A washout period needed before switching from a neuroleptic to an amphetamine

(1) Abrupt replacement of risperidone with methylphenidate can lead to severe agitation in children; (2) Abruptly switching from one pharmacological class to another can lead to complications.

Fenethylline as a possible etiology for retinal vein occlusion

We are report 3 cases of hemorrhagic central retina vein occlusion following continuous use of fenethylline hydrochloride. The hemorrhage, the edema and the engorged veins showed marked improvement after discontinuing the drug and laser supplement in one case.

Medications for adolescents with attention-deficit/hyperactivity disorder

ADHD is recognized as a neurologic condition rather than just bad behavior. Medical treatment has been recognized as very helpful. Risks of untreated ADHD are substantial. Every life area is negatively affected including school performance, drug abuse and dependence risk, driving performance, sexually transmitted diseases, unwanted pregnancy and family cohesiveness to mention some of them. Frequent misinformation in the popular media causes apprehension about medical treatment. Even after almost 60 years stimulants remain the mainstay in treatment of ADHD. Newer release systems have produced longer acting and smoother acting medication. Side effects have always been brief and mild however, newer forms cause fewer side effects than older preparations and cover symptoms for more of the waking hours of each day. Although studies in adolescents are less numerous than in children the literature standard supports the safety and efficacy of stimulants in adolescents. In addition there are non-stimulant medications that have shown efficacy in adolescents. There are now a greater number of medications and more effective medications than ever before. Clinical pearls in medication management are shared in practical terms so that these newer treatments can be used to help those affected with ADHD more effectively than ever before.

[The influence of psychoactive substance on histone acetylation modification]

Psychoactive substance abuse and addiction have increasingly become severe, which are not only a serious social problem, but an important medical problem as well. Recent studies have demonstrated that the histone acetylation modification is an important epigenetic mechanism of gene regulations and plays essential roles in psychoactive substance abuse and addiction. The present review mainly presents the influence of several psychoactive substances, including cocaine, amphetamine, methamphetamine, morphine, and alcohol, on histone acetylation modification.

[Psychostimulants]

Over the last twenty years, cocaine, amphetamines and MDMA (ecstasy) have found new categories of users, seeking for their stimulating effects. These substances may lead to real dependence and may cause serious somatic and psychiatric damage. In this perspective, we reviewed the available literature concerning problematic psychoactive drug use in Belgium.

AMPA receptor involvement in 5-hydroxytryptamine2A receptor-mediated pre-frontal cortical excitatory synaptic currents and DOI-induced head shakes

Glutamate plays an important role in the psychotomimetic effects of both channel blocking N-methyl D-aspartate (NMDA) receptor antagonists and hallucinogenic drugs which activate 5-hydroxytryptamine2A (5-HT2A) receptors. Previous work suggested that activation of non-NMDA ionotropic glutamate receptors mediates the effects of 5-HT-induced excitatory post-synaptic potentials/currents (EPSPs/EPSCs) when recording from layer V pyramidal cells in the rat medial pre-frontal cortex (mPFC). However, those effects are mediated by either alpha-amino-3-hydroxy-5-methylisoxazole-4-propionate (AMPA) or kainate receptors of the iGluk5 subtype. To test whether activation of AMPA receptors is sufficient to mediate 5-HT-induced EPSCs, a 2,3-benzodiazepine that selectively blocks AMPA receptors was assessed. This selective AMPA receptor antagonist potently suppressed 5-HT-induced EPSCs. Since phenethylamine hallucinogens induce head shakes by activating 5-HT2A receptors in the mPFC and this action is modulated by glutamate, we also examined whether selective blockade of AMPA receptors would suppress DOI-induced head shakes. As predicted, we found that selective blockade of AMPA receptors suppressed DOI-induced head shakes. Given evidence that activation of AMPA receptors is an important downstream effect for both channel blocking NMDA receptor antagonists and phenethylamine hallucinogens, we also tested multiple doses of DOI with a sub-anesthetic dose of MK-801. Synergistic action between these two classes of psychotomimetic drugs was demonstrated by MK-801 enhancing DOI-induced head shakes and locomotor activity. These findings expand the dependence of both channel blocking NMDA receptor antagonists and phenethylamine hallucinogens on enhancing extracellular glutamate.

The impact of systemic disease-associated gingival enlargement on pediatric patients

This article provides an analysis of pediatric systemic disease and the corresponding prescribed medications for selected physical and mental health conditions. The focus is on pediatric oral health, specifically the drug-associated side effect of gingival enlargement. A simple and logical analysis of current pediatric health trends reveals that gingival overgrowth is evident in societies worldwide as a serious epidemic. This article describes the morbidity and risks that are related to drug-associated gingival overgrowth, and proposes a framework of action for treating the side effects of chronic diseases and conditions in pediatric patients.

Interference with Smoking-Cessation Effects of Varenicline After Administration of Immediate-Release Amphetamine-Dextroamphetamine

An 18-year-old man with attention-deficit-hyperactivity disorder (ADHD) was prescribed varenicline for smoking cessation. He quit smoking after 1 week of therapy and remained smoke free for the next 17 days. During that time, he had also been taking amphetamine-dextroamphetamine (Adderall) on work days for his ADHD. Because his supply of amphetamine-dextroamphetamine was diminishing, he took only half (30 mg every morning) of his prescribed dosage from days 4-12 of varenicline therapy. He further reduced his dosage to 15 mg every morning on days 13 and 14 of varenicline therapy, and his supply of amphetamine-dextroamphetamine was depleted on day 15. On day 23 of varenicline therapy, he received and filled a new prescription for amphetamine-dextroamphetamine and resumed his prescribed dosage (30 mg twice/day). He began smoking again within 48 hours. Rechallenge with varenicline while the patient continued to receive amphetamine-dextroamphetamine yielded similar results. Data suggest that addition of amphetamine to varenicline may negate the partial agonism of varenicline, resulting in elimination of the smoking-cessation aid's benefits. Other potential mechanisms for the drug interaction may also exist. Thus, varenicline may not aid smoking cessation in patients undergoing treatment with amphetamine and amphetamine-like drugs.

Who are the new amphetamine users? A 10-year prospective study of young Australians

AIMS

Despite good evidence of increased availability and use of amphetamines world-wide, relatively little is known about the epidemiology of young adult amphetamine use; relationships with social functioning, other drug use and mental health at this age; nor of the adolescent predictors of such use. We examined these issues using a representative cohort of young people followed-up in Victoria, Australia.

METHODS

A stratified, random sample of 1943 adolescents was recruited from secondary schools across Victoria at age 14-15 years. This cohort was interviewed on eight occasions until the age of 24-25 years (78% follow-up at that age). Cross-sectional and predictive associations were assessed using logistic regression.

RESULTS

At age 24 years, 12% of the sample had used amphetamines in the past year, with 1-2% using at least weekly. Young adult amphetamine use was predicted strongly by adolescent drug use and was associated robustly with other drug use and dependence in young adulthood. Associations were stronger for more frequent users. Among young adults who had not been using amphetamines at age 20 years, the strongest predictor of use at age 24 years was the use of other drugs, particularly cannabis, at 20 years. Psychological distress did not predict independently an increased likelihood of amphetamine use in this cohort.

CONCLUSION

Young people in Australia using amphetamine at age 24 years are highly likely to be significant polydrug users. The risks for both initiation of young adult amphetamine use, and maintenance of such use, pertain to the heavy use of other drugs. Interventions for heavy amphetamine users at this age are likely to require attention to multiple drug problems.

Forecasting three-month outcomes in a laboratory school comparison of mixed amphetamine salts extended release (Adderall XR) and atomoxetine (Strattera) in school-aged children With ADHD

OBJECTIVE

Compare observed and forecasted efficacy of mixed amphetamine salts extended release (MAS-XR; Adderall) with atomoxetine (Strattera) in ADHD children.

METHOD

The authors analyze data from a randomized, double-blind, multicenter, parallel-group, forced-dose-escalation laboratory school study of children ages 6 to 12 with ADHD combined or hyperactive/impulsive type. Primary efficacy measures are attention and deportment scores on the SKAMP behavioral rating scale, and secondary efficacy measures are academic performance scores from the PERMP test.

RESULTS

MAS-XR elicits greater improvements than atomoxetine in each domain within 3 weeks of treatment, including attention, number of math problems attempted and correct, and overall clinical functioning. Treatment differences in each outcome measure at subsequent weeks are projected from generalized estimating equations to become greater with the duration of extension of the treatment regimen.

CONCLUSION

This study suggests that relative advantages of MAS-XR seen in the first 3 weeks are likely to be maintained in subsequent weeks.

Neurochemical consequences of dysphoric state during amphetamine withdrawal in animal models: a review

Chronic abuse of amphetamines, such as d-amphetamine (AMPH) and d-methamphetamine, results in psychological dependence, a condition in which the drug produces a feeling of satisfaction and a drive that requires periodic or continuous administration of the drug to produce overwhelming pleasure or to avoid discomfort such as dysphoria. The dysphoric state of AMPH withdrawal has been recognized as depressive syndromes, such as anhedonia, depression, anxiety, and social inhibition, in early drug abstinence. Medication for treatment of the dysphoric state is important for AMPH abusers to avoid impulsive self-injurious behavior or acts that are committed with unconscious or uncontrolled suicidal ideation. However, successful treatments for AMPH withdrawal remain elusive, since the exact molecular basis of the expression of dysphoria has not been fully elucidated. This review focuses on the molecular aspects of AMPH withdrawal as indexed by neurochemical parameters under a variety of injection regimens (for example, levels of brain monoamines and their metabolites, and gamma-aminobutyric acid, expression of genes and proteins involved in neuronal activity, and monoamine metabolism and availability) in rodent models which exhibit significant phenotypic features relevant to the syndromes of AMPH withdrawal in humans.

Bioavailability of triple-bead mixed amphetamine salts compared with a dose-augmentation strategy of mixed amphetamine salts extended release plus mixed amphetamine salts immediate release

OBJECTIVE

To compare the single-dose pharmacokinetics of triple-bead mixed amphetamine salts (MAS), an oral, once-daily, enhanced extended-release amphetamine formulation, with MAS extended release (MAS XR) (Adderall XR) + MAS immediate release (MAS IR) administered 8 h later.

METHODS

This was a phase I, randomized, open-label, single-dose, single-center, two-period, crossover study in healthy adult volunteers designed to evaluate the bioavailability of triple-bead MAS over the course of a full day. Subjects were randomized to triple-bead MAS 37.5 mg or MAS XR 25 mg + MAS IR 12.5 mg administered 8 h later (MAS XR + MAS IR). The reference treatment was designed to mimic the clinical practice of providing extended coverage by supplementing a morning dose of MAS XR with a dose of MAS IR 8 h later in order to increase the duration of action. Plasma was assayed for d-amphetamine and l-amphetamine. Treatment-emergent adverse events (TEAEs), vital signs, electrocardiograms (ECGs), and laboratory data were also collected for safety evaluation.

RESULTS

Exposure to d- and l-amphetamine was equivalent between triple-bead MAS and MAS XR + MAS IR based on maximum plasma concentration (Cmax) and area under the plasma concentration-time curve from time 0 to infinity (AUC(0-infinity)). For Cmax, least-squares mean ratios comparing triple-bead MAS with MAS XR + MAS IR were 101.0% and 90.9% for d-amphetamine and l-amphetamine, respectively, and for AUC(0-infinity) were 104.4% and 95.3% for d-amphetamine and l-amphetamine, respectively. Median time to maximum observed plasma concentration (Tmax) values for d-amphetamine and l-amphetamine were 8.0 h for triple-bead MAS and 10.0 h for MAS XR + MAS IR. There were no clinically meaningful differences between the study formulations for TEAEs or laboratory values. One subject experienced an ECG abnormality (asymptomatic premature ventricular contractions) leading to early termination from the study.

CONCLUSIONS

In healthy adults, the exposure observed with triple-bead MAS 37.5 mg was bioequivalent to MAS XR 25 mg supplemented by MAS IR 12.5 mg administered 8 h later. These data demonstrate that a single morning dose of triple-bead MAS provides equivalent plasma concentrations to those observed with a dose-augmentation strategy of MAS XR in the morning followed by MAS IR in the afternoon, while minimizing peak-to-trough fluctuations. Triple-bead MAS was also generally well-tolerated in this study.

Enduring deficits in sustained visual attention during withdrawal of intravenous methylenedioxymethamphetamine self-administration in rats: results from a comparative study with d-amphetamine and methamphetamine

Although amphetamine-derived stimulants are widely associated with neurotoxicity, it is poorly understood whether extended exposure to such drugs produces lasting effects on neurocognitive function. This study investigates whether chronically self-administered d-amphetamine, methamphetamine (MA), or methylenedioxymethamphetamine (MDMA) leads to residual deficits in a rodent test of sustained visual attention and impulsivity. Rats were trained on a five-choice serial reaction time task and subsequently trained to self-administer d-amphetamine, MA, or MDMA (all 50 microg/infusion), intravenously, for 3 weeks. Effects on performance were evaluated 24 h after drug discontinuation and for several weeks thereafter, including various challenge sessions to increase the attentional demands of the task. The results indicate divergent patterns of self-administration among the three drugs tested with increasing rates of intake evident in rats self-administering amphetamine, but not MA, and widely fluctuating rates in the MDMA group. Withdrawal of MA resulted in severe behavioral disturbances, with significant effects on accuracy, omissions, response latency, and impulsivity that lasted up to 2 weeks in some cases. Amphetamine and MDMA withdrawal were associated with similar, but shorter-lasting effects on performance. However, when challenged with a high event rate session 6 weeks after drug discontinuation, rats previously exposed to MDMA continued to show deficits in the accuracy and speed of responding. These findings show that amphetamine-derived stimulants have both short- and long-term consequences for psychomotor functioning. The demonstration of residual deficits in rats chronically exposed to MDMA raises some concern about the potential harm caused by this drug in human ecstasy users.

Pharmacology of adult ADHD with stimulants

Attention-deficit/hyperactivity disorder (ADHD) is a lifelong condition that begins in childhood and continues with adult manifestations related to the core symptoms. Approximately 50% to 75% of children with ADHD continue to meet criteria for the disorder as adolescents and adults. Adults with the disorder increasingly present to primary care physicians, psychiatrists, and other practitioners for diagnosis and treatment. Understanding the diagnosis of ADHD in adults requires knowledge of age-dependent decline of symptoms over time. Retrospective recall of symptoms and impairment are valid methods of diagnosing the disorder. ADHD is also a brain disorder with a strong neurobiologic basis, complex etiology, and genetic component. Genetic and environmental vulnerabilities give rise to abnormalities in the brain and subsequent behavioral and cognitive deficits, which may produce the symptoms associated with ADHD. Magnetic resonance imaging studies of ADHD have provided evidence that abnormalities in the brain are caused by the disorder itself rather than treatment of the disorder. Psychiatric comorbidity is common among patients with ADHD and tends to complicate treatment. Acute and long-term use of long-acting stimulant formulations (methylphenidate and amphetamine compounds) have shown robust efficacy and tolerability consistent with the treatment response established in children with ADHD. Non-stimulant medications have demonstrated efficacy as well, and may be preferred in patients with tic and substance use disorders.

In this expert roundtable supplement, Timothy E. Wilens, MD, reviews the epidemiology and clinical presentation of adult ADHD. Next, Joseph Biederman, MD, provides an overview of recent advances in the neurobiology of ADHD. Thomas J. Spencer, MD, reviews stimulant treatment of adult ADHD, and Lenard A. Adler concludes with a discussion of non-stimulant trials in adult ADHD.

Adderall abuse in Texas, 1998-2004

Adderall is used in the treatment of attention deficit hyperactivity disorder (ADHD) in children and is subject to abuse. This study describes the patterns of Adderall abuse calls received by several poison control centers in Texas during 1998-2004. Drug abuse calls were assessed by call year and geographic location. Drug abuse calls were then compared to all other human exposure (nonabuse) calls with respect to various factors. Of all Adderall exposure calls, 12% involved abuse. The number of drug abuse calls received per year increased during the first part of 7-yr period but then declined. Male patients accounted for almost 60% of both drug abuse and nonabuse calls. Adolescent patients comprised 69% of drug abuse calls and children less than 13 yr old comprised 66% of nonabuse calls. Although the majority of both types of human exposures occurred at the patient's own residence, drug abuse calls were more likely than nonabuse calls to involve exposures at another residence (6% vs. 3%), school (22% vs. 5%) and public areas (2% vs. 0.4%). Drug abuse calls were less likely than nonabuse calls to be managed outside of a health care facility (18% vs. 51%) and to be classified as no adverse effect (23% vs. 48%). Adderall abusers are more likely to be adolescents. Adderall abuse as compared to other exposures is more likely to occur outside of the person's home and involve more serious medical outcomes.

Enhanced head-twitch response to 5-HT-related agonists in thiamine-deficient mice

While many studies suggest an involvement of brain serotonergic systems in neuro-psychiatric disorders such as schizophrenia and depression, their role in Wernicke-Korsakoff syndrome (WKS) remains unclear. Since dietary thiamine deficiency (TD) in mice is considered as a putative model of WKS, it was used in the present study to investigate the function of serotonergic neurons in this disorder. After 20 days of TD feeding, the intensity of tryptophan hydroxylase immunofluorescence was found to be significantly decreased in the dorsal and medial raphe nuclei. In addition, the head-twitch response (HTR) elicited by the intracerebroventricular administration of the 5-HT(2A) agonist 2,5-dimethoxy-4-iodoamphetamine hydrochloride (DOI) was significantly increased in TD versus control mice, whereas the injection of ketanserin, a 5-HT(2A) receptor antagonist, prevented this enhancement. A single injection of thiamine HCl on the 19th day of TD feeding did not reduce the enhanced DOI-induced HTR. On the other hand, the administration of d-fenfluramine, a 5-HT releaser, did not enhance the HTR in TD mice. Together, our results indicate that TD causes a super-sensitivity of 5-HT(2A) receptors by reducing presynaptic 5-HT synthesis derived from degenerating neurons projecting from the raphe nucleus.

Benzylpiperizine-based party pills' impact on the Auckland City Hospital Emergency Department Overdose Database (2002-2004) compared with ecstasy (MDMA or methylene dioxymethamphetamine), gamma hydroxybutyrate (GHB), amphetamines, cocaine, and alcohol

AIM

To examine the impact of 'party pills' (PP; herbal highs) on the Auckland City Hospital Emergency Department Overdose Database 2002-2004, and to present figures for five other substances in that database.

METHOD

Auckland City Hospital's Emergency Department's overdose database was reviewed for 2002, 2003, and 2004 for 'herbal ingestions' and 'party pills' (PP), ecstasy, methamphetamine, GHB, cocaine, and alcohol. Adverse effects attributed to PP were examined.

RESULTS

In 2002, 1 patient presented with PP ingestion; 4 presented in 2003 and 21 in 2004 respectively (p<0.001). Of these 21 patients in 2004, 5 had allegedly ingested PP only and none required medical admission. PP only contributed to 1.58% of the overdose database for 2004.

CONCLUSION

'Party pills' appeared to have a minor impact on the overdose database at Auckland City Hospital between 2002 and 2004. There was a significant decrease in GHB presentations from 2003 to 2004 (p<0.001), but no significant fall in stimulant overdose presentations.

Adverse drug reactions during heatwaves

Patients receiving the following drugs should be closely monitored during heatwaves: psychotropics, atropinics, amphetamine-like drugs, parasympathomimetic agents such as cholinesterase inhibitors, thyroid hormones, drugs that increase the risk of renal failure in case of dehydration, and betablockers.

Smokable ("ice", "crystal meth") and non smokable amphetamine-type stimulants: clinical pharmacological and epidemiological issues, with special reference to the UK

"Ice", "crystal meth", is the smokable form of methamphetamine hydrochloride. This paper will comment on the pharmacological, epidemiological, clinical and social issues related to smoking the drug as opposed to either its injection or ingestion. Furthermore, some data related to amphetamines/methamphetamines consumption, request for treatment, seizures, related offences and deaths in the UK (1990-2002) will be offered here. Peak rates, for most indicators, were reached at the end of the '90s, to fall down in the following years. The only indicator which seemed not to show any declining rates is number of deaths, but this may be related to a more general increase in stimulant death rates recently observed in the UK. It is argued that methamphetamines, and particularly "crystal meth", could reach the same prevalence levels of use in the UK as it is already in the US but recent reclassification of the drug to Class A in the UK could help to better control this emerging issue.

The 5-HT1A Receptor Full Agonist, 8-OH-DPAT Inhibits ACTH-Induced 5-HT2A Receptor Hyperfunction in Rats: Involvement of 5-HT1A Receptors in the DOI-Induced Wet-Dog Shakes in ACTH-Treated Rats

We examined the influence of 8-hydroxy-2-di-n-propylamino tetralin (8-OH-DPAT), a serotonin 1A (5-HT1A) receptor full agonist, on the wet-dog shake response induced by the (+/-)-1-(2,5-dimethoxy-4-iodophenyl)-2-aminopropane (DOI), a 5-HT2A receptor agonist, in adrenocorticotropic hormone (ACTH)-treated rats. Chronic ACTH (100 microg/rat, s.c.) treatment for 14 d increased the wet-dog shake response induced DOI. The 8-OH-DPAT inhibited the wet-dog shake response induced by DOI in rats with ACTH for 14 d. On the other hand, the 8-OH-DPAT-induced hypothermia and flat body posture were inhibited when ACTH was administered for 14 d. These findings suggest that chronic treatment with ACTH decreased the sensitivity of the 5-HT1A receptor system; however, the inhibitory effects from the 5-HT1A receptors to the 5-HT2A receptor system is not inhibited in ACTH-treated rats.

Amphetamine lacing of an Internet-marketed neutraceutical

A 25-year-old woman presented with abdominal pain after taking an imported herbal weight-loss product. A urinary toxicology screen was positive for amphetamine, which the patient denied taking. On further investigation, the neutraceutical was found to contain an amphetamine derivative banned by the US Food and Drug Administration (FDA). Although the patient had discontinued use of the supplement before hospitalization and her symptoms steadily improved with appropriate treatment, a report was made to the FDA. Similar reports from cities across the United States prompted the FDA to confiscate shipments of the product before it could be distributed further nationally while they investigate claims against the product.