methods of the invention include (1) selecting a gelsolin therapeutic regimen for the subject, wherein the gelsolin therapeutic regimen comprises the administration of a composition comprising a gelsolin agent, in an amount effective to treat the opioid tolerance in the subject, and (2) selecting a painreducing therapeutic regimen for the subject, wherein the pain-relieving regimen comprises the administration of one or more opioids and / or a different pain-relieving agent to the subject. In some instances, the method of selecting a pain-reduction therapeutic regimen also includes determining the identity of the one or more opioids that are the basis for the subjects opioid tolerance, and optionally selecting the one or more opioids and / or the different pain-relieving agent based at least in part on the identified one or more opioids that are be basis of the subject’s opioid tolerance.

[0064] Certain aspects of the invention, include selecting a pain-reduction treatment for a subject at risk of having an opioid tolerance. Such a selection method includes: (1) selecting a gelsolin therapeutic regimen for the subject, wherein the gelsolin therapeutic regimen comprises the administration of a composition comprising a gelsolin agent, in an amount effective to reduce the risk of the opioid tolerance in the subject and; (2) selecting a pain-reducing therapeutic regimen for the subject, wherein the pain-reducing therapeutic regimen comprises the administration of one or more opioids and / or a different pain-relieving agent to the subject.

[0065] In certain embodiments of methods of the invention, selecting a pain-reduction therapeutic regimen also includes administering the selected pain-reducing therapeutic regimen to the subject 2, 3, 4, 5, 6, 7, 8, or more times and administering the selected gelsolin therapeutic regimen to the subject 2, 3, 4, 5, 6, 7, 8, or more times. In some embodiments of methods of the invention, administering the gelsolin therapeutic regimen and a selected pain-reducing therapeutic regimen may include administering a gelsolin agent prior to an administration of the one or more opioids and / or the different pain-relieving agent to the subject. Certain embodiments of methods of the invention comprise administering a gelsolin agent at essentially the same time as administering the one or more opioids and / or the different pain-relieving agent to the subject. Some embodiments of methods of the invention comprise administering a gelsolin agent at a time after the administration of one or more opioids and / or the different pain- relieving agent to the subject. It will be understood that in some embodiments on methods of the invention, a pain-reduction therapeutic regimen may include multiple administrations of a gelsolin agent and / or multiple administrations of the one or more opioids and / or other pain- relieving agent to a subject and the timing may include administering the gelsolin agent at one or more of before, essentially at the same time as, and at times after the administration of one or more opioids and / or the different pain-relieving agent. In some selection methods of the invention, the gel solin agent comprises a gel solin molecule, and optionally the gelsolin molecule is a recombinant gelsolin molecule, and may be a plasma gelsolin (pGSN).

[0066] Administering a selected gelsolin therapeutic regimen and a selected pain-reduction therapeutic regimen to a subject reduces opioid tolerance in the subject compared to a control level of opioid tolerance. In some situations, a control therapeutic level is the presence, absence, and / or severity of opioid tolerance in a subject or subjects administered the selected painreducing therapeutic regimen but not administered the selected gelsolin therapeutic regimen. The administration of a selected pain-reduction treatment may reduce the opioid tolerance in the subject by at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100% compared to the opioid tolerance of a control administered the selected pain-reduction therapeutic regimen but not the selected gelsolin therapeutic regimen. As described elsewhere herein, opioid tolerance may be determined using art-known methods, such as, but not limited to: determining or measuring one or more opioid-tolerance symptoms in the subject and / or determining the severity of the opioid tolerance in the subject.

[0067] Administering a selected pain-reduction treatment of the invention reduces pain in the subject, which may also be referred to herein as increasing pain relief in the subject. In some embodiments of pain-reduction treatment methods of the invention, administering a gelsolin agent in a selected gel solin therapeutic regimen increases pain-relief efficacy of the selected pain-reducing therapeutic regimen in the subject by at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, 100%, 125%, 150%, 175%, 200%, or more compared to the pain-relief efficacy of the selected pain-reducing therapeutic regimen of a control subject or subjects administered the selected painreducing therapeutic regimen but not administered the selected gelsolin therapeutic regimen.

[0068] Therapeutic Compositions and Methods and Monitoring Efficacy

[0069] Methods of the invention include producing a therapeutic effect in a subject that has a or is at risk of having opioid tolerance to reduce and treat the opioid tolerance. The term “therapeutic effect” as used herein in reference to an agent such as a gelsolin agent means a therapeutic effect of the gelsolin agent when it is administered to a subject having or at risk of having opioid tolerance. A therapeutic effect of gelsolin (also referred to herein as a “response” to a treatment method of the invention) can be determined, for example, by detecting one or more physiological effects of the treatment, such as the decrease or lack of symptoms or physiological characteristics of opioid tolerance following administration of the treatment. Additional means of monitoring and assessing opioid tolerance in a subject, and ways to assess and determine one or more of a level, severity, change in severity, etc. of an opioid tolerance in subject are known in the art. Non-limiting examples of physiological symptoms of opioid tolerance include, but are not limited to: reduced sensitivity to opioid pain relief treatment, respiratory depression, behavioral characteristics, etc. are known in the art and routinely assessed for opioid tolerance. Non-limiting examples of ways of determining and / or monitoring opioid use in a subject, the presence of which may indicate opioid tolerance in the subject, are tests such as blood tests to determine a level of opioids in the subject, physical assessment of a subject, signs in the subject of opioid intoxication such as depressed respiration, disorientation, etc.

[0070] In a non-limiting example, a subject receiving chronic opioid administration for pain control, especially at high doses, may be determined to need a higher amount or dose of an opioid for pain relief, then another subject who does not receive chronic opioid administration for pain control. A subject with opioid tolerance may be assumed to have developed less tolerance to opioid-induced respiratory depression than to analgesia. This means the different amounts or dosage of opioids necessary to administer to an opioid-tolerant subject and to a nonopioid-tolerant subject to reach essentially equivalent levels of pain relief in the subjects, may result in a higher level of respiratory depression in the opioid-tolerant subject than in the non- opioid-tol erant subject. Thus, the opioid-tolerant patient may have an increased risk of respiratory depression when receiving a sufficient amount or dose of opioids to result in an essentially equivalent level of pain reduction in the opioid-tolerant subject and the non-opioid- tol erant subject (see, for example C. J. Hayhurst, & M. E. Durieux, Anesthesiology February 2016, Vol. 124, 483-488.)

[0071] Some embodiments of methods of the invention may also comprise determining efficacy of an administered therapeutic regimen. For example, a level of opioid tolerance may be determined in a subject and then monitored for change. In some embodiments, determining a level of opioid tolerance comprises a behavioral assessment. In some embodiments, a level of opioid tolerance in a subject is determined and indicates the regression of, and / or a decrease in the severity of the opioid tolerance in the subject. The term “severity” when used herein in reference to opioid tolerance means the level of opioid tolerance in a subject. As a non-limiting example, a subject who has been administered an opioid for one week, may have a level of opioid tolerance that is less severe than a subject who has been administered the opioid for a longer period of time, for example 2, 3, 4, 5, 6, or more weeks.

[0072] In certain embodiments of the invention, a subject is assessed for opioid tolerance at one of more of before a regimen of administration of a gel solin agent, during a regimen of administration of a gelsolin agent, and after the end of a regimen of administration of a gelsolin agent. Such assessments may be used to determine the efficacy of the gelsolin agent administration in the subject.

[0073] Methods of the invention, in some embodiments, include administering a gelsolin agent to a subject who has or is at risk of opioid tolerance in an amount effective to result in a therapeutic effect to reduce the severity of the opioid tolerance in the subject. The gelsolin agent can be administered in conjunction with other treatments selected in a therapeutic regimen for a subject identified as having or being at risk of opioid tolerance.

[0074] Methods and compositions of the invention may be used to treat opioid tolerance. As used herein, the terms “treat,” “treated,” or “treating” when used in relation to opioid tolerance may refer to a prophylactic treatment that decreases the likelihood or risk of a subject developing the opioid tolerance, and / or may refer to a treatment after a subject has developed opioid tolerance. In some embodiments of methods of the invention, a treatment method reduces a risk of a subject developing opioid tolerance. In certain embodiments, a treatment method of the invention may be used to eliminate or ameliorate existing opioid tolerance in a subject, to prevent existing opioid tolerance in a subject from becoming more severe, and / or to slow the progression of the opioid tolerance in a subject compared to the progression of the opioid tolerance in the absence of the treatment method of the invention.

[0075] The invention in part, includes pharmaceutical compositions comprising a gelsolin agent and one or more opioids. The gelsolin agent may be a gelsolin molecule that may be a recombinant gelsolin molecule. In some embodiments, the gelsolin molecule is a plasma gelsolin (pGSN). In some embodiments, the opioid is morphine, heroin, hydromorphone, oxymorphone, fentanyl, methadone, oxycodone, hydrocodone, codeine, buprenorphine, dextromethorphan, dextropropoxyphene, loperamide, meperidine, opium, carfentanyl / carfentanil, morphone, talpentadol, tramadol, or pethidine. The pharmaceutical composition comprising a gelsolin agent may, in some embodiments, also include an opioid so the gelsolin agent and the opioid may be administered to a subject together. It will be understood that administration of a gelsolin agent and an opioid may be performed with the gelsolin agent and the opioid in separate pharmaceutical compositions.

[0076] Subjects and Samples

[0077] As used herein, a subject may be a vertebrate animal including but not limited to a human, mouse, rat, guinea pig, rabbit, cow, dog, cat, horse, goat, and non-human primate, e.g., monkey. A subject may be a mammal. In some embodiments, a subject is any human or non- human recipient of a gelsolin agent or pharmaceutical composition comprising a gelsolin agent as described herein. In some embodiments, a subject is any human or non-human recipient of a gelsolin agent or pharmaceutical composition comprising a gelsolin agent as described herein. In some embodiments, a subject is any human or non-human recipient a gelsolin therapeutic regimen and a pain-reducing therapeutic regimen of the invention.

[0078] In certain aspects of the invention, a subject may be a domesticated animal, a wild animal, or an agricultural animal. Thus, the invention can be used to treat opioid tolerance in human and non-human subjects. For instance, methods and compositions of the invention can be used in veterinary applications as well as in human treatment regimens. In some embodiments of the invention, a subject is a human. In some embodiments of the invention, a subject has or is at risk of having opioid tolerance and the subject is in need of treatment with a method of the invention. In some embodiments of methods of the invention, a subject is an animal model of opioid tolerance.

[0079] In some embodiments, a subject treated with an embodiment of a method of the invention is an adult human subject to whom an opioid is administered for treatment of pain, non-limiting examples of which are moderate or severe pain. In certain embodiments, a subject treated with an embodiment of a method of the invention is a geriatric subject. In certain embodiments, a geriatric subject is not in need of treatment for a frailty condition. In some embodiments a subject treated with an embodiment of a method of the invention is a subject abusing one or more opioids. In some embodiments, a subject treated with an embodiment of a method of the invention is not in need of a gelsolin treatment of an infection. In some embodiments, a subject treated with an embodiment of a method of the invention does not have an infection. In some embodiments, a subject treated with an embodiment of a method of the invention does not have a decompression-associated disease or condition. In some embodiments, a subject treated with an embodiment of a method of the invention does not have multiple sclerosis.

[0080] Assessments and Controls

[0081] Characteristics of opioid tolerance in a subject can be compared to control values of the characteristics of the opioid tolerance. A control value may be a predetermined value, which can take a variety of forms. It can be a single cut-off value, such as a median or mean. It can be established based upon comparative groups, such as in groups of individuals having opioid tolerance, groups of individuals who have been administered a treatment for the opioid tolerance, groups of individuals who have not been administered a treatment for the opioid tolerance, etc. Another example of comparative groups may be groups of subjects having one or more symptoms of or a diagnosis of opioid tolerance and groups of subjects without one or more symptoms of or a diagnosis of the opioid tolerance. A predetermined value, of course, will depend upon the particular population selected. Accordingly, a predetermined value selected may take into account the category in which an individual falls. Appropriate categories can be selected with no more than routine experimentation by those of ordinary skill in the art.

[0082] Controls can be used in methods of the invention to compare characteristics of different control groups, characteristics of a subject with those of a control group, etc. Comparisons between subjects and controls, one control with another control, etc. may be based on relative differences. For example, though not intended to be limiting, a physiological symptom in a subject treated with a gel solin agent in a therapeutic method of the invention, can be compared to the physiological symptom of a control group that has not been administered the gelsolin agent. The comparison may be expressed in relative terms, for example, if insensitivity of a subject to an administered opioid is a characteristic of an opioid tolerance, a determination of opioid sensitivity of a subject treated with a therapeutic method of the invention comprising administering a gelsolin agent may be compared to a control level of opioid sensitivity in a subject that is not administered the gelsolin agent. In some embodiments, a suitable control is a subject not treated with a therapeutic method of the invention. A comparison of a treated versus a control may include comparing a level of opioid tolerance between the treated subject and the selected control. In some instances, level of opioid tolerance of a subject treated with a method of the invention may be determined to be less relative to a selected control, with the comparison indicating up to a 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, 11%, 12%, 13%, 14%, 15%, 16%, 17%, 18%, 19%, 20%, 21%, 22%, 23%, 24%, 25%, 26%, 27%, 28%, 29%, 30%, 31%,

[0083] 32%, 33%, 34%, 35%, 36%, 37%, 38%, 39%, 40%, 41%, 42,%, 43%, 44%, 45%, 46%, 47%,

[0084] 48%, 49%, 50%, 51%, 52%, 53%, 54%, 55%, 56%, 57%, 58%, 59%, 60%, 61%, 62,%, 63%,

[0085] 64%, 65%, 66%, 67%, 68%, 69%, 70%, 71%, 72%, 73%, 74%, 75%, 76%, 77%, 78%, 79%,

[0086] 80%, 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%,

[0087] 96%, 97%, 98%, 99%, or 100% reduction in a level of opioid tolerance in the subject as compared to the control.

[0088] It will be understood that controls may be, in addition to predetermined values, samples of materials tested in parallel with the experimental materials. Examples include samples from control populations or control samples generated through manufacture to be tested in parallel with the experimental samples; and a control may be a sample from a subject prior to, during, or after a treatment with an embodiment of a method or composition of the invention. Thus, one or more characteristics determined for a subject at risk of having, or having opioid tolerance may be used as “control” values for those characteristics in that subject at a later time.

[0089] Timing of Administration

[0090] Some embodiments of the invention include pretreating a subject who, at the time of treatment, does not have opioid tolerance. In some embodiments, pretreatment of a subject occurs at a time in advance of the subject undertaking an opioid treatment regimen that is assessed as putting the subject at risk of developing opioid tolerance. Some embodiments of treatment methods of the invention include administering to a subject having at risk of having opioid tolerance an effective amount of a gelsolin agent, wherein the gelsolin agent is administered from just prior to the administration of the opioid of the opioid treatment regimen or up to 1, 2, 3, 4, 5, 6, 12, 18, 24, 48, 72, 96, 120, 144 hours, or more prior to the administration of the opioid to the subject. In some embodiments the gelsolin agent is administered to the subject at the time of the administration of an opioid to the subject. In some embodiments the gelsolin agent is administered after the administration of an opioid to the subject. In some embodiments, a subject received a gelsolin agent in a therapeutic method of the invention at two or three of: prior to, during, and after the administration of the opioid to the subject. It will be understood that a subject identified as being treated with an opioid or who will be treated with an opioid who might at some point develop opioid tolerance may be administered gelsolin as a prophylactic treatment to reduce the likelihood of the onset of opioid tolerance in the subject.

[0091] Pharmaceutical Compositions and Delivery

[0092] Some embodiments of methods of the invention, comprise a method for treating opioid tolerance in an individual (referred to interchangeably herein as a subject) in need of such treatment, and the treatment comprises administering to the individual a therapeutically effective amount of a gelsolin agent. In a non-limiting example, gelsolin (also referred to herein as a gelsolin agent) is administered to the subject in need of a treatment for opioid tolerance. In some embodiments, the gelsolin is administered intravenously or using another suitable administration method, non-limiting examples of which are set forth elsewhere herein. A representative example of form of gelsolin is recombinant gelsolin. Some embodiments of methods of the invention, comprise a method for a prophylactic treatment of an individual susceptible to opioid tolerance, comprising the step of administering to the individual a therapeutically effective amount of gelsolin.

[0093] A gelsolin agent may be administered to a subject in the form of a pharmacological composition (also referred to herein as a pharmaceutical composition), meaning the gelsolin agent is administered in a composition that is sterile and that may include one or more additional components. A gelsolin agent may be administered in an amount effective for producing the desired response in a unit of weight or volume suitable for administration to a subject. An opioid may be administered to a subject in the form of a pharmacological composition, (also referred to herein as a pharmaceutical composition), meaning a composition that is sterile and may include one or more additional components. An opioid may be administered in an amount effective for pain reduction in the subject. Doses of gelsolin agents and opioids administered to a subject can be chosen in accordance with different parameters, in particular in accordance with the mode of administration used and the state of the subject. Other factors include the desired period of treatment. In the event that a response in a subject is insufficient at the initial doses applied, higher doses (or effectively higher doses by a different, more localized delivery route) may be employed to the extent that a subject’s tolerance permits. The dosage of a pharmacological agent may be adjusted by an individual physician, healthcare practitioner, or veterinarian; particularly in the event of any complication. A therapeutically effective amount of gelsolin typically varies from 0.01 mg / kg to about 1000 mg / kg, from about 0.1 mg / kg to about 200 mg / kg, from about 0.2 mg / kg to about 20 mg / kg, , from about 0.5 mg / kg to about 10 mg / kg, or from about 1.0 mg / kg to about 5 mg / kg in one or more dose administrations daily, for one or more days. In some embodiments of the invention, a therapeutically effect amount varies from 1 mg / kg to 100 mg. An effective amount of an opioid for pain relief can be determined using routine procedures known to those practicing health care and / or veterinary care.

[0094] Methods of the invention include administering gelsolin and / or opioids to a subject. Methods of administration of pharmaceutical compositions are known in the art and methods disclosed herein, and other art-known methods may be used in a method of the invention to effectively deliver pharmaceutical compositions and / or agents of the invention to a desired tissue, cell, or bodily fluid. The manner and dosage administered may be adjusted by the individual physician, healthcare practitioner, or veterinarian, particularly in the event of any complication. The absolute amount administered will depend upon a variety of factors, including the material selected for administration, whether the administration is in single or multiple doses, and individual subject parameters including age of the subject, physical condition of the subject, size of the subject, weight of the subject, the severity of opioid tolerance in the subject, an opioid regimen that has been, is being and / or will be administered to the subject, etc. These factors can be identified and addressed with no more than routine experimentation.

[0095] Various modes of administration known to the skilled artisan may be used to effectively deliver to a subject, a pharmaceutical composition of the invention that comprises a gelsolin agent and / or a pharmaceutical composition of the invention that comprises one or more opioids to produce a desired therapeutic effect in the subject. Methods for administering a pharmaceutical composition of the invention may be oral, sublingual, buccal, intranasal, intravitreal, intracavity, intravenous, intramuscular, intrathecal, intraperitoneal, subcutaneous, transdermal, intradermal, topical, rectal, vaginal, intrasynovial, intra-ocular, or by inhalation administration. The invention is not limited by the particular modes of administration disclosed herein. Standard references in the art (e.g., Remington, The Science and Practice of Pharmacy, 2020, Editor: Adeboye Adejare, 23rdEdition) provide modes of administration and formulations for delivery of various pharmaceutical preparations and formulations in pharmaceutical carriers. Other art-known administration methods may be used in methods of the invention to administer one or more pharmaceutical compositions to a subject. Administration methods, in which the dose amount, schedule of administration, sites of administration, mode of administration, and the like may vary from those presented herein may be used in certain embodiments of methods of the invention.

[0096] Administration of one or more pharmacological compositions of the invention to mammals other than humans, e.g., for testing or research purposes or for veterinary therapeutic purposes, may be carried out under substantially the same conditions as described above herein. It will be understood that this invention is applicable to both human and animal subjects. Thus, this invention is intended to be used in husbandry and veterinary medicine as well as in human therapeutics.

[0097] When administered, a pharmaceutical composition of the invention is applied in a pharmaceutically acceptable amount and in a pharmaceutically acceptable composition. The term “pharmaceutically acceptable” means a non-toxic material that does not interfere with the effectiveness of the biological activity of the active ingredient(s). Such preparations may routinely contain one or more salts, buffering agents, preservatives, compatible carriers, aqueous solutions, water, etc. and optionally other therapeutic agents. Pharmaceutically acceptable carriers may include one or more diluents, fillers, salts, buffers, stabilizers, solubilizers and other materials that are well known in the art. As used herein, the term “pharmaceutically acceptable” refers to molecular entities and compositions that do not produce an adverse, allergic, or other untoward reaction when administered to an animal, such as, for example, a human, as appropriate. The preparation of a pharmaceutical composition that includes gelsolin, an opioid, and / or an additional drug will be known to those of skill in the art in light of the present disclosure, as exemplified by Remington: The Science and Practice of Pharmacy, 23rd Edition, Academic Press, 2020.

[0098] Exemplary pharmaceutically acceptable carriers are known and routinely used by those skilled in the art. In certain embodiments of the invention, such preparations may contain salt, When used in medicine, the salts may be pharmaceutically acceptable, but non-pharmaceutically acceptable salts may conveniently be used to prepare pharmaceutically acceptable salts thereof and are not excluded from the scope of the invention. Such pharmacologically and pharmaceutically acceptable salts include, but are not limited to, those prepared from the following acids: hydrochloric, hydrobromic, sulfuric, nitric, phosphoric, maleic, acetic, salicylic, citric, formic, malonic, succinic, and the like. Also, pharmaceutically acceptable salts can be prepared as alkaline metal or alkaline earth salts, such as sodium, potassium, or calcium salts. A pharmaceutical composition of the invention also may contain, optionally, suitable preservatives, such as: benzalkonium chloride, chlorobutanol, parabens, and thimerosal.

[0099] A pharmacological agent or composition may be combined, if desired, with a pharmaceutically-acceptable carrier. The term “pharmaceutically-acceptable carrier” as used herein means one or more compatible solid or liquid fdlers, diluents or encapsulating substances which are suitable for administration into a human. The term "carrier" denotes an organic or inorganic ingredient, natural or synthetic, with which the active ingredient is combined to facilitate the application. Pharmaceutically acceptable carriers that may be included in a pharmaceutical composition of the invention include diluents, fillers, salts, buffers, stabilizers, solubilizers and other materials that are well-known in the art. Exemplary pharmaceutically acceptable carriers are described in U.S. Pat. No. 5,211,657 and others are known by those skilled in the art. In certain embodiments of the invention, such preparations may contain salt, buffering agents, preservatives, compatible carriers, aqueous solutions, water, etc. When used in medicine, the salts may be pharmaceutically acceptable, but non-pharmaceutically acceptable salts may conveniently be used to prepare pharmaceutically-acceptable salts thereof and are not excluded from the scope of the invention. Components of the pharmaceutical compositions also are capable of being co-mingled with the pharmacological agents of the invention, and with each other, in a manner such that there is no interaction which would substantially impair the desired pharmaceutical efficacy. Pharmaceutical compositions used in methods of the invention may contain suitable buffering agents, as described above, including but not limited to: acetate, phosphate, citrate, glycine, borate, carbonate, bicarbonate, hydroxide (and other bases) and pharmaceutically acceptable salts of the foregoing compounds.

[0100] Pharmaceutical compositions used in methods of the invention may conveniently be presented in unit dosage form and may be prepared by any of the methods well known in the art of pharmacy. All methods include the step of bringing the active agent into association with a carrier, which constitutes one or more accessory ingredients. In general, the compositions are prepared by uniformly and intimately bringing the active compound into association with a liquid carrier, a finely divided solid carrier, or both, and then, if necessary, shaping the product.

[0101] Compositions suitable for oral administration may be presented as discrete units, such as capsules, tablets, pills, lozenges, each containing a predetermined amount of the active compound (e.g., gelsolin). Other compositions include suspensions in aqueous liquids or nonaqueous liquids such as a syrup, elixir, an emulsion, or a gel.

[0102] Pharmaceutical preparations for oral use can be obtained as solid excipient, optionally grinding a resulting mixture, and processing the mixture of granules, after adding suitable auxiliaries, if desired, to obtain tablets or dragee cores. Suitable excipients are, in particular, fillers such as sugars, including lactose, sucrose, mannitol, or sorbitol; cellulose preparations such as, for example, maize starch, wheat starch, rice starch, potato starch, gelatin, gum tragacanth, methyl cellulose, hydroxypropylmethyl-cellulose, sodium carboxymethylcellulose, and / or polyvinylpyrrolidone (PVP). If desired, disintegrating agents may be added, such as the cross-linked polyvinyl pyrrolidone, agar, or alginic acid or a salt thereof such as sodium alginate. Optionally the oral formulations may also be formulated in saline or buffers, i.e., EDTA for neutralizing internal acid conditions or may be administered without any carriers.

[0103] Also specifically contemplated are oral dosage forms of the above component or components. The component or components may be chemically modified so that oral delivery of the derivative is efficacious. Generally, the chemical modification contemplated is the attachment of at least one moiety to the component molecule itself, where said moiety permits (a) inhibition of proteolysis; and (b) uptake into the blood stream from the stomach or intestine. Also desired is the increase in overall stability of the component or components and increase in circulation time in the body. Examples of such moieties include: polyethylene glycol, copolymers of ethylene glycol and propylene glycol, carboxymethyl cellulose, dextran, polyvinyl alcohol, polyvinyl pyrrolidone and polyproline. Abuchowski and Davis, 1981, “Soluble Polymer-Enzyme Adducts” In: Enzymes as Drugs, Hocenberg and Roberts, eds., Wiley- Interscience, New York, N.Y., pp. 367-383; Newmark, et al., 1982, J. Appl. Biochem. 4: 185- 189. Other polymers that could be used are poly-1, 3-dioxolane and poly-1, 3, 6-tioxocane.

[0104] For the pharmacological agent, the location of release may be the stomach, the small intestine (the duodenum, the jejunum, or the ileum), or the large intestine. One skilled in the art has available formulations which will not dissolve in the stomach, yet will release the material in the duodenum or elsewhere in the intestine. Preferably, the release will avoid the deleterious effects of the stomach environment, either by protection of the gel solin agent or by release of the biologically active material beyond the stomach environment, such as in the intestine.

[0105] Microspheres formulated for oral administration may also be used. Such microspheres have been well defined in the art. All formulations for oral administration should be in dosages suitable for such administration.

[0106] For buccal administration, the compositions may take the form of tablets or lozenges formulated in conventional manner.

[0107] For administration by inhalation, the compounds for use according to the present invention may be conveniently delivered in the form of an aerosol spray presentation from pressurized packs or a nebulizer, with the use of a suitable propellant, e g., dichlorodifluoromethane, trichlorofluoromethane, dichlorotetrafluoroethane, carbon dioxide or other suitable gas. In the case of a pressurized aerosol the dosage unit may be determined by providing a valve to deliver a metered amount. Capsules and cartridges of e.g., gelatin for use in an inhaler or insufflator may be formulated containing a powder mix of the compound and a suitable powder base such as lactose or starch.

[0108] Also contemplated herein is pulmonary delivery of gelsolin or an opioid in a method of the invention. Gelsolin an / d or an opioid is delivered to the lungs of a mammal while inhaling and traverses across the lung epithelial lining to the blood stream. Nasal (or intranasal) delivery of a pharmaceutical composition of the present invention is also contemplated. Nasal delivery allows the passage of a pharmaceutical composition of the present invention to the blood stream directly after administering the therapeutic product to the nose, without the necessity for deposition of the product in the lung. Formulations for nasal delivery include those with dextran or cyclodextran.

[0109] The compounds, when it is desirable to deliver them systemically, may be formulated for parenteral administration by injection, e.g., by bolus injection or continuous infusion. Formulations for injection may be presented in unit dosage form, e.g., in ampoules or in multidose containers, with an added preservative. The compositions may take such forms as suspensions, solutions or emulsions in oily or aqueous vehicles, and may contain formulatory agents such as suspending, stabilizing and / or dispersing agents.

[0110] Pharmaceutical formulations for parenteral administration include aqueous solutions of the active compounds in water-soluble form. Additionally, suspensions of the active compounds may be prepared as appropriate oily injection suspensions. Suitable lipophilic solvents or vehicles include fatty oils such as sesame oil, or synthetic fatty acid esters, such as ethyl oleate or triglycerides, or liposomes. Aqueous injection suspensions may contain substances which increase the viscosity of the suspension, such as sodium carboxymethyl cellulose, sorbitol, or dextran. Optionally, the suspension may also contain suitable stabilizers or agents which increase the solubility of the compounds to allow for the preparation of highly concentrated solutions. Alternatively, the active compounds may be in powder form for constitution with a suitable vehicle, e.g., sterile pyrogen-free water, before use.

[0111] Pharmacological agent(s), including specifically but not limited to a gelsolin agent and or an opioid, may be provided in particles. Particles as used herein means nano or microparticles (or in some instances larger) which can consist in whole or in part of the gelsolin agent as described herein. The particles may contain the pharmacological agent(s) in a core surrounded by a coating, including, but not limited to, an enteric coating. The pharmacological agent(s) also may be dispersed throughout the particles. The pharmacological agent(s) also may be adsorbed into the particles. The particles may be of any order release kinetics, including zero order release, first order release, second order release, delayed release, sustained release, immediate release, and any combination thereof, etc. The particle may include, in addition to the pharmacological agent(s), any of those materials routinely used in the art of pharmacy and medicine, including, but not limited to, erodible, nonerodible, biodegradable, or nonbiodegradable material or combinations thereof. The particles may be microcapsules which contain the gel solin in a solution or in a semi-solid state. The particles may be of virtually any shape.

[0112] Both non-biodegradable and biodegradable polymeric materials can be used in the manufacture of particles for delivering the pharmacological agent(s), such as gelsolin or an opioid. Such polymers may be natural or synthetic polymers. The polymer is selected based on the period of time over which release is desired. Bioadhesive polymers of particular interest include bioerodible hydrogels described by H. S. Sawhney, C. P. Pathak and J. A. Hubell in Macromolecules, (1993) 26:581-587, the teachings of which are incorporated herein. These include polyhyaluronic acids, casein, gelatin, glutin, polyanhydrides, polyacrylic acid, alginate, chitosan, poly(methyl methacrylates), poly(ethyl methacrylates), poly(butylmethacrylate), poly(isobutyl methacrylate), poly (hexylmethacryl ate), poly(isodecyl methacrylate), poly(lauryl methacrylate), poly(phenyl methacrylate), poly(methyl acrylate), poly (isopropyl acrylate), poly(isobutyl acrylate), and poly(octadecyl acrylate).

[0113] The pharmacological agent(s) may be contained in controlled release systems. The term “controlled release” is intended to refer to any drug-containing formulation in which the manner and profde of drug release from the formulation are controlled. This refers to immediate as well as non-immediate release formulations, with non-immediate release formulations including but not limited to sustained release and delayed release formulations. The term “sustained release” (also referred to as “extended release”) is used in its conventional sense to refer to a drug formulation that provides for gradual release of a drug over an extended period of time, and that preferably, although not necessarily, results in substantially constant blood levels of a drug over an extended time period. The term “delayed release” is used in its conventional sense to refer to a drug formulation in which there is a time delay between administration of the formulation and the release of the drug therefrom. “Delayed release” may or may not involve gradual release of drug over an extended period of time, and thus may or may not be “sustained release.”

[0114] Use of a long-term sustained release implant may be particularly suitable for treatment of chronic conditions. “Long-term” release, as used herein, means that the implant is constructed and arranged to deliver therapeutic levels of the pharmacological agent(s) for at least 7 days, and preferably 30-60 days. Long-term sustained release implants are well-known to those of ordinary skill in the art and include some of the release systems described above.

[0115] Methods and compositions of the invention have important implications for subject treatment and also for the clinical development of new therapies. It is also expected that clinical investigators now will use the present methods for determining entry criteria for human subjects in clinical trials. Health care practitioners select therapeutic regimens for treatment based upon the expected net benefit to the subject. The net benefit is derived from the risk to benefit ratio.

[0116] The amount of a treatment may be varied for example by increasing or decreasing the amount of gelsolin agent administered to a subject, by changing the therapeutic composition administered, by changing the route of administration, by changing the dosage timing and so on. The effective amount will vary with the particular disease or condition being treated, the age and physical condition of the subject being treated, the severity of the disease or condition, the duration of the treatment, the specific route of administration, and like factors are within the knowledge and expertise of the health practitioner.

[0117] Effective amounts

[0118] The term “effective amount” as used herein relates to a treatment method or composition of the invention. Methods of the invention comprise administering a gelsolin agent and / or an opioid in amounts that are effective amounts. When administered to a subject in a method of the invention, an effective amount of the gelsolin agent results in a therapeutic effect against and / or a reduction in opioid tolerance in the subject. When administered to a subject in a method of the invention, effective amounts of gel solin and an opioid results in a therapeutic effect against opioid tolerance in the subject and / or pain reduction in the subject.

[0119] An effective amount is a dosage of a gelsolin and / or an opioid sufficient to provide a medically desirable result. Non-limiting examples of pharmacological agents used in certain embodiments of compositions and methods of the invention include, but are not limited to gelsolin agents. It should be understood that pharmacological agents of the invention are used to treat or prevent opioid tolerance conditions, that is, they may be used prophylactically in subjects at risk of developing opioid tolerance. Thus, an effective amount of a gelsolin agent may be an amount that lowers the risk of, slows, or perhaps prevents altogether the development of opioid tolerance. It will be recognized when the pharmacologic agent is used in acute circumstances, it is used to prevent one or more medically undesirable results that typically flow from such adverse events.

[0120] Factors involved in determining an effective amount of a gelsolin agent and / or an opioid are known to those of ordinary skill in the art and can be addressed with no more than routine experimentation, including but not limited to clinical trials to assess dosage. It is generally preferred that a maximum dose of the pharmacological agents of the invention (alone or in combination with other therapeutic agents) be used, that is, the highest safe dose according to sound medical judgment. It will be understood by those of ordinary skill in the art however, that a patient may insist upon a lower dose or tolerable dose for medical reasons, psychological reasons, or for virtually any other reasons.

[0121] The therapeutically effective amount of a pharmacological agent of the invention is that amount effective to treat the disorder, such as opioid tolerance. In the case of opioid tolerance, the desired response is inhibiting the progression of and / or reducing the severity of the opioid tolerance. This may involve only slowing the progression of the opioid tolerance temporarily, although it may include halting the progression of the opioid tolerance permanently. Inhibiting the progression of and / or reducing the severity of opioid tolerance in a subject may also involve reducing the severity of the one or more characteristics of the opioid tolerance in a subject by, or by at least 1%, 2%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or more as compared to a baseline level of severity of the one or more characteristics of opioid tolerance in the subject. Efficacy of an administered amount can be monitored by routine diagnostic methods known to those of ordinary skill in the art. The desired response to treatment of the opioid tolerance also can be delaying the onset of or even preventing the onset of opioid tolerance in a subject.

[0122] Methods of the invention comprise administering a gelsolin agent in an amount effective to treat opioid tolerance. An effective amount is a dosage of the gelsolin agent sufficient to provide a medically desirable result. The therapeutically effective amount of a pharmacological composition of the invention is that amount effective to treat the condition, such as opioid tolerance. In the case of opioid tolerance, a desired response may be inhibiting the onset and / or progression of the opioid tolerance, and / or reducing the severity, and / or reducing a level of the opioid tolerance. This may involve only slowing the progression of the opioid tolerance temporarily, although it may include halting the progression of the opioid tolerance. Efficacy of a gelsolin agent to treat opioid tolerance in a subject can be monitored by routine diagnostic methods known to those of ordinary skill in the art. The desired response to treatment of the opioid tolerance also can be preventing the onset of the opioid tolerance.

[0123] Kits

[0124] The invention also contemplates the use of kits. In some aspects of the invention, a kit can include one or more pharmaceutical preparation vial, a pharmaceutical preparation diluent vial, a gelsolin agent, and an opioid. A vial containing the diluent for the pharmaceutical preparation is optional. A diluent vial may contain a diluent such as physiological saline for diluting what could be a concentrated solution or lyophilized powder of the gelsolin agent. The instructions can include instructions for mixing a particular amount of the diluent with a particular amount of the concentrated pharmaceutical preparation, whereby a final formulation for administration, such as but not limited to injection or infusion, is prepared. The instructions may include instructions for treating a subject with effective amounts of the gelsolin agent. It also will be understood that the containers containing the preparations, whether the container is a bottle, a vial with a septum, an ampoule with a septum, an infusion bag, and the like, can contain indicia such as conventional markings that change color when the preparation has been autoclaved or otherwise sterilized.

[0125] The present invention is further illustrated by the following Examples, which in no way should be construed as further limiting. The entire contents of all the references (including literature references, issued patents, published patent applications, and co-pending patent applications) cited throughout this application are hereby expressly incorporated by reference.

[0126] The following examples are provided to illustrate specific instances of the practice of the present invention and are not intended to limit the scope of the invention. As will be apparent to one of ordinary skill in the art, the present invention will find application in a variety of compositions and methods. Examples

[0127] Example 1

[0128] Studies were performed using a withdrawal test regimen (Fig. 3A) in which morphine tolerance was induced in mice by administering three daily morphine injections to each mouse followed by tolerance testing on day four. A measure of tolerance was the length of time a mouse took to remove its tail from warm water (a negative stimulus). Fig. 3B shows results obtained with this morphine tolerance animal model. The graph (Fig. 3B) of results showing the time required by mice to remove the tail from the warm water, with measurements taken at base line (no morphine injection) and then after cumulative morphine dosing at 0.5, 1, 2 and 3 mg / kg IP.

[0129] The results indicated that the controls exhibited a slower response to remove their tail because they are injected with morphine at any dose (0.5 to 3 mg / kg) whereas the mice rendered tolerant to morphine respond to the warm water by removing their tail despite being injected with morphine (0.5, 1, or 2 mg / kg).

[0130] Example 2

[0131] Studies were performed to assess a possible relationship between morphine tolerance microparticles and CSF flow in the brain. Fig. 4 provides schematic diagrams and a graph illustrating in top panel the direction of CSF flow in the brain, lower left panel shows the lymphatic system in mouse brain, and the lower right panel shows a graph of concentration of microparticles determined in control versus morphine tolerant subjects. Fig. 4 illustrates the brain glymphatic and traditional lymphatic systems. Fluid from both systems drain to the deep cervical lymph nodes. Studies were performed in which microparticles (MPs) were measured in the deep cervical nodes. Results of the studies demonstrated a significant elevation of MPs in mice rendered morphine tolerant (shown in Fig. 4, lower right).

[0132] Additional studies were performed to assess microparticles and morphine tolerance. Certain results are shown in Fig. 5, which provides graphs showing number of microparticles found in the deep cervical lymph nodes of mice when rendered morphine tolerant and when subjected to the tolerance protocol (see Fig. 3). In addition, various drugs that antagonize different inflammatory pathways were selected and injected into mice. Procedures included injections of PEG Telomer B (0.7 pl of a 0.3% solution [w / v] IV / gram) PEG Telomer B is an agent that will destroy most MPs when injected in the blood stream], anakinra (100 mg / kg TP) [anakinra is a drug that blocks the receptor for interleukin- 1 ], methylnaltrexone (1 mg / kg IP) [methyl naltrexone is an opiate receptor blocker that does not cross the blood brain barrier], or neutropenic animals [mice are treated with an antibody to selective remove the polymorphonuclear leukocytes (also known as neutrophils) from the blood stream].

[0133] Example 3

[0134] Studies were performed to examine whether anti-nociceptive tolerance (as shown in Fig. 3) could be prevented by treating mice with agents that impede microparticle elevations (as shown in Fig. 5). Results shown in Fig. 6 indicate the time required by mice to remove the tail from warm water measured at base line and then measured after cumulative morphine dosing at 0.5, 1, 2 and 3 mg / kg IP. Studies were performed after the mice received daily sterile saline (control) or morphine at 20 mg / kg for two days and 50 mg / kg on the third day. Where indicated in Fig. 6, mice also received anakinra (100 mg / kg IP), methylnaltrexone (1 mg / kg IP), or PEG Telomer B (0.7 pl of a 0.3% solution [w / v] IV / gram). Data are mean + SE, p<0.05 by repeated measures, 2-way ANOVA. Results of the studies indicate that in morphine tolerant mice, the levels of MPs were significantly elevated compared to controls and morphine-tolerant mice treated with PEG-Telomer B, anakinra, methylnaltrexone, and morphine-tolerant mice with neutropenia.

[0135] Example 4

[0136] Studies were performed to assess microparticles that were present at elevated levels in morphine tolerant mice (see Example 3). Fig. 7 shows Western blot probed for the pro-form of IL- 10 as well as the mature protein. Plasma samples containing 100,000 MPs were centrifuged for 1 hour at 21,000 x g. Pellets were set aside for Western blotting and the supernatant centrifuged for 1 hour at 100,000g so that this pellet could also be subjected to Western blotting to assess relative content of pro- and mature IL- 10. Data beneath the figure show the concentration of IL-10 as pg / 1 million MPs from whole plasma and post-21, 000g centrifugation supernatant and pellet fractions. The results shown in the table demonstrate that IL- 10 is elevated in tolerant mice and virtually all the IL- 10 is found within microparticles. Example 5

[0137] To assess levels of blood-borne MPs in opioid-tolerant subjects. A study was conducted in which blood was collected from patients starting methadone treatment for opiate-use disorder and age-matched controls taking no medications. Fig. 8 shows results indicating elevated levels of blood-borne MPs in the opioid-tolerant patients entering methadone treatment compared to control levels.

[0138] Example 6

[0139] Studies were performed in which glymphatic flow was assessed. Fig. 9A-C provides photos and graphs illustrating results of measurement of brain glymphatic flow assessment by gadolinium (Gd) contrast MRI. Fig. 9A highlights the signal near the Vein of Galan and at deep cervical nodes. Flow was quantified using 1 mm regions of interest at these sites and normalized the signal by including a 60 mM Gd vial beneath the mouse skull within the scanning field. Images of control and tolerant mice are shown in Fig. 9B. Graphs of glymphatic flow quantifications measured in 5 mice is shown in Fig.98C. The ordinates show normalized Gd signals and abscissa shows the time following Gd injections in the mice. The MRI machine was programmed to collect images for 5 minutes and then report the value. Therefore, the abscissa is shown as sequential 5-minute intervals. The data demonstrated that mice rendered morphine tolerant exhibit elevations of glymphatic flow versus control mice that were injected with just sterile saline.

[0140] Example 7

[0141] Studies were performed to assess the impact of injecting MPs obtained from morphine- tolerant mice into naive mice. Fig. 10 illustrates results from experiments performed by injecting F-actin positive MPs from morphine tolerant mice into naive mice. Overall, the results indicated that glymphatic flow was increased by morphine injections and this contributed to the elevation of MPs found in the deep cervical nodes and blood. Results of PEG-telomer B injection studies indicated that blood-borne MPs were needed for morphine tolerance. Further studies indicated it was specifically the F-actin positive MPs that were triggering on-going inflammation. Fig. 10 illustrates that when mice were injected with F-actin MPs from tolerant mice they showed somewhat similar elevations of glymphatic flow (graphs on left) and also showed neuroinflammation (the Western blot to the right).

[0142] Example 8

[0143] A subject is assessed and determined to be at risk of opioid tolerance based at least in part on an opioid regimen to be administered to the subject. In addition to the opioid administration to the subject, the subject is administered a gel solin agent in an amount effective to reduce or eliminate onset of opioid tolerance in the subject. In some studies, the administered opioid is morphine, heroin, hydromorphone, oxymorphone, fentanyl, methadone, oxycodone, and hydrocodone, codeine, buprenorphine, dextromethorphan, dextropropoxyphene, loperamide, meperidine, opium, carfentanyl / carfentanil, morphone, tramadol, talpentadol, and / or pethidine. Based at least in part on the therapeutic opioid regimen that is administered to the subject, a therapeutic regimen comprising administration of a gelsolin agent is selected for the subject to treat opioid tolerance in the subject and the opioid therapeutic regimen and the gel solin agent therapeutic regimen are administered to the subject. The subject is assessed before, during, and after the opioid and gelsolin agent regimens and it is determined that administering the gelsolin agent to the subject reduces and / or prevents, opioid tolerance in the subject. As a result of the gelsolin regimen, the subject has reduced opioid tolerance compared to a control opioid tolerance.

[0144] Example 9

[0145] A subject is assessed and determined to be at risk of morphine tolerance based at least in part on a morphine regimen to be administered to the subject. In addition to the morphine administration to the subject, the subject is administered a gelsolin agent in an amount effective to reduce or eliminate onset of morphine tolerance in the subject. Based at least in part on the therapeutic morphine regimen administered to the subject, a therapeutic regimen comprising administration of a gelsolin agent is selected for the subject to treat morphine tolerance in the subject. The morphine therapeutic regimen and the gelsolin agent therapeutic regimen are administered to the subject. The subject is assessed before, during, and after the morphine and gelsolin agent regimens and it is determined that administering the gelsolin agent to the subject treats morphine tolerance in the subject. As a result of the gelsolin regimen, the subject has reduced morphine tolerance compared to a control morphine tolerance.

[0146] The subject is assessed before, during, and after the morphine and gelsolin agent regimens and administering the gelsolin agent to the subject reduces and / or prevents opioid tolerance in the subject. As a result of the gelsolin regimen, the subject has reduced opioid tolerance compared to a control opioid tolerance.

[0147] Example 10

[0148] A subject is identified as having opioid tolerance and the subject is administered an effective amount of a gelsolin agent as a treatment for the opioid tolerance. The subject is administered a gelsolin agent in an amount effective to reduce or eliminate the opioid tolerance in the subject. In some studies, the opioid tolerance is one or more of oxycodone tolerance, fentanyl tolerance, morphine tolerance, hydromorphone tolerance, oxymorphone tolerance, methadone tolerance, hydrocodone tolerance, tramadol tolerance, morphine tolerance, heroin tolerance, codeine tolerance, buprenorphine tolerance, dextromethorphan tolerance, dextropropoxyphene tolerance, loperamide tolerance, meperidine tolerance, opium tolerance, carfentanyl / carfentanil tolerance, morphine tolerance, talpentadol, and pethidine tolerance. A therapeutic regimen comprising administration of a gelsolin agent is selected for the subject to treat the opioid tolerance in the subject. The gelsolin agent therapeutic regimen is administered to the subject. The administration of the gelsolin agent is effective in reducing and / or preventing opioid tolerance in the subject compared to a control opioid tolerance.

[0149] Example 11

[0150] A subject is identified as having morphine tolerance and is administered an effective amount of a gelsolin agent as a treatment for the morphine tolerance. The subject is administered a gelsolin agent in an amount effective to reduce or eliminate the morphine tolerance in the subject. A therapeutic regimen comprising administration of a gelsolin agent is selected for the subject to treat the morphine tolerance in the subject. The gelsolin agent therapeutic regimen is administered to the subject. The administration of the gelsolin agent is effective in reducing and / or preventing the morphine tolerance in the subject compared to a control opioid tolerance.

[0151] Equivalents

[0152] Although several embodiments of the present invention have been described and illustrated herein, those of ordinary skill in the art will readily envision a variety of other means and / or structures for performing the functions and / or obtaining the results and / or one or more of the advantages described herein, and each of such variations and / or modifications is deemed to be within the scope of the present invention. More generally, those skilled in the art will readily appreciate that all parameters, dimensions, materials, and configurations described herein are meant to be exemplary and that the actual parameters, dimensions, materials, and / or configurations will depend upon the specific application or applications for which the teachings of the present invention is / are used. Those skilled in the art will recognize or be able to ascertain using no more than routine experimentation, many equivalents to the specific embodiments of the invention described herein. It is, therefore, to be understood that the foregoing embodiments are presented by way of example only and that, within the scope of the appended claims and equivalents thereto; the invention may be practiced otherwise than as specifically described and claimed. The present invention is directed to each individual feature, system, article, material, and / or method described herein. In addition, any combination of two or more such features, systems, articles, materials, and / or methods, if such features, systems, articles, materials, and / or methods are not mutually inconsistent, is included within the scope of the present invention.

[0153] All definitions, as defined and used herein, should be understood to control over dictionary definitions, definitions in documents incorporated by reference, and / or ordinary meanings of the defined terms.

[0154] As used herein, the term “a” or “an” when used in conjunction with the term “comprising” in the claims and / or the specification may mean “one,” but it is also consistent with the meaning of “one or more,” “at least one,” and “one or more than one.” Some embodiments of the invention may consist of or consist essentially of one or more elements, method steps, and / or methods of the invention. It is contemplated that any method described herein can be implemented with respect to any other method described herein. As used herein, the term “or” in the claims is used to mean “and / or” unless explicitly indicated to refer to alternatives only or the alternatives are mutually exclusive, although the disclosure supports a definition that refers to only alternatives and “and / or.” The phrase “and / or,” as used herein in the specification and in the claims, should be understood to mean “either or both” of the elements so conjoined, i.e., elements that are conjunctively present in some cases and disjunctively present in other cases. Other elements may optionally be present other than the elements specifically identified by the “and / or” clause, whether related or unrelated to those elements specifically identified, unless clearly indicated to the contrary.

[0155] As used herein, “comprise” and its variations, such as “comprises” and “comprising,” will be understood to imply the inclusion of a stated item, element or step or group of items, elements, or steps but not the exclusion of any other item, element or step or group of items, elements, or steps unless the context requires otherwise. Similarly, “another” or “other” may mean at least a second or more of the same or different claim element or components thereof.

[0156] All references, patents and patent applications and publications that are cited or referred to in this application are incorporated herein in their entirety herein by reference.

[0157] What is claimed is:

Claims

Claims1. A method of treating opioid tolerance in a subj ect, comprising: administering to a subject in need of such treatment, a composition comprising a gelsolin agent, in an amount effective to treat the opioid tolerance in the subject.

2. The method of claim 1, wherein the opioid tolerance is morphine tolerance.

3. The method of claim 1 or 2, wherein the gelsolin agent comprises a gelsolin molecule, a functional fragment thereof, or a functional derivative of the gel solin molecule.

4. The method of claim 3, wherein the gelsolin molecule is a plasma gelsolin (pGSN).

5. The method of claim 3, wherein the gelsolin molecule is a recombinant gelsolin molecule.

6. The method of claim 1, wherein the administration of the composition comprising the gelsolin agent is oral, sublingual, buccal, intranasal, intravenous, intramuscular, intrathecal, intraperitoneal, subcutaneous, intradermal, topical, rectal, vaginal, intrasynovial, or intra-ocular administration, orally, sublingually, intravenously, subcutaneously, topically, intrathecally, or by inhalation.

7. The method of claim 1, wherein administering the gelsolin agent has a greater therapeutic effect against the opioid tolerance in the subject compared to a control therapeutic effect against the opioid tolerance.

8. The method of claim 7, wherein the control therapeutic effect is equal to an effect against the opioid tolerance in a subject in the absence of administering the gelsolin agent.

9. The method of claim 1, wherein the administration of the gelsolin agent reduces the opioid tolerance in the subject by at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%,35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100% compared to the severity of the opioid tolerance of a control in which the gelsolin agent is not administered.

10. The method of claim 1, wherein the subject is a mammal.

11. The method of claim 10, wherein the mammal is a human.

12. The method of claim 1, wherein the gelsolin agent is administered to the subject 1, 2, 3, 4, 5, 6, 7, 8, or more times.

13. The method of claim 1, wherein the administration of the gelsolin agent increases painrelief efficacy of an opioid administered to the subject by at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100% compared to the pain-relief efficacy of the opioid of a control in which the gelsolin agent is not administered.

14. The method of claim 1, further comprising administering an opioid to the subject administered the composition comprising the gelsolin agent.

15. The method of claim 1, wherein the administered gelsolin agent reduces a level of opioid tolerance in the subject.

16. The method of claim 1, wherein the administered gelsolin agent prevents opioid tolerance in the subject.

17. The method of claim 1, wherein the opioid comprises: oxycodone, fentanyl, morphine, opium, hydromorphone, oxymorphone, methadone, or hydrocodone.

18. A method of selecting a pain-reduction treatment for a subject having an opioid tolerance, the method comprising:(a) selecting a gelsolin therapeutic regimen for the subject, comprising the administration of a composition comprising a gelsolin agent, in an amount effective to treat the opioid tolerance in the subject and;(b) selecting a pain-reducing therapeutic regimen for the subject, comprising the administration of one or more opioids and / or a different pain-relieving agent to the subject.

19. The method of claim 18, further comprising determining the identity of the opioid, and optionally selecting the one or more opioids and / or the different pain-relieving agent based at least in part on the identity of the opioid.

20. The method of claim 18, further comprising, administering the selected pain-reducing therapeutic regimen to the subject 2, 3, 4, 5, 6, 7, 8, or more times.

21. The method of claim 18, further comprising, administering the selected gelsolin therapeutic regimen to the subject 2, 3, 4, 5, 6, 7, 8, or more times.

22. The method of claim 18, wherein administering the gelsolin therapeutic regimen and the pain-reducing therapeutic regimen comprise administering the gelsolin agent at one or more of: before, in conjunction, with, and after administering the one or more opioids and / or the different pain-relieving agent to the subject.

23. The method of claim 18, wherein the gelsolin agent comprises a gelsolin molecule, wherein the gelsolin molecule is optionally a recombinant gelsolin molecule, and optionally is a plasma gelsolin (pGSN).

24. The method of claim 18, wherein administering the selected gelsolin therapeutic regimen and the selected pain-reducing therapeutic regimen has a greater therapeutic effect against the opioid tolerance in the subject compared to a control therapeutic effect against the opioid tolerance, optionally wherein the control therapeutic effect is an effect against the opioidtolerance in a subject administered the selected pain-reducing therapeutic regimen and not administered the selected gelsolin therapeutic regimen.

25. The method of claim 18, wherein the administration of the gelsolin agent reduces the opioid tolerance in the subject by at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100% compared to a control opioid tolerance in the absence of administration of the gelsolin agent.

26. The method of claim 25, wherein the opioid tolerance is measured based on one or more of the presence of one or more opioid-tolerance symptoms in the subject and the severity of the opioid tolerance in the subject.

27. The method of claim 18, wherein the subject is a mammal, optionally, the subject is a human.

28. The method of claim 18, wherein the administration of the gelsolin agent increases painrelief efficacy of the selected pain-reducing therapeutic regimen in the subject by at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, 100%, 125%, 150%, 175%, 200%, or more compared to the painrelief efficacy of the selected pain-reducing therapeutic regimen of a control not administered the gel solin agent.

29. The method of claim 18, wherein the opioid comprises: oxycodone, fentanyl, morphine, hydromorphone, oxymorphone, methadone, or hydrocodone.

30. A method of selecting a pain-reduction treatment for a subject at risk of having an opioid tolerance, the method comprising:(a) selecting a gelsolin therapeutic regimen for the subject, comprising the administration of a composition comprising a gelsolin agent, in an amount effective to reduce the risk of the opioid tolerance in the subject and;(b) selecting a pain-reducing therapeutic regimen for the subject, comprising the administration of one or more opioids and / or a different pain-relieving agent to the subject.

31. The method of claim 30, further comprising, administering the selected pain-reducing therapeutic regimen to the subject 2, 3, 4, 5, 6, 7, 8, or more times.

32. The method of claim 30, further comprising, administering the selected gelsolin therapeutic regimen to the subject 2, 3, 4, 5, 6, 7, 8, or more times.

33. The method of claim 30, wherein administering the gelsolin therapeutic regimen and the pain-reducing therapeutic regimen comprise administering the gelsolin agent to the subject at one or more of: before, in conjunction, with, and after administering the one or more opioids and / or the different pain-relieving agent to the subject.

34. The method of claim 30, wherein the gelsolin agent comprises a gelsolin molecule, wherein the gelsolin molecule is optionally a recombinant gelsolin molecule.

35. The method of claim 34, wherein the gelsolin molecule is a plasma gelsolin (pGSN).

36. The method of claim 30, wherein administering the gelsolin therapeutic regimen and the pain-reducing therapeutic regimen reduces the risk of opioid tolerance in the subject compared to a control therapeutic effect against the risk of opioid tolerance, optionally wherein the control therapeutic effect is equal to an effect against the opioid tolerance in a subject administered the pain-reducing therapeutic regimen and not administered the gelsolin therapeutic regimen.

37. The method of claim 30, wherein the administration of the gelsolin agent reduces the risk of opioid tolerance in the subject by at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100% compared to the opioid tolerance of a control that is not administered the gelsolin agent.

38. The method of claim 30, wherein the subject is a mammal, optionally, the subject is a human.

39. The method of claim 30, wherein the administration of the gelsolin agent increases painrelief efficacy of the selected pain-reducing therapeutic regimen in the subject by at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, 100%, 125%, 150%, 175%, 200%, or more compared to the painrelief efficacy of the selected pain-reducing therapeutic regimen of a control not administered the gelsolin agent.

40. The method of claim 30, wherein the opioid comprises: oxycodone, fentanyl, morphine, hydromorphone, oxymorphone, methadone, or hydrocodone.

41. A pharmaceutical composition comprising a gelsolin agent and an opioid.

42. The pharmaceutical composition of claim 41, wherein the gelsolin agent comprises a gelsolin molecule, wherein the gelsolin molecule is optionally a recombinant gelsolin molecule, and optionally is a plasma gelsolin (pGSN).

43. The pharmaceutical composition of claim 41, wherein the opioid is morphine, heroin, hydromorphone, oxymorphone, fentanyl, methadone, oxycodone, hydrocodone, codeine, buprenorphine, dextromethorphan, dextropropoxyphene, loperamide, meperidine, opium, carfentanyl / carfentanil, morphone, talpentadol, tramadol, or pethidine.

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