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Lowe DJ, Müller DJ, George TP. Ketamine Treatment in Depression: A Systematic Review of Clinical Characteristics Predicting Symptom Improvement. Curr Top Med Chem 2020; 20:1398-1414. [DOI: 10.2174/1568026620666200423094423] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/14/2020] [Accepted: 03/19/2020] [Indexed: 12/28/2022]
Abstract
Ketamine has been shown to be efficacious for the treatment of depression, specifically
among individuals who do not respond to first-line treatments. There is still, however, a lack of clarity
surrounding the clinical features and response periods across samples that respond to ketamine. This
paper systematically reviews published randomized controlled trials that investigate ketamine as an antidepressant
intervention in both unipolar and bipolar depression to determine the specific clinical features
of the samples across different efficacy periods. Moreover, similarities and differences in clinical characteristics
associated with acute versus longer-term drug response are discussed. Similarities across all
samples suggest that the population that responds to ketamine’s antidepressant effect has experienced
chronic, long-term depression, approaching ketamine treatment as a “last resort”. Moreover, differences
between these groups suggest future research to investigate the potential of stronger efficacy towards
depression in the context of bipolar disorder compared to major depression, and in participants who undergo
antidepressant washout before ketamine administration. From these findings, suggestions for the
future direction of ketamine research for depression are formed.
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Schnoll R, Wileyto EP, Gross R, Hitsman B, Hawk LW, Cinciripini P, George TP, Benowitz NL, Lubitz SF, Ashare R, Tyndale RF, Lerman C. Evaluation of nicotine patch adherence measurement using self-report and saliva cotinine among abstainers in a smoking cessation trial. Drug Alcohol Depend 2020; 210:107967. [PMID: 32224420 PMCID: PMC7190433 DOI: 10.1016/j.drugalcdep.2020.107967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 02/11/2020] [Accepted: 03/13/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Adherence to nicotine patches relates to cessation. This is the first study to examine the validity of self-reported nicotine patch adherence relative to saliva cotinine. METHODS We used data from 198 clinical trial participants who received 11 weeks of nicotine patches, self-reported patch use, had saliva cotinine 1-week after the start of treatment assessed, and were not smoking when saliva was collected (CO < 6). Self-reported patch adherence was defined as: 3-day (before saliva collection), 7-day (before saliva collection), 3-week use (7 days before, and 14 days after, saliva collection), and 11-week use (7 days before, and 10 weeks after, saliva collection). Analyses, including receiver operating characteristic curves, considered differences in nicotine metabolism. Sensitivity, specificity and positive (PPV) and negative predictive value (NPV) assessed optimal cotinine cut-point for adherence. RESULTS Self-reported 7-day (r = 0.13) and 3-week (r = 0.13) patch use marginally correlated with week 1 cotinine (p's = 0.08) but not 3-day or 11-week. Significant area under the curve (AUC) values of 0.67 (95 %CI: 0.55-0.79) and 0.72 (95 %CI: 0.57-0.88) were found using 7-day self-report for the overall sample and for slow metabolizers (p's<0.01), but not for normal metabolizers. Optimal 1-week cotinine cut-points using 7-day self-report were 170 ng/mL (overall) and 184 ng/mL (slow), with sensitivity = 0.56-0.62, specificity = 0.69-0.78, PPV = 0.96-0.97, and NPV = 0.13-0.14. CONCLUSIONS Among CO-confirmed abstainers, self-reported patch use and saliva cotinine assessed 1-week into treatment, were modestly correlated and optimal cotinine cut-point differed by rate of nicotine metabolism. Seven-day patch use may be a more valid self-report measure of patch adherence based on cotinine than 3-day, 3-week, or 11-week. Rate of nicotine metabolism may affect this relationship.
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Matheson J, Mann RE, Sproule B, Huestis MA, Wickens CM, Stoduto G, George TP, Rehm J, Le Foll B, Brands B. Acute and residual mood and cognitive performance of young adults following smoked cannabis. Pharmacol Biochem Behav 2020; 194:172937. [PMID: 32360692 DOI: 10.1016/j.pbb.2020.172937] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 04/10/2020] [Accepted: 04/27/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To examine acute and residual mood and cognitive performance in young adult regular cannabis users following smoked cannabis. METHODS Ninety-one healthy young adults completed this double-blind, placebo-controlled, parallel-groups study. Participants were randomized to receive active (12.5% THC) or placebo cannabis with a 2:1 allocation ratio, and mood [Profile of Mood States (POMS)] and cognitive performance [Hopkins Verbal Learning Test - Revised (HVLT-R), Digit Symbol Substitution Test (DSST), Continuous Performance Test (CPT), grooved pegboard (GPB)] were assessed before and 1, 24, and 48 (h) after smoking cannabis ad libitum. High and Low THC groups were based on blood THC concentrations. RESULTS One hour after smoking cannabis, compared to Placebo, in both the High and Low THC groups, there were increases in POMS Arousal and Positive Mood, and in the High THC group only, increases in Confusion, Friendliness, and Elation, and a decrease in Fatigue. Increases in Friendliness and Elation in the High THC group remained significant for 24 h. The only significant acute effect of cannabis on cognition was a decrease in the percent of words retained in the HVLT-R in the High THC group compared to Placebo (mean difference = 15.8%, 95% CI = 3.6-28.0%, p = 0.006). Unexpectedly, compared to Placebo, both the High and Low THC groups improved in DSST performance at 48 h (p ≤ 0.016). CONCLUSIONS Under the present experimental conditions, in young regular cannabis users, smoking cannabis ad libitum had significant effects on mood, some of which persisted 24 h later, yet minimal effects on cognition, and no evidence of residual cognitive impairment.
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Kozak K, George TP. Pharmacotherapy for smoking cessation in schizophrenia: a systematic review. Expert Opin Pharmacother 2020; 21:581-590. [PMID: 32011186 DOI: 10.1080/14656566.2020.1721466] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: Rates of tobacco smoking are high in people with schizophrenia with greater difficulty of quitting smoking compared to the general population, which also relate to the increased cardiovascular and cancer risks in this co-occurring disorder. Therefore, effective smoking cessation pharmacotherapies addressing tobacco co-morbidity are imperative.Areas covered: In this review, the authors performed an extensive systematic electronic literature review examining the efficacy and safety of first-line pharmacotherapies for smoking cessation, including varenicline, sustained-release bupropion, and nicotine replacement therapies (NRT) using continuous abstinence rates over 10-12-week periods in smokers with schizophrenia. Twelve trials reporting smoking cessation outcomes using interventions in schizophrenia were included and risk ratio (RR) was used.Expert opinion: Our findings support the efficacy and safety of first-line pharmacotherapies for the treatment of tobacco use disorder in smokers with schizophrenia. Further research on the long-term effectiveness and safety of these agents in community samples is warranted. Smoking cessation pharmacotherapies may warrant the consideration of the emerging use of electronic nicotine delivery systems while neuromodulation techniques also offer promise.
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Le TL, Conklin CA, George TP, Levitan RD, Mann RE, Maunder RG. Exposure to attachment figure cue reduces cigarette craving. Exp Clin Psychopharmacol 2020; 28:81-86. [PMID: 31070429 DOI: 10.1037/pha0000284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cue-induced craving among smokers is a well-documented phenomenon. Conditioning theory is used to explain how stimuli elicit cravings. Attachment theory may explain additional influences on cue-induced craving. This study tested the effects of cigarette cues and attachment figure cues on craving and affect. Cue-reactivity as a function of cue type was examined to explore the magnitude of craving effect sizes for each cue type. Thirty-six smokers (27 men) were exposed to cigarette cues (i.e., cigarette) and attachment figure cues (i.e., digital photos of people identified as attachment figures). Neutral to cue exposure differences in craving and affect were assessed. Sixty-one percent of participants reported increased craving to the cigarette cue (M = 61.1, SD = 29.4) compared to the neutral cue (M = 46.6, SD = 28.8), Mdiff = 20.7 (10.60, 30.73), Yt (23) = 4.24, p = .0003. When exposed to an attachment figure photo, 56% participants reported decreased craving (M = 38.2, SD = 31.6) compared to the neutral photo (M = 50.9, SD = 29.8), Mdiff = -15.73 (-30.83, -0.63), Yt (21) = -2.17, p = .042. There was a significant difference in the craving for cigarette cues (M = 14.5, SD = 22.8 (CI: 6.94, 22.39)), and attachment figure photos (M = -12.7, SD = 28.6 (CI: -22.38, -3.01); t(35) = 4.3, p < .001). The effect sizes for cigarette cues and attachment figure photos were d = .50, d = .42, respectively. Participants' responses to attachment cues were not influenced by their reactivity to cigarette cues or their attachment figure's smoking status. Findings support a plausible model in which an attachment figure photo decreases craving via affect regulation. Further research on cues that have an inhibitory effect on craving may inform new cessation strategies. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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Botsford SL, Yang S, George TP. Cannabis and Cannabinoids in Mood and Anxiety Disorders: Impact on Illness Onset and Course, and Assessment of Therapeutic Potential. Am J Addict 2020; 29:9-26. [PMID: 31577377 PMCID: PMC6925309 DOI: 10.1111/ajad.12963] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 08/11/2019] [Accepted: 09/17/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Cannabis use is common in people with and mood and anxiety disorders (ADs), and rates of problematic use are higher than in the general population. Given recent policy changes in favor of cannabis legalization, it is important to understand how cannabis and cannabinoids may impact people with these disorders. We aimed to assess the effects of cannabis on the onset and course of depression, bipolar disorder, ADs, and post-traumatic stress disorder (PTSD), and also to explore the therapeutic potential of cannabis and cannabinoids for these disorders. METHODS A systematic review of the literature was completed. The PubMed® database from January 1990 to May 2018 was searched. We included longitudinal cohort studies, and also all studies using cannabis or a cannabinoid as an active intervention, regardless of the study design. RESULTS Forty-seven studies were included: 32 reported on illness onset, nine on illness course, and six on cannabinoid therapeutics. Cohort studies varied significantly in design and quality. The literature suggests that cannabis use is linked to the onset and poorer clinical course in bipolar disorder and PTSD, but this finding is not as clear in depression and anxiety disorders (ADs). There have been few high-quality studies of cannabinoid pharmaceuticals in clinical settings. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE These conclusions are limited by a lack of well-controlled longitudinal studies. We suggest that future research be directed toward high-quality, prospective studies of cannabis in clinical populations with mood and ADs, in addition to controlled studies of cannabinoid constituents and pharmaceuticals in these populations. (Am J Addict 2019;00:00-00).
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Brands B, Mann RE, Wickens CM, Sproule B, Stoduto G, Sayer GS, Burston J, Pan JF, Matheson J, Stefan C, George TP, Huestis MA, Rehm J, Le Foll B. Acute and residual effects of smoked cannabis: Impact on driving speed and lateral control, heart rate, and self-reported drug effects. Drug Alcohol Depend 2019; 205:107641. [PMID: 31678833 DOI: 10.1016/j.drugalcdep.2019.107641] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 08/27/2019] [Accepted: 08/30/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Although driving under the influence of cannabis is increasingly common among young adults, little is known about residual effects on driver behavior. This study examined acute and residual effects of smoked cannabis on simulated driving performance of young cannabis users. METHODS In this double-blind, placebo-controlled, parallel-group randomized clinical trial, cannabis users (1-4 days/week) aged 19-25 years were randomized with a 2:1 allocation ratio to receive active (12.5% THC) or placebo (0.009% THC) cannabis in a single 750 mg cigarette. A median split (based on whole-blood THC concentrations at the time of driving) was used to divide the active group into low and high THC groups. Our primary outcome was simulated driving performance, assessed 30 min and 24 and 48 h after smoking. Secondary outcomes included blood THC concentrations, subjective drug effects, and heart rate. RESULTS Ninety-six participants were randomized, and 91 were included in the final analysis (30 high THC, 31 low THC, 30 placebo). Mean speed (but not lateral control) significantly differed between groups 30 min after smoking cannabis (p ≤ 0.02); low and high THC groups decreased their speed compared to placebo. Heart rate, VAS drug effect and drug high increased significantly immediately after smoking cannabis and declined steadily after that. There was little evidence of residual effects in any of the measures. CONCLUSION Acutely, cannabis caused decreased speed, increased heart rate, and increases in VAS drug effect and drug high. There was no evidence of residual effects on these measures over the two days following cannabis administration.
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Coles AS, Sasiadek J, George TP. Pharmacotherapies for co-occurring substance use and bipolar disorders: A systematic review. Bipolar Disord 2019; 21:595-610. [PMID: 31077521 DOI: 10.1111/bdi.12794] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Substance use disorders (SUDs), including those for alcohol, stimulants, tobacco, opioids and cannabis, in patients with bipolar disorder are a major clinical and public health problem, and are present in the majority of these patients. Nonetheless, the development of effective pharmacological treatments for co-occurring SUDs in bipolar illness have not been well-developed and may be an important practical reason for the reduced effectiveness of these medications in community practice. METHODS We conducted a systematic review of the literature (PubMed, Medline, Google Scholar), and identified N = 29 clinical studies, which evaluated both mental health and SUD outcomes in patients with co-occurring bipolar disorders and SUDs. RESULTS Our findings suggest the potential of valproate sodium and lamotrigine as preferred pharmacological agents for the treatment of co-occurring psychiatric and substance use outcomes in these patients. However, many of the reviewed studies are of open-label designs and of modest sample sizes. CONCLUSIONS Thus, given the gaps in our knowledge, recommendations for treatment of this common and important co-morbidity are preliminary. Accordingly, the conduct of larger, randomized controlled trials for this co-morbidity is clearly needed.
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Ekhtiari H, Tavakoli H, Addolorato G, Baeken C, Bonci A, Campanella S, Castelo-Branco L, Challet-Bouju G, Clark VP, Claus E, Dannon PN, Del Felice A, den Uyl T, Diana M, di Giannantonio M, Fedota JR, Fitzgerald P, Gallimberti L, Grall-Bronnec M, Herremans SC, Herrmann MJ, Jamil A, Khedr E, Kouimtsidis C, Kozak K, Krupitsky E, Lamm C, Lechner WV, Madeo G, Malmir N, Martinotti G, McDonald WM, Montemitro C, Nakamura-Palacios EM, Nasehi M, Noël X, Nosratabadi M, Paulus M, Pettorruso M, Pradhan B, Praharaj SK, Rafferty H, Sahlem G, Salmeron BJ, Sauvaget A, Schluter RS, Sergiou C, Shahbabaie A, Sheffer C, Spagnolo PA, Steele VR, Yuan TF, van Dongen JDM, Van Waes V, Venkatasubramanian G, Verdejo-García A, Verveer I, Welsh JW, Wesley MJ, Witkiewitz K, Yavari F, Zarrindast MR, Zawertailo L, Zhang X, Cha YH, George TP, Frohlich F, Goudriaan AE, Fecteau S, Daughters SB, Stein EA, Fregni F, Nitsche MA, Zangen A, Bikson M, Hanlon CA. Transcranial electrical and magnetic stimulation (tES and TMS) for addiction medicine: A consensus paper on the present state of the science and the road ahead. Neurosci Biobehav Rev 2019; 104:118-140. [PMID: 31271802 PMCID: PMC7293143 DOI: 10.1016/j.neubiorev.2019.06.007] [Citation(s) in RCA: 168] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/30/2019] [Accepted: 06/08/2019] [Indexed: 12/21/2022]
Abstract
There is growing interest in non-invasive brain stimulation (NIBS) as a novel treatment option for substance-use disorders (SUDs). Recent momentum stems from a foundation of preclinical neuroscience demonstrating links between neural circuits and drug consuming behavior, as well as recent FDA-approval of NIBS treatments for mental health disorders that share overlapping pathology with SUDs. As with any emerging field, enthusiasm must be tempered by reason; lessons learned from the past should be prudently applied to future therapies. Here, an international ensemble of experts provides an overview of the state of transcranial-electrical (tES) and transcranial-magnetic (TMS) stimulation applied in SUDs. This consensus paper provides a systematic literature review on published data - emphasizing the heterogeneity of methods and outcome measures while suggesting strategies to help bridge knowledge gaps. The goal of this effort is to provide the community with guidelines for best practices in tES/TMS SUD research. We hope this will accelerate the speed at which the community translates basic neuroscience into advanced neuromodulation tools for clinical practice in addiction medicine.
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Kozak K, Lowe DJE, George TP. Effects of Tobacco Smoking Status on Verbal Learning and Memory in Patients With Schizophrenia and Non-Psychiatric Controls. Am J Addict 2019; 28:503-511. [PMID: 31291035 DOI: 10.1111/ajad.12903] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 03/03/2019] [Accepted: 04/20/2019] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with schizophrenia have higher rates of tobacco smoking compared to the general population. Moreover, these patients have deficits in cognition, including verbal learning and memory. However, it is not clear whether smoking status alters verbal learning and memory in schizophrenia. We examined the effects of smoking abstinence and reinstatement on verbal learning and memory in people with schizophrenia and nonpsychiatric controls and other cognitive domains as exploratory. METHODS Smoking participants (N = 28; 14 schizophrenia smokers; 14 nonpsychiatric smokers) were studied under smoking satiated, overnight abstinence and smoking reinstatement conditions. Nonsmokers ( n = 30; 15 schizophrenia nonsmokers; 15 nonpsychiatric nonsmokers) were also studied. A comprehensive cognitive battery was administered including verbal learning and memory using the Hopkins Verbal Learning Test-Revised (HVLT-R). RESULTS A 2 (diagnosis) × 2 (smoking status) repeated measures analysis of variance with time (session) as the within-subjects factor and diagnosis and smoking status as the between-subject factors was performed for HVLT-R and other cognitive outcomes. Smoking abstinence produced a decline in verbal memory of the HVLT discrimination index in smokers with schizophrenia that was partially revised by reinstatement, although trends for other HVLT measures were not statistically significant. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE Acute cigarette smoking and abstinence may selectively alter verbal learning and memory deficits in smokers with schizophrenia compared to nonpsychiatric smoking controls and nonsmokers, but additional studies are needed to confirm the preliminary findings in this small sample. (Am J Addict 2019;00:1-9).
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Ashare RL, Thompson M, Leone F, Metzger D, Gross R, Mounzer K, Tyndale RF, Lerman C, Mahoney MC, Cinciripini P, George TP, Collman RG, Schnoll R. Differences in the rate of nicotine metabolism among smokers with and without HIV. AIDS 2019; 33:1083-1088. [PMID: 30946162 DOI: 10.1097/qad.0000000000002127] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE HIV-infected smokers lose more life years to tobacco use than to HIV infection. The nicotine metabolite ratio (NMR), a biomarker of CYP2A6, represents individual variation in the rate at which nicotine is metabolized and is associated with response to smoking cessation treatments. We evaluated whether HIV-infected smokers metabolize nicotine faster than HIV-uninfected smokers, which may contribute to the disproportionate smoking burden and may have important treatment implications. DESIGN We analysed baseline data from two clinical trials (NCT01710137; NCT01314001) to compare the NMR in HIV-infected smokers (N = 131) to HIV-uninfected smokers (N = 199). METHODS Propensity scores were used to match the groups 2 : 1 on characteristics that influence NMR: sex, race, BMI and smoking rate. Nicotine metabolites were assessed via liquid chromatography-tandem mass spectrometry methods and the ratio of 3-hydroxycotinine:cotinine was used to compute the NMR. RESULTS HIV-infected smokers had significantly higher NMR (mean = 0.47, SEM = 0.02) and were more likely to be in the highest NMR quartile compared with HIV-uninfected smokers (mean = 0.34, SEM = 0.02; Ps < 0.001). CONCLUSION The higher NMR observed among HIV-infected smokers may partially explain higher smoking rates and lower response to transdermal nicotine therapy. Understanding the mechanisms by which HIV and/or ART contribute to faster nicotine metabolism may guide the use of the NMR to personalize tobacco cessation strategies in this underserved population.
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Robinson JD, Li L, Chen M, Lerman C, Tyndale RF, Schnoll RA, Hawk LW, George TP, Benowitz NL, Cinciripini PM. Evaluating the temporal relationships between withdrawal symptoms and smoking relapse. PSYCHOLOGY OF ADDICTIVE BEHAVIORS 2019; 33:105-116. [PMID: 30614717 PMCID: PMC6405298 DOI: 10.1037/adb0000434] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Smokers attempting to quit often attribute smoking relapse to negative affect, craving, and other nicotine withdrawal symptoms. In addition, there is evidence that smoking relapse can increase these symptoms, particularly negative affect. To address this issue, we analyzed data from an 11-week smoking cessation clinical trial in which smokers (n = 1,246) were randomized to receive either nicotine replacement therapy (NRT), varenicline, or placebo, combined with behavioral counseling. Using cross-lagged analyses, we examined the temporal bidirectional relationships between self-reported measures of affect, craving, and composite withdrawal symptoms and biochemically verified smoking abstinence. The relative strength of these temporal relationships was examined by comparing the explained variances of the models. The results showed that higher negative affect, craving, and composite withdrawal symptoms increased the likelihood of subsequent smoking relapse, and that smoking relapse led to subsequent increases in these same symptoms. A comparison of the explained variances found symptom predicting subsequent relapse models to be stronger than those where relapse predicted subsequent symptoms. Although the explained variance findings generally support a negative reinforcement conceptualization of nicotine dependence, the bidirectional relationship between symptoms and smoking relapse suggests that struggling with quitting smoking leads to significant negative affect, craving, and other withdrawal symptoms that do not quickly resolve. These findings highlight the importance of addressing specific symptoms within the context of smoking cessation. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Hill KP, Palastro MD, George TP. Therapeutic cannabis use in 2018: where do we stand? Lancet Psychiatry 2019; 6:88-89. [PMID: 30686389 DOI: 10.1016/s2215-0366(18)30417-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 10/09/2018] [Accepted: 10/11/2018] [Indexed: 11/27/2022]
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Lowe DJ, Sasiadek JD, Coles AS, George TP. Cannabis and mental illness: a review. Eur Arch Psychiatry Clin Neurosci 2019; 269:107-120. [PMID: 30564886 PMCID: PMC6397076 DOI: 10.1007/s00406-018-0970-7] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 12/12/2018] [Indexed: 12/30/2022]
Abstract
With the increasing push to legalize cannabis in Western nations, there is a need to gage the potential impact of this policy change on vulnerable populations, such as those with mental illness, including schizophrenia, mood, and anxiety disorders. This is particularly important as there are strong motives in these individuals to seek short-term reward (e.g., "getting high"). Nonetheless, data to support the beneficial effects of cannabis use in psychiatric populations are limited, and potential harms in patients with psychotic and mood disorders have been increasingly documented. This article reviews the effects of cannabis in people with mental illness. Then, we provide a reconciliation of the addiction vulnerability and allostatic hypotheses to explain co-morbidity addiction in mentally ill cannabis users, as well as to further aid in developing a rational framework for the assessment and treatment of problematic cannabis use in these patients.
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George TP. FAAH inhibition for treatment of problematic cannabis use. Lancet Psychiatry 2019; 6:3-4. [PMID: 30528675 DOI: 10.1016/s2215-0366(18)30462-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 11/12/2018] [Indexed: 11/28/2022]
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Hill KP, George TP. Cannabis legalisation in Canada: a crucial trial balloon. Lancet Psychiatry 2019; 6:5-6. [PMID: 30579495 DOI: 10.1016/s2215-0366(18)30460-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 11/13/2018] [Indexed: 01/05/2023]
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Lucatch AM, Lowe DJE, Clark RC, Kozak K, George TP. Neurobiological Determinants of Tobacco Smoking in Schizophrenia. Front Psychiatry 2018; 9:672. [PMID: 30574101 PMCID: PMC6291492 DOI: 10.3389/fpsyt.2018.00672] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 11/21/2018] [Indexed: 12/22/2022] Open
Abstract
Purpose of review: To provide an overview of the underlying neurobiology of tobacco smoking in schizophrenia, and implications for treatment of this comorbidity. Recent findings: Explanations for heavy tobacco smoking in schizophrenia include pro-cognitive effects of nicotine, and remediation of the underlying pathophysiology of schizophrenia. Nicotine may ameliorate neurochemical deficits through nicotine acetylcholine receptors (nAChRs) located on the dopamine, glutamate, and GABA neurons. Neurophysiological indices including electroencephalography, electromyography, and smooth pursuit eye movement (SPEM) paradigms may be biomarkers for underlying neuronal imbalances that contribute to the specific risk of tobacco smoking initiation, maintenance, and difficulty quitting within schizophrenia. Moreover, several social factors including socioeconomic factors and permissive smoking culture in mental health facilities, may contribute to the smoking behaviors (initiation, maintenance, and inability to quit smoking) within this disorder. Summary: Tobacco smoking may alleviate specific symptoms associated with schizophrenia. Understanding the neurobiological underpinnings and psychosocial determinants of this comorbidity may better explain these potential beneficial effects, while also providing important insights into effective treatments for smoking cessation.
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Kozak K, Lucatch AM, Lowe DJE, Balodis IM, MacKillop J, George TP. The neurobiology of impulsivity and substance use disorders: implications for treatment. Ann N Y Acad Sci 2018; 1451:71-91. [PMID: 30291624 DOI: 10.1111/nyas.13977] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 09/11/2018] [Accepted: 09/13/2018] [Indexed: 12/20/2022]
Abstract
Impulsivity is strongly associated with substance use disorders (SUDs). Our review discusses impulsivity as an underlying vulnerability marker for SUDs, and treatment of co-occurring impulsivity in SUDs. Three factors should be considered for the complex relationship between impulsivity and a SUD: (1) the trait effect of impulsivity, centering on decreased cognitive and response inhibition, (2) the state effect resulting from either acute or chronic substance use on brain structure and function, and (3) the genetic and environmental factors (e.g., age and sex) may influence impulsive behavior associated with SUDs. Both subjective and objective measures are used to assess impulsivity. Together, treatment developments (pharmacological, behavioral, and neurophysiological) should consider these clinically relevant dimensions assessed by a variety of measures, which have implications for treatment matching in individuals with SUD. Despite its heterogeneity, impulsivity is a marker associated with SUDs and may be understood as an imbalance of bottom-up and top-down neural systems. Further investigation of these relationships may lead to more effective SUD treatments.
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Gendy MNS, Di Ciano P, Kowalczyk WJ, Barrett SP, George TP, Heishman S, Le Foll B. Testing the PPAR hypothesis of tobacco use disorder in humans: A randomized trial of the impact of gemfibrozil (a partial PPARα agonist) in smokers. PLoS One 2018; 13:e0201512. [PMID: 30260990 PMCID: PMC6160014 DOI: 10.1371/journal.pone.0201512] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 07/12/2018] [Indexed: 11/19/2022] Open
Abstract
Previous pre-clinical studies demonstrated a promising role of alpha-type peroxisome proliferator-activated receptors (PPARα) agonists in decreasing nicotine self-administration and nicotine-seeking behavior in animals. Our goal was to investigate the potential of gemfibrozil, a PPARα agonist, on reducing tobacco smoking in humans. Methods: This was a double-blind, placebo-controlled, crossover study evaluating the effects of gemfibrozil (1200 mg/day) on smoking in 27 treatment-seeking smokers. The study had two 2-week phases separated by a washout period of at least 1 week. In each phase and after 1 week on medication, participants underwent a lab session where cue reactivity and forced choice paradigms were conducted. Physiological responses and self-reported craving were monitored during the presentation of smoking and neutral cues. In addition, two types of cigarettes were used in the forced choice paradigms: the Nicotinized cigarettes (Nic) and the Denicotinized cigarettes (Denic). The goal of the forced choice was to calculate the percentage of choice of Nic cigarettes while taking gemfibrozil or placebo. The number of quit days was calculated during the two quit attempts weeks (one while taking gemfibrozil and one while taking placebo) of the study. Results: There were no significant differences between gemfibrozil and placebo groups in the percentage of choice of Nic cigarettes, the cue-reactivity (both physiological and subjective measures), or in the number of days of abstinence. Conclusions: Although preclinical studies with PPAR α agonists showed promising results, this preliminary study did not demonstrate positive effect of gemfibrozil on tobacco use and cessation indices.
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Peng AR, Schnoll R, Hawk LW, Cinciripini P, George TP, Lerman C, Tyndale RF. Predicting smoking abstinence with biological and self-report measures of adherence to varenicline: Impact on pharmacogenetic trial outcomes. Drug Alcohol Depend 2018; 190:72-81. [PMID: 29986268 PMCID: PMC6085881 DOI: 10.1016/j.drugalcdep.2018.04.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 04/17/2018] [Accepted: 04/21/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Adherence to pharmacotherapies for tobacco dependence, such as varenicline, is necessary for effective treatment. The relationship between varenicline adherence, determined by commonly used indirect (i.e., self-reported pill counts) and infrequently used direct (i.e., varenicline levels) methods, and abstinence outcomes have not been previously examined, nor has their impact on the outcomes of a genetically randomized clinical trial been assessed. METHODS At Week 1 following target quit date, self-reported pill count and salivary varenicline levels were obtained from participants (N = 376) in a smoking cessation clinical trial (NCT01314001). Point-prevalence abstinence was biochemically-verified by salivary cotinine at Week 1 and by exhaled carbon monoxide at Week 1, end-of-treatment, 6 and 12 months following treatment. Blood nicotine metabolite ratio (NMR) was obtained at baseline. RESULTS Adherent individuals based on varenicline levels were significantly more likely to be abstinent than non-adherent individuals at Week 1 (odds ratios [ORs] 1.92-3.16, p's≤0.006), end-of-treatment (OR = 2.53, p = .004), and six months following treatment (OR = 2.30, p = .03). In contrast, pill counts did not consistently predict abstinence. Including direct measures of adherence enhanced the association between rate of nicotine metabolism (NMR) and end-of-treatment abstinence; normal metabolizers (NMR ≥ 0.31) were significantly more likely than slow metabolizers (NMR < 0.31) to be abstinent at end-of-treatment (OR = 2.00, p = .005). CONCLUSION Adherence based on salivary varenicline, rather than on pill counts, is predictive of Week 1 abstinence, irrespective of the biomarker of abstinence assessed, and of long-term abstinence. Direct measures of adherence enhance the ability to assess the impact of a biomarker or genetic marker on abstinence outcomes.
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Kozak K, Dermody SS, Rabin RA, Zack M, Barr MS, Tyndale RF, George TP. Effects of varenicline on cognitive function in non-smokers with schizophrenia. Schizophr Res 2018; 197:562-563. [PMID: 28291692 DOI: 10.1016/j.schres.2017.03.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/06/2017] [Accepted: 03/07/2017] [Indexed: 11/30/2022]
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George TP, Hill KP, Vaccarino FJ. Cannabis Legalization and Psychiatric Disorders: Caveat "Hemp-tor". CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2018; 63:447-450. [PMID: 29482358 PMCID: PMC6099771 DOI: 10.1177/0706743718762387] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Ramlakhan JU, Zomorrodi R, Downar J, Blumberger DM, Daskalakis ZJ, George TP, Kiang M, Barr MS. Using Mismatch Negativity to Investigate the Pathophysiology of Substance Use Disorders and Comorbid Psychosis. Clin EEG Neurosci 2018; 49:226-237. [PMID: 29502434 DOI: 10.1177/1550059418760077] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Substance use disorders (SUDs) have a devastating impact on society and place a heavy burden on health care systems. Given that alcohol, tobacco, and cannabis use have the highest prevalence, further understanding of the underlying pathophysiology of these SUDs is crucial. Electroencephalography is an inexpensive, temporally superior, and translatable technique which enables investigation of the pathobiology of SUDs through the evaluation of various event-related potential components, including mismatch negativity (MMN). The goals of this review were to investigate the effects of acute and chronic alcohol, tobacco, and cannabis use on MMN among nonpsychiatric populations and patients with comorbid psychosis. A literature search was performed using the database PubMed, and 36 articles met our inclusion and exclusion criteria. We found a pattern of attenuation of MMN amplitude among patients with alcoholism across acute and chronic alcohol use, and this dysregulation was not heritable. Reports were limited, and results were mixed on the effects of acute and chronic tobacco and cannabis use on MMN. Reports on comorbid SUDs and psychosis were even fewer, and also presented mixed findings. These preliminary results suggest that MMN deficits may be associated with SUDs, specifically alcohol use disorder, and serve as a possible biomarker for treating these common disorders.
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Samokhvalov AV, Probst C, Awan S, George TP, Le Foll B, Voore P, Rehm J. Outcomes of an integrated care pathway for concurrent major depressive and alcohol use disorders: a multisite prospective cohort study. BMC Psychiatry 2018; 18:189. [PMID: 29898697 PMCID: PMC6001012 DOI: 10.1186/s12888-018-1770-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 05/29/2018] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND In 2013, an Integrated Care Pathway (ICP) for concurrent Major Depressive (MDD) and Alcohol Use (AUD) Disorders was developed at the Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada. The ICP was further implemented at 8 other clinical sites across Ontario (the DA VINCI Project) in 2015-2017. The goal of this study was to systematically describe and analyze the main clinical outcomes of the project. METHODS Data on a non-randomized cohort of patients receiving ICP-based treatment were collected prospectively at nine clinical sites in a variety of clinical settings. STATISTICAL METHODS descriptive statistics, t-test, chi-square, ANOVA, generalized linear models. RESULTS Two hundred forty-six patients were enrolled, 58.8% males, mean age was 45.6 years, 170 patients received treatment at academic health centres (AHC), 49 - at community hospitals (CH) and 27 - in family health teams (FHT). There were no major differences in anamnestic parameters and depression severity between the three settings, but there were differences in baseline drinking patterns between subgroups (F = 4.271, df = 2, p = 0.015). Overall completion rate was 70.7% with no significant variation between settings (χ2 = 3.35, df = 2, p = 0.19). Treatment duration in AHC was the longest, and completion rates were the highest. There was a statistically significant and clinically meaningful reduction in the number of drinking days per week (1.81, t = 8.78, p < 0.001). The cohort overall demonstrated significant and meaningful reduction in severity of cravings (Penn Alcohol Craving Scale: 4.42, t = 8.63, p < 0.001) and depressive symptoms (Quick Inventory of Depressive Symptomatology: 4.25, t = 11.26, p < 0.001). While some of the baseline patient characteristics and treatment parameters varied between the settings, the variation in clinical outcomes was mostly insignificant, though clinical improvement was more pronounced in academic setting and with individual therapy. CONCLUSIONS The study demonstrated that ICP is a feasible and effective treatment for concurrent AUD and MDD that delivers meaningful clinical improvement in a variety of settings. A randomized controlled study is needed to properly compare the treatment outcomes between ICP model and treatment as usual and to further explore the role of various factors on treatment outcomes.
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Taghavi T, Novalen M, Lerman C, George TP, Tyndale RF. A Comparison of Direct and Indirect Analytical Approaches to Measuring Total Nicotine Equivalents in Urine. Cancer Epidemiol Biomarkers Prev 2018; 27:882-891. [PMID: 29853480 DOI: 10.1158/1055-9965.epi-18-0018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 03/15/2018] [Accepted: 05/23/2018] [Indexed: 12/23/2022] Open
Abstract
Background: Total nicotine equivalents (TNE), the sum of nicotine and metabolites in urine, is a valuable tool for evaluating nicotine exposure. Most methods for measuring TNE involve two-step enzymatic hydrolysis for indirect quantification of glucuronide metabolites. Here, we describe a rapid, low-cost direct LC/MS assay.Methods: In 139 smokers' urine samples, Bland-Altman, correlation, and regression analyses were used to investigate differences in quantification of nicotine and metabolites, TNE, and nicotine metabolite ratio (NMR) between direct and indirect LC/MS methods. DNA from a subset (n = 97 smokers) was genotyped for UGT2B10*2 and UGT2B17*2, and the known impact of these variants was evaluated using urinary ratios determined by the direct versus indirect method.Results: The direct method showed high accuracy (0%-9% bias) and precision (3%-14% coefficient of variation) with similar distribution of nicotine metabolites to literary estimates and good agreement between the direct and indirect methods for nicotine, cotinine, and 3-hydroxycotinine (ratios 0.99-1.07), but less agreement for their respective glucuronides (ratios 1.16-4.17). The direct method identified urinary 3HC+3HC-GLUC/COT as having the highest concordance with plasma NMR and provided substantially better estimations of the established genetic impact of glucuronidation variants compared with the indirect method.Conclusions: Direct quantification of nicotine and metabolites is less time-consuming and less costly, and provides accurate estimates of nicotine intake, metabolism rate, and the impact of genetic variation in smokers.Impact: Lower cost and maintenance combined with high accuracy and reproducibility make the direct method ideal for smoking biomarker, NMR, and pharmacogenomics studies. Cancer Epidemiol Biomarkers Prev; 27(8); 882-91. ©2018 AACR.
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