Smoking and chronic obstructive pulmonary disease (COPD). Parallel epidemics of the 21 century

One hundred million deaths were caused by tobacco in the 20(th) century, and it is estimated that there will be up to one billion deaths attributed to tobacco use in the 21(st) century. Chronic obstructive pulmonary disease (COPD) is rapidly becoming a global public health crisis with smoking being recognized as its most important causative factor. The most effective available treatment for COPD is smoking cessation. There is mounting evidence that the rate of progression of COPD can be reduced when patients at risk of developing the disease stop smoking, while lifelong smokers have a 50% probability of developing COPD during their lifetime. More significantly, there is also evidence that the risk of developing COPD falls by about half with smoking cessation. Several pharmacological interventions now exist to aid smokers in cessation; these include nicotine replacement therapy, bupropion, and varenicline. All pharmacotherapies for smoking cessation are more efficacious than placebo, with odds ratios of about 2. Pharmacologic therapy should be combined with nonpharmacologic (behavioral) therapy. Unfortunately, despite the documented efficacy of these agents, the absolute number of patients who are abstinent from smoking at 12 months of follow-up is low.

The politics and bio-ethics of regulatory trust: case-studies of pharmaceuticals

Drawing on case studies from the modern era of pharmaceutical regulation in the UK, US and Europe, I examine how the extent and distribution of trust between regulators, the pharmaceutical industry, and the medical profession about drug testing and monitoring influences knowledge and regulatory judgements about the efficacy and safety of prescription drugs. Introducing the concepts of 'acquiescent' and 'investigative' norms of regulatory trust, I demonstrate how investigative norms of regulatory trust-which deter pharmaceutical companies from assuming that their data analyses will be accepted without independent de-construction-drive up bioethical and regulatory standards of drug assessment in the interests of health. By contrast, acquiescent norms of regulatory trust, which are associated with industrial capture and professional closure of interests, promote permissive standards allowing patients to take pharmaceuticals with greater risks to health and less evidence of therapeutic efficacy.

Heterogeneity in preferences for smoking cessation

Promoting cessation is a cornerstone of tobacco control efforts by public-health agencies. Economic information to support cessation programs has generally emphasized cost-effectiveness or the impact of cigarette pricing and smoking restrictions on quit rates. In contrast, this study provides empirical estimates of smoker preferences for increased efficacy and other attributes of smoking cessation therapies (SCTs). Choice data were collected through a national survey of Canadian smokers. We find systematic preference heterogeneity for therapy types and SCT attributes between light and heavy smokers, as well as random heterogeneity using random parameters logit models. Preference heterogeneity is greatest between length of use and types of SCTs. We estimate that light smokers would be willing to pay nearly $500 ($CAN) to increase success rates to 40% with the comparable figure for heavy smokers being near $300 ($CAN). Results from this study can be used to inform research and development for smoking cessation products and programs and suggest important areas of future inquiry regarding heterogeneity of smoker preferences and preferences for other health programs.

Illicit use of prescription ADHD medications on a college campus: a multimethodological approach

OBJECTIVE

The authors used quantitative and qualitative methodologies to investigate college students' perceptions and use of illegal Attention Deficit Hyperactivity Disorder (ADHD) stimulants during spring and summer 2006.

PARTICIPANTS

From fall 2005 through fall 2006, the authors studied 1,811 undergraduates at a large, public, southeastern research university in the United States.

METHODS

The authors administered surveys to these students and conducted 175 in-depth interviews.

RESULTS

Of the study participants, 34% reported the illegal use of ADHD stimulants. Most illegal users reported using ADHD stimulants primarily in periods of high academic stress and found them to reduce fatigue while increasing reading comprehension, interest, cognition, and memory. Furthermore, most had little information about the drug and found procurement to be both easy and stigmafree.

CONCLUSIONS

This study supplies a rich understanding of the growing national trend of illegal ADHD stimulant use. The authors discuss strategies for stemming the tide of ADHD stimulant use.

Bupropion for the treatment of methamphetamine dependence

Bupropion was tested for efficacy in increasing weeks of abstinence in methamphetamine-dependent patients, compared to placebo. This was a double-blind placebo-controlled study, with 12 weeks of treatment and a 30-day follow-up. Five outpatient substance abuse treatment clinics located west of the Mississippi participated in the study. One hundred and fifty-one treatment-seekers with DSM-IV diagnosis of methamphetamine dependence were consented and enrolled. Seventy-two participants were randomized to placebo and 79 to sustained-release bupropion 150 mg twice daily. Patients were asked to come to the clinic three times per week for assessments, urine drug screens, and 90-min group psychotherapy. The primary outcome was the change in proportion of participants having a methamphetamine-free week. Secondary outcomes included: urine for quantitative methamphetamine, self-report of methamphetamine use, subgroup analyses of balancing factors and comorbid conditions, addiction severity, craving, risk behaviors for HIV, and use of other substances. The generalized estimating equation regression analysis showed that, overall, the difference between bupropion and placebo groups in the probability of a non-use week over the 12-week treatment period was not statistically significant (p=0.09). Mixed model regression was used to allow adjustment for baseline factors in addition to those measured (site, gender, level of baseline use, and level of symptoms of depression). This subgroup analysis showed that bupropion had a significant effect compared to placebo, among male patients who had a lower level of methamphetamine use at baseline (p<0.0001). Comorbid depression and attention-deficit/hyperactivity disorder did not change the outcome. These data suggest that bupropion, in combination with behavioral group therapy, was effective for increasing the number of weeks of abstinence in participants with low-to-moderate methamphetamine dependence, mainly male patients, regardless of their comorbid condition.

A preliminary investigation of naltrexone augmentation of bupropion to stop smoking with less weight gain

Certain barriers prevent some cigarette smokers from attempting to quit, particularly the fear of post-cessation weight gain. This investigation was an open label study of naltrexone hydrochloride (25 mg/day) in combination with sustained-release (SR) bupropion hydrochloride (300 mg/day) for smoking cessation and minimization of post-quit weight gain in weight-concerned smokers. The study sample (n=20) was compared to matched controls (n=20) who received an identical psychosocial intervention and bupropion SR treatment regimen. The primary outcomes analyzed were: (a) biochemically verified continuous abstinence from smoking over the 6-week treatment, (b) point prevalence abstinence in the last 7 days of treatment, and (c) weight gain from baseline. Neither adherence to the combination pharmacotherapy nor the percentage of patients reporting adverse events differed significantly between the two groups nor were there differences in either continuous or point prevalence abstinence from smoking. Although not statistically significant in this small sample, continuously abstinent participants in the naltrexone+bupropion group gained less weight (mean=1.67 lb) than those in the bupropion only group (mean=3.17 lb; p=.35; Cohen's d=0.56). The results of this preliminary study suggest that combining naltrexone and bupropion may help minimize post-cessation weight gain, but does not result in higher smoking cessation rates compared to bupropion alone. The effect size for the difference in weight gain among continuously abstinent participants was in the moderate range, suggesting that this treatment deserves further study in an appropriately powered clinical trial as an adjunct for weight-concerned smokers, who may value the weight-suppressant effect of naltrexone.

The effects of the dopamine and serotonin transporter polymorphisms on clinical features and treatment response in geriatric depression: a pilot study

BACKGROUND

The authors examined the role of dopamine and serotonin transporter genetic polymorphisms in clinical and cognitive features of subjects with late-life depression, and in preferential treatment response to the combination of methylphenidate and citalopram.

METHOD

The authors studied fifteen outpatients with major depression in a pilot ten-week double-blind trial of methylphenidate combined with citalopram and compared to citalopram and placebo. Response was defined as a score on the Hamilton Depression Rating Scale (24-item) of less than 10. All underwent genotyping to determine the dopamine (DAT VNTR) and serotonin (5HTTLPR) transporter polymorphisms.

RESULTS

Subjects with DAT VNTR 10/10 genotype had greater cognitive executive dysfunction at baseline compared to others. However, they responded preferentially to methylphenidate added to citalopram with a greater reduction in depression severity over time compared to other subjects.

CONCLUSIONS

DAT VNTR 10/10 genotype may be associated with an endophenotype of late-life depression with executive dysfunction that responds preferentially to methylphenidate added to a selective serotonin reuptake inhibitor, which warrants replication in a large sample.

[Medication-induced mandibular luxation in a seven-year-old patient]

A seven-year-old boy presented with a right-side mandibular luxation resulting from an acute unilateral dystonia of the masticatory muscles. Repositioning took place under a general anaesthetic. The luxation recurred the same day. Once again the jaw was repositioned under a general anaesthetic. In view of the rarity of jaw dislocation in someone so young it was assumed that it could have been caused by a dystonia possibly resulting from the patient's medication. The patient was known to have Attention Deficit Hyperactivity Disorder (ADHD). To treat the condition, the patient's psychiatrist had prescribed 1 mg risperidone daily for one year and 10 mg methylphenidate daily for two years. Following the discussion with the psychiatrist, the patient was taken off both of these drugs and instead was prescribed oxazepam. So far the luxation has not recurred.

Treatment of tobacco dependence: integrating recent progress into practice

Tobacco use is one of the leading preventable causes of death in developed countries. Adoption of approaches that have demonstrated efficacy to improve the treatment of tobacco dependence are critical to reduce the health consequences of tobacco use. We summarize the latest epidemiologic data on tobacco use, the mechanisms that underlie tobacco dependence, and advances in pharmacotherapy and nonpharmacologic interventions available for the treatment of tobacco dependence. Specifically, we discuss the use of nicotine replacement therapy, bupropion and varenicline in primary care settings.

Anticholinergic drugs versus other medications for overactive bladder syndrome in adults

BACKGROUND

Overactive bladder syndrome is defined as "urgency with or without urge incontinence, usually with frequency and nocturia". It is a common condition with significant economic and quality of life implications. While the condition's pathophysiology remains to be fully elucidated, pharmacotherapy is the main treatment option. Despite uncertainty as to drug treatment of choice, anticholinergics are increasingly being used in primary and secondary care settings. This review compares anticholinergic drugs with other types or classes of drugs for treating overactive bladder syndromes.

OBJECTIVES

To compare anticholinergic drugs with other types or classes of drugs for treating overactive bladder symptoms.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 20 December 2006) and the reference lists of relevant articles. No language or other limits were imposed.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials comparing anticholinergic drugs with other drugs for the treatment of overactive bladder symptoms. At least one arm of the study used an anticholinergic drug and at least one other arm used a non-anticholinergic drug.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed the identified studies for eligibility and methodological quality and independently extracted data from the included studies. Data analysis was performed using RevMan software (version 4.2.8).

MAIN RESULTS

Twelve trials were included in the review. There were seven crossover trials and five parallel group studies. For the comparisons between anticholinergic drugs with tricyclic antidepressants, alpha adrenergic agonists, afferent nerve inhibitors, and calcium channel blocker a single trial was identified for each. Nine trials compared flavoxate with anticholinergics. There was no evidence of a difference in cure rates between anticholinergics and flavoxate. Adverse effects were more frequent in anticholinergic groups versus flavoxate groups (RR 2.28 95% CI 1.45 to 3.56). There was no strong evidence to favour either anticholinergic drugs or the comparators.

AUTHORS' CONCLUSIONS

Many of the drugs considered in trials in this review are no longer used in clinical practice (and this includes the most commonly tested - flavoxate). There is inadequate evidence as to determine whether any of the available drugs are better or worse than anticholinergic medications. Larger randomised controlled trials in clinical settings are required to further establish the role of these medications in the management of overactive bladder syndrome.

Hyperactivité et prescription de Ritaline® dans le canton de Vaud (Suisse), 2002

BACKGROUND

The estimated prevalence of Attention Deficit Hyperactivity Disorder (ADHD) reported in European countries is 2 to 5% of school age children. Political concern has been expressed in Switzerland about possible over treatment with methylphenidate. The purpose of this research, commissioned by the regional public health authority, was to assess the prescription of methylphenidate (Ritalin) for children as a treatment of ADHD.

METHODS

The regional health authority collected all prescriptions of Ritalin delivered in pharmacies during 2002. Data available from prescriptions and analyzed were: age, sex and place of residence of the patient, dosage prescribed, date of prescription, place of practice and medical specialization of doctors. Only patients living in the canton of Vaud and aged less than 20 years were included in the analysis.

RESULTS

Six hundred and ninety-seven patients, aged less than 20 years, received Ritalin in 2002. The mean age was 12.1 years (median: 12 years; range: 3-19), 15% were female. These patients represented 0.74% of the 5-14 years old population living in the canton of Vaud. Eighty percent of patients had a prescription from a specialist (pediatrician or psychiatrist) during the year.

CONCLUSIONS

Less than 1% of the young population receives methylphenidate in the canton of Vaud. Dosage complies with the recommendations of the Swiss Medic Compendium. The large majority of patients receive prescriptions for methylphenidate from specialists. A new study based on the 2005 data will be conducted to follow changes in the prescription of Ritalin.

An Epidemic that Deserves More Attention: Epidemiology, Prevention, and Treatment of Smokeless Tobacco

Smokeless tobacco (ST) use is common, especially in southern and rural areas. It is expected to become more popular with the recent move to sell more ST in areas where indoor smoking is banned. ST use usually starts in adolescence, which places this group at high risk. Nicotine dependence occurs almost exclusively in people who start using ST in their adolescent years, so it is crucial to prevent the introduction of ST to this age group. The debate over whether ST is a gateway to smoking or a bridge to quitting has not been fully answered. ST should not replace smoking where indoor smoking is banned. ST is less harmful than smoking, but nicotine replacement therapy (NRT) is much safer than ST. NRT and bupropion are helpful in the treatment of ST dependence by decreasing withdrawal symptoms and preventing weight gain after cessation.

Chronic bupropion attenuated the anhedonic component of nicotine withdrawal in rats via inhibition of dopamine reuptake in the nucleus accumbens shell

Bupropion, a dopamine reuptake inhibitor, is an effective therapy for smoking cessation, but the behavioral and neurochemical mechanisms mediating its antismoking properties are relatively unknown. To explore the hypothesis that bupropion ameliorates nicotine withdrawal partly by a dopamine-dependent mechanism, we investigated the effects of chronic bupropion on potassium-stimulated dopamine overflow in the nucleus accumbens shell in nicotine-withdrawing rats. We also assessed the effects of chronic bupropion on behavioral aspects of nicotine withdrawal measured by elevations in brain reward thresholds and somatic signs of withdrawal. Rats were treated with nicotine or saline for 7 days and then coadministration of bupropion or saline was initiated. After 14 days of coadministration of bupropion/saline and nicotine/saline, nicotine/saline administration was terminated, whereas bupropion/saline administration continued. These conditions mimic bupropion administration in human smokers. Cessation of nicotine administration in non-bupropion-treated rats elevated reward thresholds reflecting a reward deficit, increased somatic signs and diminished potassium-evoked dopamine overflow in the nucleus accumbens shell. Chronic bupropion lowered reward thresholds and increased potassium-evoked dopamine release regardless of previous nicotine exposure, possibly by inhibition of dopamine reuptake, and thus attenuated the anhedonic and neurochemical effects of nicotine withdrawal. Chronic bupropion blocked withdrawal-associated increased somatic signs. Finally, acute experimenter-administered nicotine enhanced brain reward function equally in all groups, indicating that bupropion does not alter the reward-facilitating effects of experimenter-administered nicotine. In conclusion, the bupropion-induced increase in extracellular dopamine in the nucleus accumbens shell may ameliorate the anhedonia associated with nicotine withdrawal, which in turn may facilitate smoking cessation.

No improvement by amphetamine on learned non-use, attempts, success or movement in skilled reaching by the rat after motor cortex stroke

Amphetamine (AMPH) has been proposed as a treatment for post-stroke motor deficits when coupled with symptom-relevant physical rehabilitation. Whereas a number of experimental studies report improvements in endpoint measures of skilled reaching for food by rats, there has been no assessment of whether beneficial effects extend to overcoming learned non-use of the limb in the acute post-stroke period or to the qualitative deficits in movement in the chronic post-stroke period. In addition to evaluating the effects of AMPH on success, these were the objectives of the present study. In three different reaching experiments, groups of rats were pre-trained in skilled reaching for food prior to receiving a motor cortex stroke via pial removal. Postoperatively the rats received periodic AMPH treatment and daily rehabilitation. In the acute post-stroke period, AMPH failed to prevent the development of learned non-use of the limb, and in the acute and chronic period failed to improve recovery of reaching success, and also failed to improve the qualitative aspects of reaching movements. Nevertheless, AMPH did enhance adjunct non-reaching movements of locomotion, rearing and turning. The results are discussed in relation to the idea that the beneficial effects of post-stroke AMPH treatment do not extend to all movements, especially the movements of a forelimb in retrieving and consuming food.

Optimizing on smoke free legislation making the most of the opportunity

Stop smoking service provision faces significant challenges in optimizing the opportunities raised through the smoke free legislation, which prohibits smoking in a public place. There are a number of innovations in service provision allowing a more tailored and flexible approach to stopping smoking, where the patient requirements are central. Innovations such as cut down then stop (CDTS), combination nicotine replacement therapy (NRT) use, and new drug therapy Champix all provide increased options for the smoker.