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Harbaugh CM, Lee JS, Chua KP, Kenney B, Iwashyna TJ, Englesbe MJ, Brummett CM, Bohnert AS, Waljee JF. Association Between Long-term Opioid Use in Family Members and Persistent Opioid Use After Surgery Among Adolescents and Young Adults. JAMA Surg 2019; 154:e185838. [PMID: 30810738 DOI: 10.1001/jamasurg.2018.5838] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Prior studies have found a substantial risk of persistent opioid use among adolescents and young adults undergoing surgical and dental procedures. It is unknown whether family-level factors, such as long-term opioid use in family members, is associated with persistent opioid use. Objective To determine whether long-term opioid use in family members is associated with persistent opioid use among opioid-naive adolescents and young adults undergoing surgical and dental procedures. Design, Setting, and Participants This retrospective cohort study used data from a commercial insurance claims database for January 1, 2010, to June 30, 2016, to study 346 251 opioid-naive patients aged 13 to 21 years who underwent 1 of 11 surgical and dental procedures and who were dependents on a family insurance plan. Exposures Long-term opioid use in family members, defined as having 1 or more family members who (1) filled opioid prescriptions totaling a 120 days' supply or more during the 12 months before the procedure date or (2) filled 3 or more opioid prescriptions in the 90 days before the procedure date. Main Outcomes and Measures The main outcome measure was persistent opioid use, defined as 1 or more postoperative prescription opioid fills between 91 and 180 days among patients with an initial opioid prescription fill. Generalized estimating equations with robust SEs clustered at the family level were used to model persistent opioid use as a function of long-term opioid use among family members, controlling for procedure, total morphine milligram equivalents of the initial fill, and patient and family characteristics. Results A total of 346 251 patients (mean [SD] age, 17.0 [2.3] years; 175 541 [50.7%] female) were studied. Among these patients, 257 085 (74.3%) had an initial opioid fill. Among patients with an initial opioid fill, 11 016 (4.3%) had long-term opioid use in a family member. Persistent opioid use occurred in 453 patients (4.1%) with long-term opioid use in a family member compared with 5940 patients (2.4%) without long-term opioid use in a family member (adjusted odds ratio, 1.54; 95% CI, 1.39-1.71). Conclusion and Relevance The findings suggest that long-term opioid use among family members is associated with persistent opioid use among opioid-naive adolescents and young adults undergoing surgical and dental procedures. Physicians should screen young patients for long-term opioid use in their families and implement heightened efforts to prevent opioid dependence among patients with this important risk factor.
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Affiliation(s)
- Calista M Harbaugh
- National Clinician Scholars Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.,Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Jay S Lee
- Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Kao-Ping Chua
- Department of Pediatrics and Communicable Diseases, Child Health Evaluation and Research Center, University of Michigan, Ann Arbor
| | - Brooke Kenney
- Michigan Opioid Prescribing Engagement Network, Ann Arbor
| | - Theodore John Iwashyna
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.,Veterans Affairs (VA) Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan
| | | | - Chad M Brummett
- Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Amy S Bohnert
- Veterans Affairs (VA) Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Jennifer F Waljee
- Department of Surgery, University of Michigan Medical School, Ann Arbor
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Bao W, Volgin AD, Alpyshov ET, Friend AJ, Strekalova TV, de Abreu MS, Collins C, Amstislavskaya TG, Demin KA, Kalueff AV. Opioid Neurobiology, Neurogenetics and Neuropharmacology in Zebrafish. Neuroscience 2019; 404:218-232. [PMID: 30710667 DOI: 10.1016/j.neuroscience.2019.01.045] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 01/22/2019] [Accepted: 01/23/2019] [Indexed: 01/28/2023]
Abstract
Despite the high prevalence of medicinal use and abuse of opioids, their neurobiology and mechanisms of action are not fully understood. Experimental (animal) models are critical for improving our understanding of opioid effects in vivo. As zebrafish (Danio rerio) are increasingly utilized as a powerful model organism in neuroscience research, mounting evidence suggests these fish as a useful tool to study opioid neurobiology. Here, we discuss the zebrafish opioid system with specific focus on opioid gene expression, existing genetic models, as well as its pharmacological and developmental regulation. As many human brain diseases involve pain and aberrant reward, we also summarize zebrafish models relevant to opioid regulation of pain and addiction, including evidence of functional interplay between the opioid system and central dopaminergic and other neurotransmitter mechanisms. Additionally, we critically evaluate the limitations of zebrafish models for translational opioid research and emphasize their developing utility for improving our understanding of evolutionarily conserved mechanisms of pain-related, addictive, affective and other behaviors, as well as for fostering opioid-related drug discovery.
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Affiliation(s)
- Wandong Bao
- School of Pharmacy and School of Life Sciences, Southwest University, Chongqing, China
| | - Andrey D Volgin
- Military Medical Academy, St. Petersburg, Russia; Institute of Experimental Medicine, Almazov National Medical Research Centre, Ministry of Healthcare of Russian Federation, St. Petersburg, Russia; Institute of Translational Biomedicine, St. Petersburg State University, St. Petersburg, Russia; Scientific Research Institute of Physiology and Basic Medicine, Novosibirsk, Russia
| | - Erik T Alpyshov
- School of Pharmacy and School of Life Sciences, Southwest University, Chongqing, China
| | - Ashton J Friend
- Tulane University School of Science and Engineering, New Orleans, LA, USA; The International Zebrafish Neuroscience Research Consortium, New Orleans, LA, USA
| | - Tatyana V Strekalova
- Sechenov First Moscow State Medical University, Institute of Molecular Medicine, Laboratory of Psychiatric Neurobiology and Department of Normal Physiology, Moscow, Russia; Department of Neuroscience, Maastricht University, Maastricht, Netherlands; Institute of General Pathology and Pathophysiology, Moscow, Russia
| | - Murilo S de Abreu
- The International Zebrafish Neuroscience Research Consortium, New Orleans, LA, USA; Bioscience Institute, University of Passo Fundo (UPF), Passo Fundo, RS, Brazil
| | - Christopher Collins
- ZENEREI Research Center, Slidell, LA, USA; The International Zebrafish Neuroscience Research Consortium, New Orleans, LA, USA
| | - Tamara G Amstislavskaya
- Scientific Research Institute of Physiology and Basic Medicine, Novosibirsk, Russia; The International Zebrafish Neuroscience Research Consortium, New Orleans, LA, USA
| | - Konstantin A Demin
- Institute of Experimental Medicine, Almazov National Medical Research Centre, Ministry of Healthcare of Russian Federation, St. Petersburg, Russia; Institute of Translational Biomedicine, St. Petersburg State University, St. Petersburg, Russia
| | - Allan V Kalueff
- School of Pharmacy and School of Life Sciences, Southwest University, Chongqing, China; Institute of Experimental Medicine, Almazov National Medical Research Centre, Ministry of Healthcare of Russian Federation, St. Petersburg, Russia; Institute of Translational Biomedicine, St. Petersburg State University, St. Petersburg, Russia; Ural Federal University, Ekaterinburg, Russia; Granov Russian Research Center of Radiology and Surgical Technologies, Ministry of Healthcare of Russian Federation, Pesochny, Russia; Scientific Research Institute of Physiology and Basic Medicine, Novosibirsk, Russia; ZENEREI Research Center, Slidell, LA, USA; The International Zebrafish Neuroscience Research Consortium, New Orleans, LA, USA.
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Salazar L, Findlay L. Implementation and Evaluation of an Opioid Risk Questionnaire in the Outpatient Plastic Surgery Setting. Plast Surg Nurs 2019; 39:136-141. [PMID: 31790042 DOI: 10.1097/psn.0000000000000278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Most patients undergoing plastic and cosmetic surgery are prescribed an opioid for postoperative pain control. With the advent of the opioid epidemic in our country, screening for opioid risk has become a topic of many health care discussions. However, there has been little mention of using an opioid risk questionnaire specific to the outpatient plastic surgery setting. This project consisted of distribution of an opioid risk questionnaire to adult patients undergoing outpatient plastic surgery. Data were collected at preoperative appointments from participating patients (n = 27). Although the sample size was small, two patients (7%) were identified as having a history of substance abuse, and both of those patients reported they had also received treatment for their substance abuse. In addition, six patients (22%) reported having a family history of substance abuse. Such findings suggest that clinicians working in outpatient plastic surgery should screen their patients for substance abuse and misuse.
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Affiliation(s)
- Leah Salazar
- Leah Salazar, DNP, APRN-BC, RN, is a board-certified family nurse practitioner working in outpatient plastic and cosmetic surgery in Reno, Nevada. Lillian Findlay, PhD, APRN, is a board-certified nurse practitioner and clinical nurse specialist in psychiatric mental health and a faculty member of the University of Alabama, Tuscaloosa
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Park J, Sung JY, Kim DK, Kong ID, Hughes TL, Kim N. Genetic association of human Corticotropin-Releasing Hormone Receptor 1 (CRHR1) with Internet gaming addiction in Korean male adolescents. BMC Psychiatry 2018; 18:396. [PMID: 30572854 PMCID: PMC6302290 DOI: 10.1186/s12888-018-1974-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 12/05/2018] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The number of people with Internet gaming addiction (IGA) is increasing around the world. IGA is known to be associated with personal characteristics, psychosocial factors, and physiological factors. However, few studies have examined the genetic factors related to IGA. This study aimed to investigate the association between IGA and stress-related genetic variants. METHODS This cross-sectional study was conducted with 230 male high school students in a South Korean city. We selected five stress-related candidate genes: DAT1, DRD4, NET8, CHRNA4, and CRHR1. The DAT1 and DRD4 genes were genotyped by polymerase chain reaction, and the NET8, CHRNA4, and CRHR1 genes were genotyped by pyrosequencing analysis. We performed a Chi-square test to examine the relationship of these five candidate genes to IGA. RESULTS Having the AA genotype and the A allele of the CRHR1 gene (rs28364027) was associated with higher odds of belonging to the IGA participant group (p = .016 and p = .021, respectively) than to the non-IGA group. By contrast, the DAT1, DRD4, NET8, and CHRNA4 gene polymorphisms showed no significant difference between the IGA group and control group. CONCLUSIONS These results indicate that polymorphism of the CRHR1 gene may play an important role in IGA susceptibility in the Korean adolescent male population. These findings provide a justification and foundation for further investigation of genetic factors related to IGA.
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Affiliation(s)
- Jooyeon Park
- College of Nursing, Keimyung University, Daegu, Republic of Korea
| | - Jin-Young Sung
- Department of Medical Genetics, School of Medicine, Keimyung University, Daegu, Republic of Korea
| | - Dae-Kwang Kim
- Department of Medical Genetics, School of Medicine, Keimyung University, Daegu, Republic of Korea
| | - In Deok Kong
- Department of Physiology, Wonju College of Medicine, Yonsei University, Wonju, Republic of Korea
| | - Tonda L Hughes
- School of Nursing and Department of Psychiatry, Columbia University, New York City, USA
| | - Nahyun Kim
- College of Nursing, Keimyung University, Daegu, Republic of Korea.
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Cheng Z, Zhou H, Sherva R, Farrer LA, Kranzler HR, Gelernter J. Genome-wide Association Study Identifies a Regulatory Variant of RGMA Associated With Opioid Dependence in European Americans. Biol Psychiatry 2018; 84:762-770. [PMID: 29478698 PMCID: PMC6041180 DOI: 10.1016/j.biopsych.2017.12.016] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 12/22/2017] [Accepted: 12/30/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Opioid dependence (OD) is at epidemic levels in the United States. Genetic studies can provide insight into its biology. METHODS We completed an OD genome-wide association study in 3058 opioid-exposed European Americans, 1290 of whom met criteria for a DSM-IV diagnosis of OD. Analysis used DSM-IV criterion count. RESULTS By meta-analysis of four cohorts, Yale-Penn 1 (n = 1388), Yale-Penn 2 (n = 996), Yale-Penn 3 (n = 98), and SAGE (Study of Addiction: Genetics and Environment) (n = 576), we identified a variant on chromosome 15, rs12442183, near RGMA, associated with OD (p = 1.3 × 10-8). The association was also genome-wide significant in Yale-Penn 1 taken individually and nominally significant in two of the other three samples. The finding was further supported in a meta-analysis of all available opioid-exposed African Americans (n = 2014 [1106 meeting DSM-IV OD criteria]; p = 3.0 × 10-3) from three cohorts; there was nominal significance in two of these samples. Thus, of seven subsamples examined in two populations, one was genome-wide significant, and four of six were nominally (or nearly) significant. RGMA encodes repulsive guidance molecule A, which is a central nervous system axon guidance protein. Risk allele rs12442183*T was correlated with higher expression of a specific RGMA transcript variant in frontal cortex (p = 2 × 10-3). After chronic morphine injection, the homologous mouse gene (Rgma) was upregulated in C57BL/6J striatum. Coexpression analysis of 1301 brain samples revealed that RGMA messenger RNA expression was associated with that of four genes implicated in other psychiatric disorders, including GRIN1. CONCLUSIONS This is the first study to demonstrate an association of RGMA with OD. It provides a new lead into our understanding of OD pathophysiology.
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Affiliation(s)
- Zhongshan Cheng
- Division of Human Genetics, Department of Psychiatry, Yale University School of Medicine, New Haven, Massachusetts; VA Connecticut Healthcare Center, West Haven, Massachusetts
| | - Hang Zhou
- Division of Human Genetics, Department of Psychiatry, Yale University School of Medicine, New Haven, Massachusetts; VA Connecticut Healthcare Center, West Haven, Massachusetts
| | - Richard Sherva
- Departments of Neurology, Ophthalmology, Genetics & Genomics, Epidemiology, and Biostatistics, Boston University School of Medicine and School Public Health, Boston, Massachusetts
| | - Lindsay A Farrer
- Departments of Neurology, Ophthalmology, Genetics & Genomics, Epidemiology, and Biostatistics, Boston University School of Medicine and School Public Health, Boston, Massachusetts
| | - Henry R Kranzler
- Center for Studies of Addiction, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Joel Gelernter
- Division of Human Genetics, Department of Psychiatry, Yale University School of Medicine, New Haven, Massachusetts; Departments of Genetics and Neuroscience, Yale University School of Medicine, New Haven, Massachusetts; VA Connecticut Healthcare Center, West Haven, Massachusetts.
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Henry M, Alias A, Frenkiel S, Richardson K, Hier M, Zeitouni A, Kost K, Mlynarek A, Black M, MacDonald C, Chartier G, Rosberger Z. Contribution of psychiatric diagnoses to extent of opioid prescription in the first year post-head and neck cancer diagnosis: A longitudinal study. Psychooncology 2018; 28:107-115. [PMID: 30308695 DOI: 10.1002/pon.4917] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 08/31/2018] [Accepted: 10/06/2018] [Indexed: 11/12/2022]
Abstract
PURPOSE The purpose of this study was to determine, within the first-year post-head and neck cancer (HNC) diagnosis, the contribution of past and upon HNC psychiatric diagnoses (ie, substance use disorder, major depressive disorder, and anxiety disorder) to the extent (ie, cumulated dose) of opioid prescription. METHODS Prospective longitudinal study of 223 consecutive adults (on 313 approached; 72% participation) newly diagnosed (<2 weeks) with a first occurrence of primary HNC, including Structured Clinical Interviews for DSM-IV disorders, validated psychometric measures, and medical chart reviews. Opioid doses were translated into standardized morphine milligram equivalents (MME) using CDC guidelines. A model of variables was tested using multiple linear regression. RESULTS Fifty-five percent (123/223) of patients received opioids at some point during the first 12 months post-HNC diagnosis, 37.7% (84/223) upon HNC diagnosis (pre-treatment), 40.8% (91/223) during treatments, and 31.4% (70/223) post-treatment. The multiple linear regression indicated that an AD (P = 0.04) upon HNC diagnosis in early stage contributes to cumulated MME dose in the first year post-HNC diagnosis. CONCLUSION This study underlines how anxiety has important repercussions on the management of pain and illustrates the importance of screening for AD upon HNC diagnosis to allow for early prophylactic treatment and support.
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Affiliation(s)
- Melissa Henry
- McGill University, Montreal, Canada.,Jewish General Hospital, Montreal, Canada
| | | | - Saul Frenkiel
- McGill University, Montreal, Canada.,Jewish General Hospital, Montreal, Canada.,McGill University Health Centre, Montreal, Canada
| | - Keith Richardson
- McGill University, Montreal, Canada.,McGill University Health Centre, Montreal, Canada
| | - Michael Hier
- McGill University, Montreal, Canada.,Jewish General Hospital, Montreal, Canada
| | - Anthony Zeitouni
- McGill University, Montreal, Canada.,McGill University Health Centre, Montreal, Canada
| | - Karen Kost
- McGill University, Montreal, Canada.,McGill University Health Centre, Montreal, Canada
| | - Alex Mlynarek
- McGill University, Montreal, Canada.,Jewish General Hospital, Montreal, Canada.,McGill University Health Centre, Montreal, Canada
| | - Martin Black
- McGill University, Montreal, Canada.,Jewish General Hospital, Montreal, Canada
| | | | | | - Zeev Rosberger
- McGill University, Montreal, Canada.,Jewish General Hospital, Montreal, Canada
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Ahmed M, Ul Haq I, Faisal M, Waseem D, Taqi MM. Implication of OPRM1 A118G Polymorphism in Opioids Addicts in Pakistan: In vitro and In silico Analysis. J Mol Neurosci 2018; 65:472-479. [PMID: 30033503 PMCID: PMC6132783 DOI: 10.1007/s12031-018-1123-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 07/11/2018] [Indexed: 12/04/2022]
Abstract
Single nucleotide polymorphism in OPRM1 gene is associated with hedonic and reinforcing consequences of opioids. Risk and protective alleles may vary in different populations. One hundred healthy controls and 100 opioids (predominantly heroin) addicts from Pakistani origin were genotyped for A118G (N40D) polymorphism in OPRM1. Structural and functional impact of the polymorphism on encoded protein was predicted by in silico analysis. Results show significant association between homozygous GG genotype and opioid addiction in Pakistani population (p value = 0.016). In silico analysis by SIFT (TI = 0.61), PolyPhen (PISC = 0.227), PANTHER (subPSEC = -1.7171), and SNP effect predicted this SNP benign for encoded protein. Superimposing wild-type and mutated proteins by MODELLER shows no change (RMSD = 0.1) in extracellular ligand binding domain of μ-opioid receptor. However, Haploreg and RegulomeDB predicted OPRM1 gene repression by chromatin condensation and increased binding affinity of RXRA transcription factor that may reduce protein translation and hence the number of available receptors to bind with drugs, which may trigger underlying mechanisms for opioids addiction. Thus, this study outlines causal relationship between opioids addiction and genetic predisposition in Pakistani population.
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Affiliation(s)
- Madiha Ahmed
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
| | - Ihsan Ul Haq
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
| | - Muhammad Faisal
- Faculty of Health Studies, University of Bradford, Richmond Rd, Bradford, UK.
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK.
| | - Durdana Waseem
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
| | - Malik Mumtaz Taqi
- Division of Mental Health and Addiction, NORMENT, University of Oslo, Oslo, Norway
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Sun Y, Zhang Y, Zhang D, Chang S, Jing R, Yue W, Lu L, Chen D, Sun Y, Fan Y, Shi J. GABRA2 rs279858-linked variants are associated with disrupted structural connectome of reward circuits in heroin abusers. Transl Psychiatry 2018; 8:138. [PMID: 30061709 PMCID: PMC6066482 DOI: 10.1038/s41398-018-0180-0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 05/11/2018] [Indexed: 12/16/2022] Open
Abstract
The reward system plays a vital role in drug addiction. The purpose of this study is to investigate the structural connectivity characteristics and driving-control subnetwork patterns of reward circuits in heroin abusers and assess the genetic modulation on the reward network. We first defined the reward network based on systematic literature review, and built the reward network based on diffusion tensor imaging data of 78 heroin abusers (HAs) and 79 healthy controls (HCs) using structural connectomics. Then we assessed genetic factors that might modulate changes in the reward network by performing imaging-genetic screening for 22 addiction-related polymorphisms. The genetic association was validated by performing genetic associations (1032 HAs and 2863 HCs) and expanded-variant analysis. Finally, we estimated the association between these genetic variations, reward network, and clinical performance. We found that HAs had widespread deficiencies in the structural connectivity of the reward circuit (center in VTA-linked connections), which correlated with cognition deficiency. The disruptions synchronously were shown on the reward driving system and reward control system. GABRA2 rs279858-linked variants might be a key genetic modulator for heroin vulnerability by affecting the connections of reward network and cognition. The role of the reward network connections that mediates the effects of rs279858 on cognition would be disrupted by heroin addiction. These findings provide new insights into the neurocircuitry and genetic mechanisms of addiction.
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Affiliation(s)
- Yan Sun
- National Institute on Drug Dependence, Peking University, 100191 Beijing, China
| | - Yang Zhang
- National Institute on Drug Dependence, Peking University, 100191 Beijing, China
- Department of Pharmacology School of Basic Medical Sciences, Peking University Health Science Center, 100191 Beijing, China
| | - Dai Zhang
- National Laboratory of Pattern Recognition Institute of Automation, Chinese Academy of Sciences, 100190 Beijing, China
| | - Suhua Chang
- Institute of Mental Health/Peking University Sixth Hospital and Key Laboratory of Mental Health, Peking University, 100191 Beijing, China
| | - Rixing Jing
- National Laboratory of Pattern Recognition Institute of Automation, Chinese Academy of Sciences, 100190 Beijing, China
| | - Weihua Yue
- Institute of Mental Health/Peking University Sixth Hospital and Key Laboratory of Mental Health, Peking University, 100191 Beijing, China
| | - Lin Lu
- National Institute on Drug Dependence, Peking University, 100191 Beijing, China
- Institute of Mental Health/Peking University Sixth Hospital and Key Laboratory of Mental Health, Peking University, 100191 Beijing, China
| | - Dong Chen
- Sanshui addiction treatment hospital, 528100 Guangdong, China
| | - Yankun Sun
- National Institute on Drug Dependence, Peking University, 100191 Beijing, China
- Department of Pharmacology School of Basic Medical Sciences, Peking University Health Science Center, 100191 Beijing, China
| | - Yong Fan
- Department of Radiology Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Jie Shi
- National Institute on Drug Dependence, Peking University, 100191 Beijing, China
- Beijing Key Laboratory on Drug Dependence Research, 100191 Beijing, China
- The State Key Laboratory of Natural and Biomimetic Drugs, 100191 Beijing, China
- The Key Laboratory for Neuroscience of the Ministry of Education and Health, Peking University, 100191 Beijing, China
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Abstract
BACKGROUND Opioid use disorder has drastically increased in recent years within adult populations. Limited understanding exists regarding how people enter medication-assisted treatment (MAT) for opioid use disorder-particularly those who initiate opioid use to treat a painful condition. OBJECTIVES This research examines the process involved when adults first initiate the use of opioid medicines to treat pain through enrollment in an outpatient MAT program. METHODS Grounded theory methodology guided the study. Data analysis included interpretation of interview transcripts from 10 adults who were enrolled in a single outpatient MAT program in the Pacific Northwest. Inclusion criteria were adults in MAT reporting that their initial use of opioids was to treat their pain. Corbin and Strauss' approach to theory development was followed. RESULTS A newly developed theory titled Living With Persistent Pain: From Opioid Initiation to Substance Use Treatment was supported by three predominant categories emerging from the data: "addiction pathway," "becoming normal," and "relationship spectrum." The core category "living with pain" was described as a complex and tumultuous process spanning the emergence of pain, to the initial use of opioid medicines, through opioid addiction and MAT. A notable aspect of this process was the turning point to enter MAT, which was both helped and hindered by significant relationships. CONCLUSIONS The decision to enter MAT for opioid addiction was key to helping participants gain a sense of normalcy. Insights gained from participants' experiences-particularly in relationships with healthcare providers-can be used to guide treatment approaches.
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Abstract
Pain is an unpleasant feeling usually resulting from tissue damage that can persist along weeks, months, or even years after the injury, turning into pathological chronic pain, the leading cause of disability. Currently, pharmacology interventions are usually the first-line therapy but there is a highly variable analgesic drug response. Pharmacogenetics (PGx) offers a means to identify genetic biomarkers that can predict individual analgesic response opening doors to precision medicine. PGx analyze the way in which the presence of variations in the DNA sequence (single-nucleotide polymorphisms, SNPs) could be responsible for portions of the population reaching different levels of pain relief (phenotype) due to gene interference in the drug mechanism of action (pharmacodynamics) and/or its concentration at the place of action (pharmacokinetics). SNPs in the cytochrome P450 enzymes genes (CYP2D6) influence metabolism of codeine, tramadol, hydrocodone, oxycodone, and tricyclic antidepressants. Blood concentrations of some NSAIDs depend on CYP2C9 and/or CYP2C8 activity. Additional candidate genes encode for opioid receptors, transporters, and other molecules important for pharmacotherapy in pain management. However, PGx studies are often contradictory, slowing the uptake of this information. This is likely due, in large part, to a lack of robust evidence demonstrating clinical utility and to its polygenic response modulated by other exogenous or epigenetics factors. Novel therapies, including targeting of epigenetic changes and gene therapy-based approaches, broaden future options to improve understanding of pain and the treatment of people who suffer it.
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Affiliation(s)
- Ana M Peiró
- Clinical Pharmacology Unit, Department of Health of Alicante-General Hospital, Alicante, Spain; Neuropharmacology on Pain (NED), Alicante Institute for Health and Biomedical Research (ISABIAL-FISABIO Foundation), Alicante, Spain.
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Abstract
The prescribing of opioid analgesics for pain management-particularly for management of chronic noncancer pain (CNCP)-has increased more than fourfold in the United States since the mid-1990s. Yet there is mounting evidence that opioids have only limited effectiveness in the management of CNCP, and the increased availability of prescribed opioids has contributed to upsurges in opioid-related addiction cases and overdose deaths. These concerns have led to critical revisiting and modification of prior pain management practices (e.g., guidelines from the Centers for Disease Control and Prevention), but the much-needed changes in clinical practice will be facilitated by a better understanding of the pharmacology and behavioral effects of opioids that underlie both their therapeutic effects (analgesia) and their adverse effects (addiction and overdose). With these goals in mind, this review first presents an overview of the contemporary problems associated with opioid management of CNCP and the related public health issues of opioid diversion, overdose, and addiction. It then discusses the pharmacology underlying the therapeutic and main adverse effects of opioids and its implications for clinical management of CNCP within the framework of recent clinical guidelines for prescribing opioids in the management of CNCP.
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Affiliation(s)
- Nora Volkow
- National Institute on Drug Abuse, Rockville, Maryland 20852;
| | - Helene Benveniste
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut 06510;
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Farisco M, Evers K, Changeux JP. Drug Addiction: From Neuroscience to Ethics. Front Psychiatry 2018; 9:595. [PMID: 30524319 PMCID: PMC6262362 DOI: 10.3389/fpsyt.2018.00595] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 10/26/2018] [Indexed: 12/22/2022] Open
Abstract
In the present paper, we suggest a potential new ethical analysis of addiction focusing on the relationship between aware and unaware processing in the brain. We take the case of the opioids epidemics to argue that a consideration of both aware and unaware processing provides a more comprehensive ethical framework to discuss the ethical issues raised by addiction. Finally, our hypothesis is that in addition to identified Central Nervous System's neuronal/neurochemical factors contributing to addictive dynamics, the socio-economic status plays a causal role through epigenetic processes, originating the need for additional reward in the brain. This provides a strong base for a socio-political form of responsibility for preventing and managing addiction crisis.
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Affiliation(s)
- Michele Farisco
- Centre for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden.,Science and Society Unit, Biogem, Biology and Molecular Genetics Institute, Ariano Irpino, Italy
| | - Kathinka Evers
- Centre for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden
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Sharafshah A, Fazel H, Albonaim A, Omarmeli V, Rezaei S, Mirzajani E, Ajamian F, Keshavarz P. Association of OPRD1 Gene Variants with Opioid Dependence in Addicted Male Individuals Undergoing Methadone Treatment in the North of Iran. J Psychoactive Drugs 2017. [DOI: 10.1080/02791072.2017.1290303] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Alireza Sharafshah
- Master’s Student, Cellular and Molecular Research Center, Faculty of Medicine, Guilan University of Medical Sciences, Rasht, Iran
- Master’s Student, Genetic Laboratory, Department of Biology, Faculty of Sciences, University of Guilan, Rasht, Iran
| | - Hedyeh Fazel
- Master’s Student, Cellular and Molecular Research Center, Faculty of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Ali Albonaim
- Master’s Student, Cellular and Molecular Research Center, Faculty of Medicine, Guilan University of Medical Sciences, Rasht, Iran
- Master’s Student, Genetic Laboratory, Department of Biology, Faculty of Sciences, University of Guilan, Rasht, Iran
| | - Vahid Omarmeli
- Master’s Student, Cellular and Molecular Research Center, Faculty of Medicine, Guilan University of Medical Sciences, Rasht, Iran
- Master’s Student, Genetic Laboratory, Department of Biology, Faculty of Sciences, University of Guilan, Rasht, Iran
| | - Sajjad Rezaei
- Assistant Professor, Department of Psychology, University of Guilan, Rasht, Iran
| | - Ebrahim Mirzajani
- Assistant Professor, Department of Biochemistry and Biophysics, Faculty of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Farzam Ajamian
- Assistant Professor in Molecular Genetics and Engineering, Department of Biology, Faculty of Sciences (FA), University of Guilan, Rasht, Iran
| | - Parvaneh Keshavarz
- Associate Professor, Cellular and Molecular Research Center, Faculty of Medicine, Guilan University of Medical Sciences, Rasht, Iran
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Deyo RA, Hallvik SE, Hildebran C, Marino M, Dexter E, Irvine JM, O'Kane N, Van Otterloo J, Wright DA, Leichtling G, Millet LM. Association Between Initial Opioid Prescribing Patterns and Subsequent Long-Term Use Among Opioid-Naïve Patients: A Statewide Retrospective Cohort Study. J Gen Intern Med 2017; 32:21-27. [PMID: 27484682 PMCID: PMC5215151 DOI: 10.1007/s11606-016-3810-3] [Citation(s) in RCA: 239] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 06/20/2016] [Accepted: 06/29/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Long-term efficacy of opioids for non-cancer pain is unproven, but risks argue for cautious prescribing. Few data suggest how long or how much opioid can be prescribed for opioid-naïve patients without inadvertently promoting long-term use. OBJECTIVE To examine the association between initial opioid prescribing patterns and likelihood of long-term use among opioid-naïve patients. DESIGN Retrospective cohort study; data from Oregon resident prescriptions linked to death certificates and hospital discharges. PARTICIPANTS Patients filling opioid prescriptions between October 1, 2012, and September 30, 2013, with no opioid fills for the previous 365 days. Subgroup analyses examined patients under age 45 who did not die in the follow-up year, excluding most cancer or palliative care patients. MAIN MEASURES Exposure: Numbers of prescription fills and cumulative morphine milligram equivalents (MMEs) dispensed during 30 days following opioid initiation ("initiation month"). OUTCOME Proportion of patients with six or more opioid fills during the subsequent year ("long-term users"). KEY RESULTS There were 536,767 opioid-naïve patients who filled an opioid prescription. Of these, 26,785 (5.0 %) became long-term users. Numbers of fills and cumulative MMEs during the initiation month were associated with long-term use. Among patients under age 45 using short-acting opioids who did not die in the follow-up year, the adjusted odds ratio (OR) for long-term use among those receiving two fills versus one was 2.25 (95 % CI: 2.17, 2.33). Compared to those who received < 120 total MMEs, those who received between 400 and 799 had an OR of 2.96 (95 % CI: 2.81, 3.11). Patients initiating with long-acting opioids had a higher risk of long-term use than those initiating with short-acting drugs. CONCLUSIONS Early opioid prescribing patterns are associated with long-term use. While patient characteristics are important, clinicians have greater control over initial prescribing. Our findings may help minimize the risk of inadvertently initiating long-term opioid use.
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Affiliation(s)
- Richard A Deyo
- Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code FM, Portland, OR, 97239, USA. .,Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, OR, USA. .,Department of Medicine and The Oregon Institute for Occupational Health Sciences, Oregon Health and Science University, Portland, OR, USA.
| | | | | | - Miguel Marino
- Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code FM, Portland, OR, 97239, USA.,Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Eve Dexter
- Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code FM, Portland, OR, 97239, USA
| | - Jessica M Irvine
- Acumentra Health, Portland, OR, USA.,OCHIN Inc., Portland, OR, USA
| | | | - Joshua Van Otterloo
- Injury and Violence Prevention Program for the State of Oregon, Portland, OR, USA
| | - Dagan A Wright
- Injury and Violence Prevention Program for the State of Oregon, Portland, OR, USA
| | | | - Lisa M Millet
- Injury and Violence Prevention Program for the State of Oregon, Portland, OR, USA
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65
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Crusio WE, Dhawan E, Chesler EJ, Delprato A. Analysis of morphine responses in mice reveals a QTL on Chromosome 7. F1000Res 2016; 5:2156. [PMID: 27746909 PMCID: PMC5043443 DOI: 10.12688/f1000research.9484.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2016] [Indexed: 11/28/2022] Open
Abstract
In this study we identified a quantitative trait locus (QTL) on mouse Chromosome 7 associated with locomotor activity and rearing post morphine treatment. This QTL was revealed after correcting for the effects of another QTL peak on Chromosome 10 using composite interval mapping. The positional candidate genes are
Syt9 and
Ppfibp2. Several other genes within the interval are linked to neural processes, locomotor activity, and the defensive response to harmful stimuli.
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Affiliation(s)
- Wim E Crusio
- Institut de Neurosciences Cognitives et Intégratives d'Aquitaine, UMR 5287, University of Bordeaux, Pessac cedex, France; Institut de Neurosciences Cognitives et Intégratives d'Aquitaine, UMR 5287, CNRS, Pessac, France
| | - Esha Dhawan
- Lambert High School, Suwanee, USA; BioScience Project, Wakefield, USA
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66
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Xie X, Liu H, Zhang J, Chen W, Zhuang D, Duan S, Zhou W. Association between genetic variations of NMDA receptor NR3 subfamily genes and heroin addiction in male Han Chinese. Neurosci Lett 2016; 631:122-125. [PMID: 27542340 DOI: 10.1016/j.neulet.2016.08.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 07/07/2016] [Accepted: 08/14/2016] [Indexed: 01/17/2023]
Abstract
Growing amounts of evidence suggest that N-Methyl-d-aspartate (NMDA) receptor mediated glutamate neurotransmission may be involved in the pathophysiology of drug dependence. The NMDA receptor consists of three subfamilies (NR1, NR2, and NR3). The ability of subunit NR3 to negatively modulate the NMDA receptor function makes it an attractive candidate gene of heroin addiction. The purpose of this study is to explore the association between four single nucleotide polymorphisms (SNPs) of NR3 gene and heroin addiction. Genotyping of two SNPs (rs3739722 and rs17189632) in GRIN3A and two SNPs (rs4807399 and rs2240158) in GRIN3B was performed using TaqMan SNP genotyping method. The association between heroin addiction and these SNPs was assessed among 332 male heroin dependent patients and 400 male normal control subjects. The results showed the genotype and allele frequencies of rs17189632 and rs2240158 were significantly different between the cases and the controls (nominal P values were 0.0284, 0.0136 for rs17189632; 0.0048, 0.0013 for rs2240158, respectively). After Bonferroni correction, rs2240158 of GRIN3B was still found to be associated with heroin addiction. The frequencies of haplotype C-A at GRIN3A (rs3739722-rs17189632) and of C-C and C-T at GRIN3B (rs4807399-rs2240158) differed significantly between the cases and the controls. The genotype and allele distributions of rs3739722 and rs4807399 were not significantly different between in the cases and in the controls (P>0.05). These results suggest that GRIN3A rs17189632 and GRIN3B rs2240158 may contribute to the susceptibility of heroin addiction.
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Affiliation(s)
- Xiaohu Xie
- Laboratory of Behavioral Neuroscience, Ningbo Addiction Research and Treatment Center, School of Medicine, Ningbo University, Ningbo, Zhejiang, China
| | - Huifen Liu
- Laboratory of Behavioral Neuroscience, Ningbo Addiction Research and Treatment Center, School of Medicine, Ningbo University, Ningbo, Zhejiang, China
| | - Jianbing Zhang
- Laboratory of Behavioral Neuroscience, Ningbo Addiction Research and Treatment Center, School of Medicine, Ningbo University, Ningbo, Zhejiang, China
| | - Weisheng Chen
- Laboratory of Behavioral Neuroscience, Ningbo Addiction Research and Treatment Center, School of Medicine, Ningbo University, Ningbo, Zhejiang, China
| | - Dingding Zhuang
- Laboratory of Behavioral Neuroscience, Ningbo Addiction Research and Treatment Center, School of Medicine, Ningbo University, Ningbo, Zhejiang, China
| | - Shiwei Duan
- School of Medicine, Ningbo University, Ningbo, Zhejiang, China.
| | - Wenhua Zhou
- Laboratory of Behavioral Neuroscience, Ningbo Addiction Research and Treatment Center, School of Medicine, Ningbo University, Ningbo, Zhejiang, China.
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67
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Who Benefits from Chronic Opioid Therapy? Rethinking the Question of Opioid Misuse Risk. Healthcare (Basel) 2016; 4:healthcare4020029. [PMID: 27417617 PMCID: PMC4934582 DOI: 10.3390/healthcare4020029] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 05/17/2016] [Accepted: 05/17/2016] [Indexed: 01/14/2023] Open
Abstract
Beginning in the late 1990s, a movement began within the pain management field focused upon the underutilization of opioids, thought to be a potentially safe and effective class of pain medication. Concern for addiction and misuse were present at the start of this shift within pain medicine, and an emphasis was placed on developing reliable and valid methods and measures of identifying those at risk for opioid misuse. Since that time, the evidence for the safety and effectiveness of chronic opioid therapy (COT) has not been established. Rather, the harmful, dose-dependent deleterious effects have become clearer, including addiction, increased risk of injuries, respiratory depression, opioid induced hyperalgesia, and death. Still, many individuals on low doses of opioids for long periods of time appear to have good pain control and retain social and occupational functioning. Therefore, we propose that the question, “Who is at risk of opioid misuse?” should evolve to, “Who may benefit from COT?” in light of the current evidence.
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Affiliation(s)
- Nora D Volkow
- From the National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD (N.D.V.); and the Treatment Research Institute, Philadelphia (A.T.M.)
| | - A Thomas McLellan
- From the National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD (N.D.V.); and the Treatment Research Institute, Philadelphia (A.T.M.)
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69
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Meshkin B, Lewis K, Kantorovich S, Anand N, Davila L. Adding Genetic Testing to Evidence-Based Guidelines to Determine the Safest and Most Effective Chronic Pain Treatment for Injured Workers. INTERNATIONAL JOURNAL OF BIOMEDICAL SCIENCE : IJBS 2015; 11:157-65. [PMID: 26759531 PMCID: PMC4699130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 10/15/2015] [Indexed: 11/23/2022]
Abstract
Published guidelines for treating injured workers include the need for personalized treatment to manage chronic pain symptoms and increase functional status. However, they often fail to clarify how to objectively personalize these treatments. Further, certain patients need analgesic relief beyond the short term. In these cases, it is not sufficient or reasonable to utilize the typical broad protocol-based justifications for reduction of opioids and other medications in a haphazard manner based purely on poor response, without attempting to elucidate possible pharmacogenetic reasons for this. These guidelines acknowledge the problem of substance abuse and set forth methods for treatment and prevention. Although it has been established in the scientific community that an individual's experience of pain and likelihood for addiction both have genetic components, genetic testing is not routinely included as part of the overall treatment plan for injured workers with chronic pain. Because decisions in cases of workplace injury should be based on scientific evidence, genetic testing results can add some objective information to the existing subjective and objective clinical data; help ascertain the efficacy and potential for toxicity of treatment; and therefore provide more information for accurate clinical decisions. We propose the addition of genetic testing to consensus guidelines for treating injured workers in order to improve patients' functional status, increase productivity, improve safety of prescribing, decrease the likelihood of substance abuse, and save on overall healthcare costs.
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70
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Phenotypic heterogeneity in study populations may significantly confound the results of genetic association studies on alcohol dependence. Psychiatr Genet 2015; 25:234-40. [DOI: 10.1097/ypg.0000000000000105] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hancock DB, Levy JL, Gaddis NC, Glasheen C, Saccone NL, Page GP, Bierut LJ, Kral AH, Johnson EO. Replication of ZNF804A gene variant associations with risk of heroin addiction. GENES, BRAIN, AND BEHAVIOR 2015; 14:635-40. [PMID: 26382569 PMCID: PMC4715582 DOI: 10.1111/gbb.12254] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 08/28/2015] [Accepted: 09/14/2015] [Indexed: 12/19/2022]
Abstract
Heroin addiction is heritable, but few specific genetic variants have been reproducibly associated with this disease. The zinc finger protein 804A (ZNF804A) gene is a biologically plausible susceptibility gene for heroin addiction, given its function as a transcription factor in human brain. Novel associations of two common ZNF804A single nucleotide polymorphisms (SNPs), rs7597593 and rs1344706, with heroin addiction have been reported in Han Chinese. Both SNPs have also been implicated for regulating ZNF804A expression in human brain, including the addiction-relevant dorsolateral prefrontal cortex. In this independent replication study, we tested the rs7597593 and rs1344706 SNP genotypes and their corresponding haplotypes for association with heroin addiction using cases drawn from the Urban Health Study and population controls: total N = 10 757 [7095 European Americans (EAs) and 3662 African Americans (AAs)]. We independently replicated both ZNF804A SNP associations in EAs: the rs7597593-T (P = 0.016) and rs1344706-A (P = 0.029) alleles both being associated with increased risk of heroin addiction, consistent with the prior report. Neither SNP was associated in AAs alone, but meta-analysis across both ancestry groups resulted in significant associations for rs1344706-A [P = 0.016, odds ratio (95% confidence interval) = 1.13 (1.02-1.25)] and its haplotype with rs7597593-T [P = 0.0067, odds ratio (95% confidence interval) = 1.16 (1.04-1.29)]. By showing consistent associations across independent studies and diverse ancestry groups, our study provides evidence that these two ZNF804A SNPs and their risk haplotype are among the few replicable genetic associations with heroin addiction.
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Affiliation(s)
- Dana B. Hancock
- Behavioral and Urban Health Program, Behavioral Health and Criminal Justice Division, Research Triangle Institute (RTI) International, Research Triangle Park, North Carolina, USA
| | - Joshua L. Levy
- Research Computing Division, RTI International, Research Triangle Park, North Carolina, USA
| | - Nathan C. Gaddis
- Research Computing Division, RTI International, Research Triangle Park, North Carolina, USA
| | - Cristie Glasheen
- Behavioral and Urban Health Program, Behavioral Health and Criminal Justice Division, Research Triangle Institute (RTI) International, Research Triangle Park, North Carolina, USA
| | - Nancy L. Saccone
- Department of Genetics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Grier P. Page
- Fellow Program, Center for Genomics in Public Health and Medicine Genomics, and Statistical Genetics, and Environmental Research Program, RTI International, Atlanta, Georgia, USA
| | - Laura J. Bierut
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Alex H. Kral
- Behavioral and Urban Health Program, Behavioral Health and Criminal Justice Division, San Francisco, California, USA
| | - Eric O. Johnson
- Fellow Program and Behavioral Health and Criminal Justice Division, RTI International, Research Triangle Park, North Carolina, USA
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