Intravenous cocaine challenges during naltrexone maintenance: a preliminary study

Opposing neural effects of naltrexone on food reward and aversion: implications for the treatment of obesity

RATIONALE

Opioid antagonism reduces the consumption of palatable foods in humans but the neural substrates implicated in these effects are less well understood.

OBJECTIVES

The aim of the present study was to examine the effects of the opioid antagonist, naltrexone, on neural response to rewarding and aversive sight and taste stimuli.

METHODS

We used functional magnetic resonance imaging (fMRI) to examine the neural responses to the sight and taste of pleasant (chocolate) and aversive (mouldy strawberry) stimuli in 20 healthy volunteers who received a single oral dose of naltrexone (50 mg) and placebo in a double-blind, repeated-measures cross-over, design.

RESULTS

Relative to placebo, naltrexone decreased reward activation to chocolate in the dorsal anterior cingulate cortex and caudate, and increased aversive-related activation to unpleasant strawberry in the amygdala and anterior insula.

CONCLUSIONS

These findings suggest that modulation of key brain areas involved in reward processing, cognitive control and habit formation such as the dorsal anterior cingulate cortex (dACC) and caudate might underlie reduction in food intake with opioid antagonism. Furthermore we show for the first time that naltrexone can increase activations related to aversive food stimuli. These results support further investigation of opioid treatments in obesity.

Effects of acute oral naltrexone on the subjective and physiological effects of oral D-amphetamine and smoked cocaine in cocaine abusers

Despite the prevalent worldwide abuse of stimulants, such as amphetamines and cocaine, no medications are currently approved for treating this serious public health problem. Both preclinical and clinical studies suggest that the opioid antagonist naltrexone (NTX) is effective in reducing the abuse liability of amphetamine, raising the question of whether similar positive findings would be obtained for cocaine. The purpose of this study was to evaluate the ability of oral NTX to alter the cardiovascular and subjective effects of D-amphetamine (D-AMPH) and cocaine (COC). Non-treatment-seeking COC users (N=12) completed this 3-week inpatient, randomized, crossover study. Participants received 0, 12.5, or 50 mg oral NTX 60 min before active or placebo stimulant administration during 10 separate laboratory sessions. Oral AMPH (0, 10, and 20 mg; or all placebo) was administered in ascending order within a laboratory session using a 60-min interdose interval. Smoked COC (0, 12.5, 25, and 50 mg; or all placebo) was administered in ascending order within a laboratory session using a 14-min interdose interval. Active COC and AMPH produced dose-related increases in cardiovascular function that were of comparable magnitude. In contrast, COC, but not AMPH, produced dose-related increases in several subjective measures of positive drug effect (eg, high, liking, and willingness to pay for the drug). NTX did not alter the cardiovascular effects of AMPH or COC. NTX also did not alter positive subjective ratings after COC administration, but it did significantly reduce ratings of craving for COC and tobacco during COC sessions. These results show that (1) oral AMPH produces minimal abuse-related subjective responses in COC smokers, and (2) NTX reduces craving for COC and tobacco during COC sessions. Future studies should continue to evaluate NTX as a potential anti-craving medication for COC dependence.

Cocaine modulates the expression of opioid receptors and miR-let-7d in zebrafish embryos

Prenatal exposure to cocaine, in mammals, has been shown to interfere with the expression of opioid receptors, which can have repercussions in its activity. Likewise, microRNAs, such as let-7, have been shown to regulate the expression of opioid receptors and hence their functions in mammals and in vitro experiments. In light of this, using the zebrafish embryos as a model our aim here was to evaluate the actions of cocaine in the expression of opioid receptors and let-7d miRNA during embryogenesis. In order to determine the effects produced by cocaine on the opioid receptors (zfmor, zfdor1 and zfdor2) and let-7d miRNA (dre-let-7d) and its precursors (dre-let-7d-1 and dre-let-7d-2), embryos were exposed to 1.5 µM cocaine hydrochloride (HCl). Our results revealed that cocaine upregulated dre-let-7d and its precursors, and also increased the expression of zfmor, zfdor1 and zfdor2 during early developmental stages and decreased them in late embryonic stages. The changes observed in the expression of opioid receptors might occur through dre-let-7d, since DNA sequences and the morpholinos of opioid receptors microinjections altered the expression of dre-let-7d and its precursors. Likewise, opioid receptors and dre-let-7d showed similar distributions in the central nervous system (CNS) and at the periphery, pointing to a possible interrelationship between them.In conclusion, the silencing and overexpression of opioid receptors altered the expression of dre-let-7d, which points to the notion that cocaine via dre-let-7 can modulate the expression of opioid receptors. Our study provides new insights into the actions of cocaine during zebrafish embryogenesis, indicating a role of miRNAs, let-7d, in development and its relationship with gene expression of opioid receptors, related to pain and addiction process.

MDMA ("ecstasy") abuse as an example of dopamine neuroplasticity

A number of reviews have focused on the short- and long-term effects of MDMA and, in particular, on the persistent deficits in serotonin neurotransmission that accompany some exposure regimens. The mechanisms underlying the serotonin deficits and their relevance to various behavioral and cognitive consequences of MDMA use are still being debated. It has become clear, however, that some individuals develop compulsive and uncontrolled drug-taking that is consistent with abuse. For other drugs of abuse, this transition has been attributed to neuroadaptations in central dopamine mechanisms that occur as a function of repeated drug exposure. A question remains as to whether similar neuroadaptations occur as a function of exposure to MDMA and the impact of serotonin neurotoxicity in the transition from use to abuse. This review focuses specifically on this issue by first providing an overview of human studies and then reviewing the animal literature with specific emphasis on paradigms that measure subjective effects of drugs and self-administration as indices of abuse liability. It is suggested that serotonin deficits resulting from repeated exposure to MDMA self-administration lead to a sensitized dopaminergic response to the drug and that this sensitized response renders MDMA comparable to other drugs of abuse.

Role of mu- and delta-opioid receptors in the nucleus accumbens in cocaine-seeking behavior

Earlier studies suggest that opioid receptors in the ventral tegmental area, but not the nucleus accumbens (NAc), play a role in relapse to drug-seeking behavior. However, environmental stimuli that elicit relapse also release the endogenous opioid beta-endorphin in the NAc. Using a within-session extinction/reinstatement paradigm in rats that self-administer cocaine, we found that NAc infusions of the mu-opioid receptor (MOR) agonist DAMGO moderately reinstated responding on the cocaine-paired lever at low doses (1.0-3.0 ng/side), whereas the delta-opioid receptor (DOR) agonist DPDPE induced greater responding at higher doses (300-3000 ng/side) that also enhanced inactive lever responding. Using doses of either agonist that induced responding on only the cocaine-paired lever, we found that DAMGO-induced responding was blocked selectively by pretreatment with the MOR antagonist, CTAP, whereas DPDPE-induced responding was selectively blocked by the DOR antagonist, naltrindole. Cocaine-primed reinstatement was blocked by intra-NAc CTAP but not naltrindole, indicating a role for endogenous MOR-acting peptides in cocaine-induced reinstatement of cocaine-seeking behavior. In this regard, intra-NAc infusions of beta-endorphin (100-1000 ng/side) induced marked cocaine-seeking behavior, an effect blocked by intra-NAc pretreatment with the MOR but not DOR antagonist. Conversely, cocaine seeking elicited by the enkephalinase inhibitor thiorphan (1-10 microg/side) was blocked by naltrindole but not CTAP. MOR stimulation in more dorsal caudate-putamen sites was ineffective, whereas DPDPE infusions induced cocaine seeking. Together, these findings establish distinct roles for MOR and DOR in cocaine relapse and suggest that NAc MOR could be an important therapeutic target to neutralize the effects of endogenous beta-endorphin release on cocaine relapse.

Naltrexone attenuates the subjective effects of amphetamine in patients with amphetamine dependence

Amphetamine abuse and dependence is a global health concern with a collateral increase in medical and social problems. Although some of the neurobiological mechanisms underlying amphetamine dependence and its devastating effects in humans are known, the development of rational and evidence-based treatment is lagging. There is evidence from preclinical studies suggesting that the endogenous opioid system plays a role in mediating some of the behavioral and neurochemical effects of amphetamine in a variety of controlled settings. In the present study we assessed the effects of naltrexone, an opioid antagonist (50 mg) on the subjective physiological and biochemical response to dexamphetamine (30 mg) in 20 amphetamine-dependent patients. Patients received naltrexone/amphetamine followed by placebo/amphetamine, 1 week apart in a randomized double-blind placebo-controlled design. The primary objective of the study was to evaluate the effect of pretreatment with naltrexone on the subjective response to amphetamine, using a Visual Analog Scale. The secondary objective was to investigate the effects of naltrexone on physiological and biochemical responses to amphetamine, as measured by changes in blood pressure, heart rate, skin conductance, and cortisol. Naltrexone significantly attenuated the subjective effects produced by dexamphetamine in dependent patients (p<0.001). Pretreatment with naltrexone also significantly blocked the craving for dexamphetamine (p<0.001). There was no difference between the groups on the physiological measures. The results suggest that the subjective effects of amphetamine could be modulated via the endogenous opioid system. The potential of naltrexone as an adjunct pharmaceutical for amphetamine dependence is promising.

Beta-endorphin and drug-induced reward and reinforcement

Although drugs of abuse have different acute mechanisms of action, their brain pathways of reward exhibit common functional effects upon both acute and chronic administration. Long known for its analgesic effect, the opioid beta-endorphin is now shown to induce euphoria, and to have rewarding and reinforcing properties. In this review, we will summarize the present neurobiological and behavioral evidences that support involvement of beta-endorphin in drug-induced reward and reinforcement. Currently, evidence supports a prominent role for beta-endorphin in the reward pathways of cocaine and alcohol. The existing information indicating the importance of beta-endorphin neurotransmission in mediating the reward pathways of nicotine and THC, is thus far circumstantial. The studies described herein employed diverse techniques, such as biochemical measurements of beta-endorphin in various brain sites and plasma, and behavioral measurements, conducted following elimination (via administration of anti-beta-endorphin antibodies or using mutant mice) or augmentation (by intracerebral administration) of beta-endorphin. We suggest that the reward pathways for different addictive drugs converge to a common pathway in which beta-endorphin is a modulating element. Beta-endorphin is involved also with distress. However, reviewing the data collected so far implies a discrete role, beyond that of a stress response, for beta-endorphin in mediating the substance of abuse reward pathway. This may occur via interacting with the mesolimbic dopaminergic system and also by its interesting effects on learning and memory. The functional meaning of beta-endorphin in the process of drug-seeking behavior is discussed.

Striatal and ventral pallidum dynorphin concentrations are markedly increased in human chronic cocaine users

Interest in development of therapeutics targeting brain neuropeptide systems for treatment of cocaine addiction (e.g., kappa opioid agonists) is based on animal data showing interactions between the neuropeptides, brain dopamine, and cocaine. In this autopsied brain study, our major objective was to establish by radioimmunoassay whether levels of dynorphin and other neuropeptides (e.g., metenkephalin, neurotensin and substance P) are increased in the dopamine-rich caudate, putamen, and nucleus accumbens of human chronic cocaine users (n=12) vs. matched control subjects (n=17) as predicted by animal findings. Changes were limited to markedly increased dynorphin immunoreactivity in caudate (+92%), decreased caudate neurotensin (-49%), and a trend for increased dynorphin (+75%) in putamen. In other examined subcortical/cerebral cortical areas dynorphin levels were normal with the striking exception of the ventral pallidum (+346%), whereas cerebral cortical metenkephalin levels were generally decreased and neurotensin variably changed. Our finding that, in contradistinction to animal data, the other striatal neuropeptides were not increased in human cocaine users could be explained by differences in pattern and contingency between human drug users and the animal models. However, the human dynorphin observations parallel well animal findings and suggest that the dynorphin system is upregulated, manifested as elevated neuropeptide levels, after chronic drug exposure in striatum and ventral pallidum. Our postmortem brain data suggest involvement of striatal dynorphin systems in human cocaine users and should add to the interest in the testing of new dynorphin-related therapeutics for the treatment of cocaine addiction.

Nalmefene induced elevation in serum prolactin in normal human volunteers: partial kappa opioid agonist activity?

In humans, mu- and kappa-opioid receptor agonists lower tuberoinfundibular dopamine, which tonically inhibits prolactin release. Serum prolactin is, therefore, a useful biomarker for tuberoinfundibular dopamine. The current study evaluated the unexpected finding that the relative mu- and kappa-opioid receptor selective antagonist nalmefene increases serum prolactin, indicating possible kappa-opioid receptor agonist activity. In all, 33 healthy human volunteers (14 female) with no history of psychiatric or substance use disorders received placebo, nalmefene 3 mg, and nalmefene 10 mg in a double-blind manner. Drugs were administered between 0900 and 1000 on separate days via 2-min intravenous infusion. Serial blood specimens were analyzed for serum levels of prolactin. Additional in vitro studies of nalmefene binding to cloned human kappa-opioid receptors transfected into Chinese hamster ovary cells were performed. Compared to placebo, both doses of nalmefene caused significant elevations in serum prolactin (p<0.002 for nalmefene 3 mg and p<0.0005 for nalmefene 10 mg). There was no difference in prolactin response between the 3 and 10 mg doses. Binding assays confirmed nalmefene's affinity at kappa-opioid receptors and antagonism of mu-opioid receptors. [(35)S]GTPgammaS binding studies demonstrated that nalmefene is a full antagonist at mu-opioid receptors and has partial agonist properties at kappa-opioid receptors. Elevations in serum prolactin following nalmefene are consistent with this partial agonist effect at kappa-opioid receptors. As kappa-opioid receptor activation can lower dopamine in brain regions important to the persistence of alcohol and cocaine dependence, the partial kappa agonist effect of nalmefene may enhance its therapeutic efficacy in selected addictive diseases.

Effects of naltrexone on the subjective response to amphetamine in healthy volunteers

While dopaminergic mechanisms in amphetamine-taking behavior have been extensively studied, the contribution of the endogenous opioid system is less clear. We assessed the effects of an opioid antagonist, naltrexone (50 mg), on the subjective response to an oral dose of dexamphetamine (30 mg) in 12 healthy volunteers in a double-blind, placebo-controlled design. Volunteers received a total of 4 combinations of the study preparation (placebo-naltrexone, placebo-amphetamine) over 4 occasions with 1-week intervals. The primary objective of the study was to evaluate the effect of pretreatment with naltrexone on the subjective response to amphetamine. This was measured using a Visual Analog Scale, assessing the subjective effects over 7 hours. The secondary objective was to measure the effects of naltrexone on behavioral and physiologic responses to amphetamine. This was measured by blood pressure, heart rate, skin conductance, and speed of reading at the end of each session. Amphetamine produced significant effects on subjective arousal when compared to placebo after 1 hour (P < 0.001) and continued to be evident until 7 hours. Pretreatment with naltrexone significantly attenuated the subjective effects of amphetamine (P < 0.05), and this effect was time-dependent with a reduction from the 3-hour time point. Naltrexone did not influence the behavioral and physiologic effects of amphetamine in this sample. The results provide preliminary evidence that naltrexone may reduce the reinforcing effects of amphetamine via modulation of the opioid system. The potential of naltrexone as an adjunct pharmaceutical for the treatment of amphetamine dependence is promising and needs to be investigated further.

Blockade of ventral pallidal opioid receptors induces a conditioned place aversion and attenuates acquisition of cocaine place preference in the rat

Peripheral administration of naloxone is known to produce a conditioned place aversion and to block cocaine-induced conditioned place preference. The ventral pallidum receives a dense enkephalinergic projection from the nucleus accumbens and is implicated as a locus mediating the rewarding and reinforcing effects of psychostimulant and opiate drugs. We sought to provide evidence for the involvement of pallidal opioid receptors in modulating affective state using the place-conditioning paradigm. Microinjection of naloxone (0.01-10 microg) into the ventral pallidum once a day for 3 days dose-dependently produced a conditioned place aversion when tested in the drug-free state 24 h after the last naloxone injection. This effect was reproduced using the mu-opioid receptor selective agonist D-Phe-Cys-Tyr-D-Trp-Orn-Thr-Pen-Thr-NH(2) (CTOP, 1 microg). Locomotor activity was reduced following injection of the highest dose of naloxone (10 microg) but elevated following CTOP (1 microg). Daily injection of cocaine (10 mg/kg) for 3 days produced a conditioned place preference 24 h later. This effect of cocaine was attenuated by concomitant intra-ventral pallidal injection of naloxone at a dose (0.01 microg) that had no significant aversive property when injected alone. In contrast, the locomotor activation induced by peripheral cocaine injection was unaffected by naloxone injection into the ventral pallidum. The data implicate endogenous opioid peptide systems within the ventral pallidum as regulators of hedonic status.

Effects of naltrexone and isradipine, alone or in combination, on cocaine responses in humans

Preclinical studies suggested that combination of naltrexone and isradipine may be useful for the treatment of cocaine addiction. This study examined whether naltrexone and isradipine, alone or in combination, would attenuate the subjective and physiological effects of cocaine in humans. Seven cocaine users participated in a randomized, double-blind, placebo-controlled inpatient study. Before each of the seven experimental sessions, subjects were treated orally with naltrexone (50 mg or placebo), isradipine (10 mg or placebo), or naltrexone plus isradipine. Subjects then received a single dose of intranasal cocaine (4 mg or 100 mg/70 kg). Isradipine alone attenuated the systolic blood pressure response to cocaine. In contrast, isradipine plus naltrexone treatment attenuated both the systolic and diastolic blood pressure responses. Naltrexone alone did not affect the blood pressure response to cocaine. For subjective response to cocaine, isradipine, alone or in combination with naltrexone, did not have significant effects. Naltrexone treatment alone attenuated the rating of "good effects" from cocaine without affecting other subjective responses. These results suggest that isradipine alone or in combination with naltrexone attenuates some of the physiological effects of cocaine.

Naloxone depresses cocaine self-administration and delays its initiation on the following day

While dopamine mechanisms play a crucial role in cocaine-taking behavior, the contribution of endogenous opioid systems is less clear. We assessed the effects of opioid receptor blockade by naloxone (1 mg/kg, s.c.) on the daily performance and subsequent initiation of cocaine self-administration in trained rats. Naloxone decreased self-administration rate by approximately half, with the effect varying from complete blockade to no change. On the day following naloxone treatment, the latencies from the drug availability cue to the first self-administration were consistently longer than before naloxone treatment. Measurement of brain temperature and behavioral observations suggested a lower than normal level of motivational arousal as a factor for slow initiation of cocaine-taking behavior. After the first drug infusion, however, performance was uniformly normal. These data suggest endogenous opioid systems play a role in cocaine-taking behavior and indicate a residual inhibitory consequence of naloxone treatment on the initiation of this behavior.

Therapeutic vaccines for substance dependence

Several immunotherapies are under development for nicotine, cocaine and phencyclidine and a cocaine vaccine has started human trials. These therapies promise a new approach to diseases that have had limited treatment success and tremendous morbidity. Both the cocaine and nicotine addiction immunotherapies have reduced 'relapse' to drug use in animal model systems. To date, the active cocaine vaccine has few side effects and induces considerable antibody titers after active immunization in humans. Studies with the monoclonal phencyclidine immunotherapy provide intriguing evidence of sustained protection for months after single-dose administration. Other immunotherapy may include treatment of drug overdose, prevention of brain or cardiac toxicity and protection of a fetus during pregnancy in a drug abuser.

Sigma(1) (sigma(1)) receptor antagonists represent a new strategy against cocaine addiction and toxicity

Cocaine is a highly addictive substance abused worldwide. Its mechanism of action involves initially inhibition of neuronal monoamine transporters in precise brain structures and primarily the dopamine reuptake system located on mesolimbic neurons. Cocaine rapidly increases the dopaminergic neurotransmission and triggers adaptive changes in numerous neuronal circuits underlying reinforcement, reward, sensitization and the high addictive potential of cocaine. Current therapeutic strategies focus on counteracting the cocaine effects directly on the dopamine transporter, through post-synaptic D(1), D(2) or D(3) receptors or through the glutamatergic, serotoninergic, opioid or corticotropin-releasing hormone systems. However, cocaine administration also results in the activation of numerous particular targets. Among them, the sigma(1) (sigma(1)) receptor is involved in several acute or chronic effects of cocaine. The present review will first bring concise overviews of the present strategies followed to alleviate cocaine addiction and animal models developed to analyze the pharmacology of cocaine addiction. Evidence involving activation of the sigma(1) receptor in the different aspects of cocaine abuse, will then be detailed, following acute, repeated, or overdose administration. The therapeutic potentials and neuropharmacological perspectives opened by the use of selective sigma(1) receptor antagonists in cocaine addiction will finally be discussed.

Human therapeutic cocaine vaccine: safety and immunogenicity

This randomized, double blind, placebo controlled, phase I clinical trial assessed the safety and immunogenicity of a therapeutic cocaine vaccine TA-CD in 34 former cocaine abusers: 8 at 13 microg active vaccine, 10 at 82 microg and 10 at 709 microg, with two additional subjects getting placebo in each cohort. All got intra-muscular injections at 0-2 months and were monitored for safety and antibody production for 3 months. Of the 34 subjects 27 completed the full course of three injections, of these, only 24 returned for the final scheduled visit at day 84. The vaccine was well-tolerated and had no serious drug-related adverse events, although three subjects at the highest dose experienced brief post injection twitching. Fifteen subjects on TA-CD therapeutic vaccine were followed for 1 year. Antibody levels were correlated with vaccine dose and number of injections. Anti-cocaine antibodies were detected after the second injection, peaked at 3 months and declined to baseline by 1 year. Thus, the therapeutic vaccine was well tolerated with dose related increases in antibody levels, and a high proportion of patients recruited into the study were retained.

Effects of cocaine prior to and during bupropion maintenance in cocaine-abusing volunteers

The effects of cocaine were examined prior to and during bupropion maintenance in nonopioid-dependent cocaine abusers. Prior to bupropion maintenance, subjects underwent an experimental session during which repeated cocaine doses (0, 50, 100 mg/70 kg) were administered intranasally. Then subjects were maintained on bupropion (150 and 300 mg per day) and underwent experimental sessions as before. Cocaine, regardless of bupropion, produced dose-related increases in several stimulant-like self-reports, performance and cardiovascular measures. Bupropion decreased POMS ratings of friendliness and vigor, regardless of cocaine dose. Bupropion enhanced and attenuated cocaine-induced increases in ratings on the LSD and BG subscales of the ARCI, respectively. These results suggest that bupropion does not alter the acute subjective or cardiovascular effects of cocaine in a robust manner.

Endogenous opioids and reward

The discovery of endogenous opioids has markedly influenced the research on the biology of addiction and reward brain processes. Evidence has been presented that these brain substances modulate brain stimulation reward, self-administration of different drugs of abuse, sexual behaviour and social behaviour. There appears to be two different domains in which endogenous opioids, present in separate and distinct brain regions, are involved. One is related to the modulation of incentive motivational processes and the other to the performance of certain behaviours. It is concluded that endogenous opioids may play a role in the vulnerability to certain diseases, such as addiction and autism, but also when the disease is present, such as alcoholism.

Neurobiological adaptations to psychostimulants and opiates as a basis of treatment development

Abuse of illicit substances, in particular psychostimulants and opiates, is a worldwide public health issue. Chronic use of cocaine and amphetamine causes common neurobiological adaptations that may guide new treatment development. These include perturbations in dopamine and serotonin neurotransmission, leading to trials of antidepressants, and serotonin and dopamine augmentation strategies. The detection of cerebral perfusion abnormalities caused by psychostimulants has led to examination of antiplatelet and excitatory amino acid (EAA) antagonist therapies. Further, development of cocaine vaccines allows for testing of peripheral blockade approaches to cocaine addiction. New approaches to behavioral treatments for cocaine dependence are also reviewed. For opiate dependence, understanding of heroin's effects on mu and kappa opiate receptors has led to investigations of the partial mu agonist buprenorphine in opiate maintenance. Evidence for hyper-excitability of locus coeruleus (LC) noradrenergic neurons and EEA inputs to the LC guides trials of new alpha 2-adrenergic agonists and EEA antagonists to alleviate opiate withdrawal. Finally, clinical experience with withdrawal from methadone and LAAM has led to trials of antagonist-accelerated opiate withdrawal. Improved treatment of psychostimulant and opiate addiction is critically needed, and likely to have wide-reaching impact in health care and society.

Effects of lamotrigine on behavioral and cardiovascular responses to cocaine in human subjects

We evaluated the effects of acute pretreatment with lamotrigine, a putative glutamate release inhibitor, on the physiological and behavioral responses to intranasal cocaine in cocaine-dependent volunteers (N = 8). The study employed a double-blind, placebo-controlled, within-subject design. Subjects participated in six experimental sessions. On each study day, placebo, lamotrigine 125 mg, or lamotrigine 250 mg was administered orally in the morning, followed 2 hours later by intranasal cocaine 120 mg/70 kg or placebo. Measurements of heart rate and blood pressure were acquired, and subjects responded to mood state questionnaires at predetermined time intervals. Cocaine alone produced increases in heart rate, blood pressure, and several measures of pleasurable mood and drug effects. Lamotrigine alone produced a mild relaxing effect. Lamotrigine pretreatment altered neither the physiological responses nor the subjective ratings of cocaine's pleasurable or aversive mood effects.

Substance abuse and emergency psychiatry

Given the high rates of comorbidity, patients commonly present with multiple diagnoses to PESs or crisis services. Clinicians must be well versed in the evaluation, differential diagnosis, and treatment of patients with substance-abuse disorders or other Axis I, II, or III conditions if they are to provide state-of-the-art treatment of patients in need of emergency care.

The effects of naltrexone maintenance on the response to yohimbine in healthy volunteers

BACKGROUND

Preclinical research suggests that opiate antagonists may alter stress responsiveness. This study describes the effect of pretreatment with the opioid antagonist naltrexone on the response to a noradrenergic stressor, the alpha-2-receptor-antagonist, yohimbine, in healthy subjects. The current study was designed to compare the change in responses to yohimbine after 2 weeks of treatment with naltrexone to the response after at least 2 weeks of treatment with placebo.

METHODS

After a week of placebo naltrexone treatment, ten subjects were randomized into a double-blind cross-over to placebo or active naltrexone (50 mg p.o. daily) on weeks 2 to 4, and the converse condition for weeks 5 to 7. Subjects received challenges in a random, fixed sequence with placebo and active yohimbine (i.v., 0.2 mg/kg) on weeks 1, 4, and 7. The active-active combination generally had the strongest drug effects.

RESULTS

There were statistically significant (p < .05) interactions of naltrexone condition X yohimbine condition for subject ratings of "nervous," "not liking the drug effect," "talkative," and "urge to urinate," and a trend (p < .10) for cortisol levels.

CONCLUSIONS

The results suggest that clinically used naltrexone doses alter sensitivity to yohimbine.

Psychostimulant abuse: the case for combined behavioral and pharmacological treatments

Behavioral and pharmacological therapies have been used alone and in combination for the treatment of substance abuse; however, to date, no single treatment approach for psychostimulant abuse has demonstrated widespread efficacy. This paper describes the various functions that are served by both behavioral therapies and pharmacotherapies and their respective mechanisms of action. It is argued that combined treatments can be expected to produce additive effects because the two approaches operate through different and potentially complementary mechanisms. Illustrations of these underlying principles and experimental support for the use of combined treatments are drawn from smoking cessation research, which has broadly applied combined behavioral and pharmacological therapies for treating abuse of nicotine, a mild stimulant. In addition, the results of recent studies that have evaluated the efficacy of behavioral techniques and/or potential pharmacotherapies for treating cocaine abuse are reviewed. Finally, methodological strategies are recommended for future evaluations of combined therapy approaches to conclusively evaluate separate and combined efficacy of treatments for psychostimulant abuse.

Cardiovascular effects of cocaine in humans: laboratory studies

Studies in which healthy, carefully screened, experienced cocaine users receive cocaine under controlled laboratory conditions, although often overlooked by the medical community, are an excellent source of data on the cardiovascular effects of cocaine. Cocaine is generally self-administered in repeated-dose 'binges', and studies simulating this pattern provide interesting cardiovascular information, such as the selective development of acute tolerance or the unique effects of some drug combinations. Studies with intranasal, intravenous, and smoked cocaine all show that under conditions in which subjects are allowed to take cocaine repeatedly, heart rate generally returns to near baseline levels between doses despite gradually increasing cocaine blood levels. Blood pressure either shows the same pattern, or gradual increases with repeated dosing. Analyses of cardiovascular activity as a function of cocaine plasma level indicate the rapid development of acute (i.e., within session) tolerance to cocaine. Cocaine self-administration often occurs in the presence of behavioral stressors, or in combination with other drugs of abuse or cocaine abuse treatment medications. Performance of a behaviorally-demanding task increases heart rate and blood pressure. When cocaine is taken prior to task performance larger increases in heart rate are observed than with either drug or task alone. An unexpected cardiovascular interaction was observed in subjects who inhaled cocaine and drank ethanol-containing beverages. This combination resulted in heart rate increases that were significantly larger than observed with either drug alone. Combinations of i.v. cocaine and smoked marijuana also increased heart rate above levels seen with either drug alone. A single intravenous dose of cocaine and morphine in combination, however, produced cardiovascular effects similar to those produced by cocaine alone. The effects of these drug combinations on blood pressure were often equal to the effect of one drug alone. Since cocaine is frequently taken in combination with potential treatment drugs, these interactions can be assessed under controlled settings prior to large-scale treatment studies. For instance, maintenance on the antidepressant desipramine increased baseline heart rate and diastolic pressure. Cocaine administration engendered increases in heart rate and blood pressure above the desipramine-elevated baselines. Clearly, drug interactions can have unexpected cardiovascular effects, and laboratory studies provide a controlled setting for understanding and studying these interactions.

Influence of naloxone upon motor activity induced by psychomotor stimulant drugs

Naloxone, an opioid receptor antagonist, attenuates a wide range of behavioral effects of d-amphetamine, such as the stimulation of motor activity. To investigate the pharmacological selectivity of the naloxone/amphetamine interaction, we assessed the effects of naloxone (5.0 mg/kg SC) upon motor activity induced in rats by a range of psychomotor stimulant drugs with a mechanism of action either similar to or different from that of d-amphetamine. Each of the drugs tested caused dose-dependent increases in both gross and fine activity. Naloxone attenuated the gross but not the fine activity response to d- and l-amphetamine, but had no influence upon the other catecholamine-releasing drugs, methamphetamine and phendimetrazine. In contrast, naloxone increased the gross but not the fine activity response to the catecholamine uptake inhibitors cocaine and mazindol, but had no effects upon the motor response to methylphenidate. The responses to other stimulant drugs (apomorphine, caffeine, scopolamine) were unaffected by naloxone pretreatment. The present findings extend the range of conditions under which naloxone and, by inference, endogenous opioid systems, modulate the behavioral response to psychomotor stimulants. However, the differential effects of naloxone upon the motor response to individual stimulant drugs support previous suggestions of fundamental differences in mechanisms of action among these compounds.

Endogenous opiates: 1992

This paper is the fifteenth installment of our annual review of research concerning the opiate system. It includes papers published during 1992 involving the behavioral, non-analgesic, effects of the endogenous opiate peptides. The specific topics this year include stress; tolerance and dependence; eating; drinking; gastrointestinal and renal function; mental illness and mood; learning, memory, and reward; cardiovascular responses; respiration and thermoregulation; seizures and other neurological disorders; electrical-related activity; general activity and locomotion; sex, pregnancy, and development; immunological responses; and other behaviors.