Pharmacokinetic & Pharmacodynamic Interaction of Lofexidine and Buprenorphine in Buprenorphine Maintained Patients

This will be a randomized, double-blind, placebo-controlled multiple ascending dose study to
assess the safety, tolerability, and electrocardiographic effects of lofexidine in 30
buprenorphine-maintained adult subjects. The study will include a Screening Visit, an
Inpatient Treatment Visit, and a Follow-Up Visit. Subjects will be randomized in 4:1 ratio to
receive up to 4 tablets of lofexidine (0.2 mg/tablet) QID or 4 tablets matching placebo QID.

Subjects who are on a stable dose of total daily sublingual buprenorphine 16-24 mg/day with
or without naloxone (Suboxone® or Subutex®, respectively), 16 - 24 mg/day, and who satisfy
inclusion and exclusion criteria will be eligible for the study. Subjects who are eligible
for the study will be encouraged to begin shifting their medication dose to a total daily
dose at 2 PM in anticipation of the study dosing schedule during the Inpatient Treatment
Visit. Subjects who are receiving Suboxone tablets or Subutex at study enrollment will be
converted to Suboxone film at the inpatient check-in and will receive Suboxone sublingual
film throughout the study. Within 21 days of the Screening Visit, subjects will report to the
inpatient study facility to begin the Inpatient Treatment Visit which will last between
approximately 11 to 21 days. This visit will include an inpatient check-in (1 day),
Buprenorphine Baseline (1 day), Initial Lofexidine Titration (3 to 5 days), 1 or 2 Lofexidine
Plateaus (2 to 4 days), Buprenorphine Reduction (2 to 6 days) and Buprenorphine Re-Titration
and Discharge (2 to 4 days). The order of steps subjects will proceed through during the
Inpatient Treatment Visit will vary depending on whether subjects are able to titrate to the
highest dose of lofexidine or placebo during the Initial Lofexidine Titration. The highest
dose of lofexidine (or placebo) will be 4 tablets QID (0.2 mg lofexidine per tablet or
placebo) for a total daily lofexidine dose of 16 tablets (3.2 mg or placebo).

During the Buprenorphine Baseline phase subjects will take a single daily dose of
buprenorphine at 2 PM. Buprenorphine Baseline Day study assessments will begin at
approximately 7 AM and include electrocardiogram (ECG) monitoring, blood collection for
buprenorphine pharmacokinetics, and opiate withdrawal assessments (Clinical Opiate Withdrawal
Scale, COWS and Short Opiate Withdrawal Scale, SOWS). The next day subjects will proceed to
the Initial Lofexidine Titration phase. Subjects will continue using their baseline
buprenorphine dose. Lofexidine will be initiated at 2 tablets (0.4 mg or placebo) QID and
titrated in daily increments of a single tablet (0.2 mg or placebo) QID to a total daily dose
of 0.8 mg QID (or placebo), if tolerated by the subject. Lofexidine doses will escalate daily
unless at any point the subject meets protocol-defined dose hold criteria (described below),
which will trigger a reduction in dose to the previous highest tolerated dose (or to the 1
tablet dose, 0.2 mg or placebo, if subjects cannot tolerate the initial 2 tablets, 0.4 mg or
placebo). Once subjects have titrated to the highest dose (ie, 4 tablets QID) or once the
highest tolerated dose has been determined, they will proceed to a 2-day Lofexidine Plateau
phase during which they will continue to receive their buprenorphine maintenance dose. If the
subject is unable to titrate up to 4 tablets QID (0.8 mg or placebo), the subject will
continue to receive their highest tolerated dose in equal increments (eg, 2 or 3 tablets QID
at 8AM, 1PM, 6PM, 11PM) for both days of the plateau. Subjects who tolerate 4 tablets QID
(0.8 mg or placebo) on the first day will receive the 4 tablets QID (0.8 mg or placebo)
according to the normal dosing schedule. On the second day, the lofexidine dosing schedule
will be modified with subjects receiving a 1-tablet increase (ie, 0.2 mg or placebo) of the 1
PM lofexidine dose (5 tablets: 1 mg or placebo) and a 1-tablet reduction (0.2 mg or placebo)
in the subsequent lofexidine dose (3 tablets: 0.6 mg or placebo) with the other 2 doses of 4
tablets (0.8 mg or placebo) for a total daily dose of 16 tablets (3.2 mg/day or placebo). On
the second day of the Lofexidine Plateau phase, subjects will undergo ECG monitoring and
blood collection for buprenorphine and lofexidine pharmacokinetics. COWS and SOWS assessments
will be performed on both days of the Lofexidine Plateau.

Subjects who are titrated to a daily dose of 4 tablets (0.8 mg or placebo) QID while
receiving their full dose of buprenorphine will undergo a 4-day buprenorphine dose reduction
of 50% while continuing to take lofexidine or placebo at a daily dose of 16 tablets to
evaluate the effects of lofexidine on buprenorphine withdrawal signs and symptoms. These
subjects who complete the initial Lofexidine Plateau at a dose of 0.8 mg lofexidine (or
placebo) QID and who reach a COWS of 5 or greater prior to the fourth day of the reduced
buprenorphine dose administration may proceed early to Buprenorphine Re-titration and
Discharge at the Investigator's discretion. If the COWS score does not reach 5 within 4 days,
the subject will proceed to Buprenorphine Re-titration and Discharge.

Subjects who are unable to titrate to the highest lofexidine dose (4 tablets: 0.8 mg or
placebo QID) while receiving their full dose of buprenorphine will undergo a buprenorphine
dose reduction of 50% for up to 6 days while continuing to receive their highest tolerated
dose of lofexidine from the initial titration. On the fourth day (or earlier at the
investigator's discretion based on withdrawal response), lofexidine titration will resume by
adding an incremental 1 tablet (0.2 mg or placebo) QID to the previously established
tolerated dose up to the maximum 4 tablet (0.8 mg or placebo) QID dose. During these
subsequent titration attempts lofexidine (or placebo) doses will escalate daily beginning on
the fourth day of the reduction (or earlier based on discretion of the investigator) unless
in any event a subject meets protocol defined dose-hold criteria (described below), which
will trigger a reduction in dose to the previous highest tolerated dose and will require the
Lofexidine Plateau procedures described above to be repeated while maintaining the subject on
their newly reduced buprenorphine dose (eg, 50% of their maintenance dose). Subjects who are
unable to titrate to a higher lofexidine dose during the 50% Buprenorphine Reduction than the
dose they titrated to during the Initial Lofexidine Titration will not repeat the Lofexidine
Plateau procedures. During Buprenorphine Reduction, COWS and SOWS assessments of opiate
withdrawal will be performed. On days when the lofexidine dose is increased, holter
monitoring and pharmacokinetic (PK) sampling will be done for those subjects who did not
titrate all the way up to the maximum dose of lofexidine during the initial titration period.

Following completion of the Lofexidine Plateau (repeated as necessary) and Buprenorphine
Reduction, subjects will begin the Buprenorphine Re-Titration and Discharge phase during
which lofexidine or placebo will be discontinued and buprenorphine will be re-titrated to the
starting dose (or to a higher or lower dose relative to baseline as medically indicated at
the discretion of the investigator). Lofexidine may be used to treat withdrawal symptoms, if
necessary. Following successful buprenorphine titration and completion of study assessments,
subjects will be discharged from the inpatient study clinic.

Subjects will return to the study clinic for a follow-up visit 7 days (±2 days) following
clinic discharge for safety follow-up and adverse event collection. Subjects will be
discharged from the study at this time unless they are medically unstable on their dose of
buprenorphine. Subject may be medically followed at a regular interval, as determined by the
investigator, until the subject is considered sufficiently stable for study discharge.

Subjects who withdraw consent or meet any one of the following study termination criteria
prior to completion of the study will be withdrawn. Study termination criteria will apply
only to pre-dose sitting vital signs and the daily safety ECG readings (excluding HR).
Baseline values for vital signs and ECG readings refer to values obtained at the time
subjects are admitted to the clinic. 1.Cardiovascular events including the following*: a.
Systolic blood pressure (SBP) <70 mmHg and >20% below baseline value, b. Diastolic blood
pressure (DBP) <40 mmHg and >20% below baseline value (if subject is asymptomatic, DBP
termination criteria <30 mmHg), c. Heart rate <40 bpm and >20% below baseline value (if
subject is asymptomatic, HR termination criteria <30 bpm), d. Changes in QTcF that meet any
of the following criteria: i.QTcF >500 ms in females or QTcF>480 ms in males, ii. QTcF >25%
above baseline value for both males and females, iii. QTcF<500 ms in females or QTcF <480 ms
in males with a persistent (ie, greater than 24 hours) increase in QTcF value >60 ms from
baseline accompanied by abnormal electrolytes (ie, potassium and sodium), e. Absolute QRS>120
ms along with a 25% increase from baseline, f. Absolute PR>240 ms along with a 25% increase
from baseline, g. Syncope h. Clinically significant arrhythmia (including telemetry
indication of ventricular tachycardia, ventricular fibrillation, Torsade de Pointes, 2nd
degree AV block)

*ECGs and vital signs may be repeated as appropriate to confirm values and rule out
extraneous results. 2.Serious medical problems thought to be related or unrelated to the
study medications. 3.Intercurrent illness or medical complications that, in the opinion of
the site investigator, preclude safe administration of study medications.

At the time of termination from the study, subjects will be discontinued from lofexidine or
placebo; however, they may remain inpatient for usually up to 4 days, with extension allowed
as deemed necessary per Investigator, while their buprenorphine maintenance dose is
re-titrated to their pre-study maintenance dose.

Inclusion Criteria:

- Adult male and/or female, 18 to 60 years of age (inclusive).

- Receiving buprenorphine maintenance treatment for opioid dependence at a stable total
daily dose of 16-24 mg for at least 4 weeks prior to check-in for the Inpatient
Treatment Visit.

- Body mass index ≥ 18 and ≤ 35 (kg/m2).

- Normal screening results or abnormal results that have been deemed by the Investigator
as clinically insignificant.

- Able to understand and willing to sign an informed consent form (ICF).

- Females practicing adequate birth control or non-childbearing potential. Medically
acceptable birth control methods for this study include intrauterine device (IUD);
vasectomized partner (minimum of 6 months); post-menopausal (at least 2 years);
surgically sterile (at least 6 months); double barrier (diaphragm with spermicide,
condoms with vaginal spermicide); abstinence; implanted or intrauterine hormonal
contraceptives in use for at least 6 consecutive months prior to study dosing and
throughout the study duration; and oral, patch and injected hormonal contraceptives or
vaginal hormonal device (ie, NuvaRing®) in use for at least 3 consecutive months prior
to study dosing and throughout the study duration.

Exclusion Criteria:

- Abnormal cardiovascular exam at screening and before randomization, including any of
the following*:

- clinically significant abnormal electrocardiogram (ECG) (eg, significant first degree
atrioventricular block, complete left bundle branch block [LBBB], second or third
degree heart block, clinically significant arrhythmia, or QTcF interval (machine read)
greater than 450 msec for males and greater than 470 msec for females)

- heart rate < 55 bpm or symptomatic bradycardia

- systolic blood pressure (SBP) < 95 mmHg or symptomatic hypotension

- diastolic blood pressure (DBP) < 65 mmHg

- blood pressure (BP) > 155/95 mmHg

- change in orthostatic SBP, DBP, or heart rate >25% below sitting values

- prior history of myocardial infarction (MI) or evidence of prior MI on ECG

- history of long QT syndrome or relative with this condition

- history of syncopal episodes

- intraventricular conduction delay with QRS duration >120 ms

- evidence of ventricular pre-excitation (eg, Wolff Parkinson White syndrome)

*ECGs and vitals may be repeated as appropriate in order to confirm values and rule
out extraneous results.

- History or presence of significant or clinically unstable cardiovascular (including
atrial fibrillation, congestive heart failure, myocardial ischemia, indwelling
pacemaker), hepatic, renal, hematological, gastrointestinal, endocrine, immunologic,
psychiatric, neurologic, or dermatologic disease.

- History or presence of any degree of chronic obstructive pulmonary disease.

- History of suicidal ideations or depression requiring professional intervention
including counseling or antidepressant medication over the past 12 months.

- Positive drug (urine)/alcohol (breath) test at screening or check-in excluding
buprenorphine. Subjects who have a positive test for heroin, tetrahydrocannabinol
(THC), and benzodiazepines at the Screening Visit may be enrolled if the test is
negative at check-in to the Inpatient Treatment Visit. Subjects who have a positive
test for heroin, THC or benzodiazepines at the Screening Visit must sign an ICF at
check-in to the Inpatient Clinic Visit.

- Receiving buprenorphine for pain management.

- Positive test for human immunodeficiency virus (HIV) or hepatitis B surface antigen
(HBsAg). Subjects with a positive test for hepatitis C antibodies (HCV) may be
enrolled if subject is asymptomatic.

- Estimated creatinine clearance < 80 mL/minute at screening (Cockcroft-Gault formula).

- AST, ALT, or alkaline phosphatase > 3.0 x upper limit of normal at screening or
check-in.

- Amylase or lipase > 1.5 x upper limit normal at screening or check-in.

- Clinically significant out-of-reference range clinical chemistry values, with
particular attention to potassium, magnesium, and calcium.

- History of hypotension.

- History of hypersensitivity or allergy to clonidine or any clonidine analogue.

- Use of any new prescription medication within 12 days prior to check-in.

- Use of any over-the-counter medication, including herbal products, within the 5 days
prior to check-in. Up to 3200 mg per day of ibuprofen or up to 2 grams per day of
acetaminophen is allowed at the discretion of the principal investigator or his
designee.

- Use of any drug known to affect QTc within 30 days prior to check-in (tobacco and
buprenorphine excluded).

- Blood donation or significant blood loss within 30 days prior to check-in.

- Plasma donation within 7 days prior to check-in.

- Participation in another clinical trial within 30 days prior to check-in.

- Females who are pregnant or lactating.

- Participation in a prior study of lofexidine hydrochloride.

- Any other condition or prior therapy, which, in the opinion of the Investigator, would
make the subject unsuitable for this study.