Predicting the Abuse Liability of Drugs with Animal Drug Self-Administration Procedures: Psychomotor Stimulants and Hallucinogens

Future Newborns with Opioid-Induced Neonatal Abstinence Syndrome (NAS) Could Be Assessed with the Genetic Addiction Risk Severity (GARS) Test and Potentially Treated Using Precision Amino-Acid Enkephalinase Inhibition Therapy (KB220) as a Frontline Modality Instead of Potent Opioids

In this nonsystematic review and opinion, including articles primarily selected from PubMed, we examine the pharmacological and nonpharmacological treatments of neonatal abstinence syndrome (NAS) in order to craft a reasonable opinion to help forge a paradigm shift in the treatment and prevention of primarily opioid-induced NAS. Newborns of individuals who use illicit and licit substances during pregnancy are at risk for withdrawal, also known as NAS. In the US, the reported prevalence of NAS has increased from 4.0 per 1000 hospital births in 2010 to 7.3 per 1000 hospital births in 2017, which is an 82% increase. The management of NAS is varied and involves a combination of nonpharmacologic and pharmacologic therapy. The preferred first-line pharmacological treatment for NAS is opioid therapy, specifically morphine, and the goal is the short-term improvement in NAS symptomatology. Nonpharmacological therapies are individualized and typically focus on general care measures, the newborn-parent/caregiver relationship, the environment, and feeding. When used appropriately, nonpharmacologic therapies can help newborns with NAS avoid or reduce the amount of pharmacologic therapy required and the length of hospitalization. In addition, genetic polymorphisms of the catechol-o-methyltransferase (COMT) and mu-opioid receptor (OPRM1) genes appear to affect the length of stay and the need for pharmacotherapy in newborns with prenatal opioid exposure. Therefore, based on this extensive literature and additional research, this team of coauthors suggests that, in the future, in addition to the current nonpharmacological therapies, patients with opioid-induced NAS should undergo genetic assessment (i.e., the genetic addiction risk severity (GARS) test), which can subsequently be used to guide DNA-directed precision amino-acid enkephalinase inhibition (KB220) therapy as a frontline modality instead of potent opioids.

Adverse effects of psychedelics: From anecdotes and misinformation to systematic science

BACKGROUND

Despite an increasing body of research highlighting their efficacy to treat a broad range of medical conditions, psychedelic drugs remain a controversial issue among the public and politicians, tainted by previous stigmatisation and perceptions of risk and danger.

OBJECTIVE

This narrative review examines the evidence for potential harms of the classic psychedelics by separating anecdotes and misinformation from systematic research.

METHODS

Taking a high-level perspective, we address both psychological and psychiatric risks, such as abuse liability and potential for dependence, as well as medical harms, including toxicity and overdose. We explore the evidence base for these adverse effects to elucidate which of these harms are based largely on anecdotes versus those that stand up to current scientific scrutiny.

RESULTS

Our review shows that medical risks are often minimal, and that many - albeit not all - of the persistent negative perceptions of psychological risks are unsupported by the currently available scientific evidence, with the majority of reported adverse effects not being observed in a regulated and/or medical context.

CONCLUSIONS

This highlights the importance for clinicians and therapists to keep to the highest safety and ethical standards. It is imperative not to be overzealous and to ensure balanced media reporting to avoid future controversies, so that much needed research can continue.

A Bayesian hierarchical model for individual participant data meta-analysis of demand curves

Individual participant data meta-analysis is a frequently used method to combine and contrast data from multiple independent studies. Bayesian hierarchical models are increasingly used to appropriately take into account potential heterogeneity between studies. In this paper, we propose a Bayesian hierarchical model for individual participant data generated from the Cigarette Purchase Task (CPT). Data from the CPT details how demand for cigarettes varies as a function of price, which is usually described as an exponential demand curve. As opposed to the conventional random-effects meta-analysis methods, Bayesian hierarchical models are able to estimate both the study-specific and population-level parameters simultaneously without relying on the normality assumptions. We applied the proposed model to a meta-analysis with baseline CPT data from six studies and compared the results from the proposed model and a two-step conventional random-effects meta-analysis approach. We conducted extensive simulation studies to investigate the performance of the proposed approach and discussed the benefits of using the Bayesian hierarchical model for individual participant data meta-analysis of demand curves.

Dopamine Circuit Mechanisms of Addiction-Like Behaviors

Addiction is a complex disease that impacts millions of people around the world. Clinically, addiction is formalized as substance use disorder (SUD), with three primary symptom categories: exaggerated substance use, social or lifestyle impairment, and risky substance use. Considerable efforts have been made to model features of these criteria in non-human animal research subjects, for insight into the underlying neurobiological mechanisms. Here we review evidence from rodent models of SUD-inspired criteria, focusing on the role of the striatal dopamine system. We identify distinct mesostriatal and nigrostriatal dopamine circuit functions in behavioral outcomes that are relevant to addictions and SUDs. This work suggests that striatal dopamine is essential for not only positive symptom features of SUDs, such as elevated intake and craving, but also for impairments in decision making that underlie compulsive behavior, reduced sociality, and risk taking. Understanding the functional heterogeneity of the dopamine system and related networks can offer insight into this complex symptomatology and may lead to more targeted treatments.

More than Smoke and Patches: The Quest for Pharmacotherapies to Treat Tobacco Use Disorder

Tobacco use is a persistent public health issue. It kills up to half its users and is the cause of nearly 90% of all lung cancers. The main psychoactive component of tobacco is nicotine, primarily responsible for its abuse-related effects. Accordingly, most pharmacotherapies for smoking cessation target nicotinic acetylcholine receptors (nAChRs), nicotine's major site of action in the brain. The goal of the current review is twofold: first, to provide a brief overview of the most commonly used behavioral procedures for evaluating smoking cessation pharmacotherapies and an introduction to pharmacokinetic and pharmacodynamic properties of nicotine important for consideration in the development of new pharmacotherapies; and second, to discuss current and potential future pharmacological interventions aimed at decreasing tobacco use. Attention will focus on the potential for allosteric modulators of nAChRs to offer an improvement over currently approved pharmacotherapies. Additionally, given increasing public concern for the potential health consequences of using electronic nicotine delivery systems, which allow users to inhale aerosolized solutions as an alternative to smoking tobacco, an effort will be made throughout this review to address the implications of this relatively new form of nicotine delivery, specifically as it relates to smoking cessation. SIGNIFICANCE STATEMENT: Despite decades of research that have vastly improved our understanding of nicotine and its effects on the body, only a handful of pharmacotherapies have been successfully developed for use in smoking cessation. Thus, investigation of alternative pharmacological strategies for treating tobacco use disorder remains active; allosteric modulators of nicotinic acetylcholine receptors represent one class of compounds currently under development for this purpose.

Evaluation of the Reinforcing Strength of Phendimetrazine Using a Progressive-Ratio Schedule of Reinforcement in Rhesus Monkeys

Stimulant abuse is a persistent public health problem with no Food and Drug Administration-approved pharmacotherapy. Although monoamine-releasing drugs such as d-amphetamine can decrease cocaine self-administration in human and animal laboratory studies, their potential for abuse limits clinical utility. "Abuse-deterrent" formulations of monoamine releasers, such as prodrugs, hold greater clinical promise if their abuse potential is, as theorized, lower than that of cocaine. In these studies, we determined the reinforcing strength of phendimetrazine (PDM), a prodrug for the amphetamine-like monoamine releaser phenmetrazine; both drugs have been shown to decrease cocaine self-administration in laboratory animals. To date, no study has directly compared PDM (Schedule III) with cocaine (Schedule II) under progressive-ratio (PR) schedules of reinforcement, which are better suited than fixed-ratio schedules to directly compare reinforcing strength of drugs. Dose-response curves for cocaine (saline, 0.001-0.3 mg/kg per injection) and PDM (0.1-1.0 mg/kg per injection) were generated in six cocaine-experienced male rhesus monkeys during 4-hour sessions with a 20-minute limited hold (LH). Under these conditions, the maximum number of injections was not significantly different between cocaine and PDM. The reinforcing strength of doses situated on the peaks of the cocaine and PDM dose-effect curves were redetermined with a 60-minute LH. The mean number of injections increased for both drugs, but not for saline. Cocaine presentations resulted in significantly higher peak injections than PDM with a 60-minute LH, which is consistent with the lower scheduling of PDM. These results support PDM as Schedule III and highlight the importance of schedule parameters when comparing reinforcing strength of drugs using a PR schedule of reinforcement. SIGNIFICANCE STATEMENT: One strategy for reducing cocaine use is to identify a treatment that substitutes for cocaine but has lower abuse potential. In a rhesus monkey model of drug abuse, this study compared the reinforcing strength of cocaine and phendimetrazine, a drug that has been shown to decrease cocaine use in some studies.

Effects of combined coffee and alcohol use over cigarette demand among treatment-seeking smokers

OBJECTIVE

This study is aimed at comparing the relative reinforcing efficacy (RRE) of nicotine though CPT performance in function of alcohol and coffee consumption of treatment-seeking smokers.

MATERIAL AND METHODS

A total of 88 treatment-seeking smokers (60.2 % female) completed the CPT. A multivariate analysis of variance (MANOVA) was used to compare alcohol (consumers and abstainers of alcohol) and coffee intake (high coffee consumers and low coffee consumers) on CPT indices.

RESULTS

Univariate effects of coffee × alcohol use interaction were significant for elasticity [F (1, 83) = 4.9435, p = .038, η2 = .051] and intensity [F (1, 83) = 6.972, p = .01, η2 = .077].

CONCLUSIONS

Alcohol and coffee use is associated with an elevated cigarette demand among treatment-seeking smokers. This finding suggests the need for specific interventions to reduce alcohol and coffee use in order to increase the effectiveness of treatments for smoking cessation.

Intravenous and oral caffeine self-administration in rats

Caffeine is widely consumed for its psychoactive effects worldwide. No pre-clinical study has established reliable caffeine self-administration, but we found that caffeine can enhance the reinforcing effects of non-drug rewards. The goal of the present studies was to determine if this effect of caffeine could result in reliable caffeine self-administration. In 2 experiments rats could make an operant response for caffeine delivered in conjunction with an oral 'vehicle' including saccharin (0.2% w/v) as a primary reinforcer. In Experiment 1, intravenous (IV) caffeine infusions were delivered in conjunction with oral saccharin for meeting the schedule of reinforcement. In control conditions, oral saccharin alone or presentations of IV caffeine alone served as the reinforcer. In Experiment 2, access to caffeine was provided in an oral vehicle containing water, decaffeinated instant coffee (0.5% w/v), or decaffeinated coffee and saccharin (0.2%). The concentration of oral caffeine was then manipulated across testing sessions. Oral and IV caffeine robustly increased responding for saccharin in a manner that was repeatable, reliable, and systematically related to unit IV dose. However, the relationship between oral caffeine dose and operant behavior was less systematic; the rats appeared to titrate their caffeine intake by reducing the consummatory response (drinking) rather than the appetitive response (lever pressing). These studies establish reliable volitional caffeine self-administration in rats. The reinforcement enhancing effects of caffeine may help to explain widespread caffeine use by humans, who ingest caffeine in complex vehicles with reinforcing properties.

Craving espresso: the dialetics in classifying caffeine as an abuse drug

Caffeine is the most consumed psychoactive substance in the world; in general, it is not associated to potentially harmful effects. Nevertheless, few studies were performed attempting to investigate the caffeine addiction. The present review was mainly aimed to answer the following question: is caffeine an abuse drug? To adress this point, the effects of caffeine in preclinical and clinical studies were summarized and critically analyzed taking account the abuse disorders described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). We concluded that the diagnostic criteria evidenced on DSM-V to intoxication-continued use and abstinence are not well supported by clinical studies. The fact that diagnostic criteria is not widely supported by preclinical or clinical studies may be due specially to a controversy in its exactly mechanism of action: recent literature point to an indirect, rather than direct modulation of dopamine receptors, and auto-limitant consumption due to adverse sensations in high doses. On the other hand, it reports clear withdrawal-related symptoms. Thus, based on a classical action on reward system, caffeine only partially fits its mechanism of action as an abuse drug, especially because previous research does not report a clear effect of dopaminergic activity enhance on nucleus accumbens; despite this, there are reports concerning dopaminergic modulation by caffeine on the striatum. However, based on human and animal research, caffeine withdrawal evokes signals and symptoms, which are relevant enough to include this substance among the drugs of abuse.

An intravenous self-administration procedure for assessing the reinforcing effects of hallucinogens in nonhuman primates

INTRODUCTION

Self-administration procedures are the gold standard for investigating the reinforcing effects of drugs. The notable exception to good correspondence between laboratory self-administration studies and human drug taking behavior has historically been the classic hallucinogens.

METHOD

The present study used a well-established daily access procedure, followed by a novel intermittent access procedure, to investigate the reinforcing effects of LSD in baboons.

RESULTS

Rates of self-injection in the daily access procedure were minimal. One baboon self-administered 0.001mg/kg and a second baboon self-administered 0.0032mg/kg above vehicle levels, though rates of self-injection were clearly low and neither of the two remaining baboons self-administered any LSD dose tested in the daily access procedure. Rates of self-injection using an intermittent access procedure with discriminative stimuli resulted in two doses of LSD being self-administered above vehicle levels in two of three baboons tested (0.01 and 0.032mg/kg in one baboon; 0.0032 and 0.01mg/kg in a second). In addition, the number of self-injections at these doses was higher (range=3-6 injections) in the intermittent access procedure than in the daily access procedure (range=1-2 injections).

DISCUSSION

The present study is the first to demonstrate LSD self-administration in a laboratory animal, and though the results are limited, they indicate intermittent access procedures with discriminative stimuli may provide a reliable and valid method for investigating the reinforcing effects of IV self-administered hallucinogens in laboratory animals. The usefulness of such procedures should be further evaluated in a larger number of subjects.

Nicotine reinforcement in never-smokers

RATIONALE

Global tobacco-related mortality dwarfs that of all other drugs. Nicotine is believed to be the primary agent responsible for tobacco use and addiction. However, nicotine is a relatively weak and inconsistent reinforcer in nonhumans and nicotine reinforcement has not been demonstrated in never-smokers.

OBJECTIVES

This study investigated the discriminative, subjective, and reinforcing effects of nicotine in never-smokers.

METHODS

Eighteen never-smokers (< 50 lifetime nicotine exposures) participated in a double-blind study. During a drug discrimination phase, volunteers ingested oral nicotine and placebo capsules (quasi-random order) at least 2 h apart and rated subjective effects repeatedly for 2 h after ingestion in daily sessions. Blocks of 10 sessions were continued until significant discrimination was achieved (p ≤ 0.05, binomial test; ≥ 8 of 10). Following discrimination, nicotine choice was tested by having volunteers choose which capsule set to ingest on each daily session. Successive blocks of 10 sessions were conducted until choice for nicotine or placebo met significance within each volunteer (≥ 8 of 10 sessions).

RESULTS

All 18 volunteers significantly discriminated nicotine from placebo; the lowest dose discriminated ranged from 1.0 to 4.0 mg/70 kg. Nine volunteers significantly chose nicotine (choosers) and nine significantly chose placebo (nicotine avoiders). The choosers reported predominately positive nicotine subjective effects (e.g., alert/attentive, good effects, liking), while avoiders tended to report negative effects (e.g., dizzy, upset stomach, disliking). Both choosers and avoiders attributed their choice to the qualitative nature of drug effects.

CONCLUSIONS

These results provide the first evidence that nicotine can function as a reinforcer in some never-smokers.

The Reinforcing Effects of Nicotine in Humans and Nonhuman Primates: A Review of Intravenous Self-Administration Evidence and Future Directions for Research

INTRODUCTION

Cigarette smoking is largely driven by the reinforcing properties of nicotine. Intravenous (IV) self-administration procedures are the gold standard for investigating the reinforcing effects of psychoactive drugs. The goal of this review was to examine the results of published investigations of the reinforcing effects of nicotine measured using IV self-administration procedures in humans and nonhuman primates.

RESULTS

The body of literature using nonhuman primate subjects indicates nicotine functions as a positive reinforcer when available for self-administration via IV catheters. However, it can also be difficult to establish IV nicotine self-administration in nonhuman primates and sometimes supplemental strategies have been required (e.g., priming injections or food deprivation) before subjects acquire the behavior. Although the body of literature using human subjects is limited, the evidence indicates nicotine functions as a reinforcer via the IV route of administration in adult cigarette smokers. Rates of nicotine self-injection can be variable across subjects and responding is sometimes inconsistent across sessions in both humans and nonhuman primates.

CONCLUSIONS

The Family Smoking Prevention and Tobacco Control Act, enacted in 2009, gave the Food and Drug Administration regulatory authority over the manufacture, marketing, and distribution of tobacco products. Research examining the threshold reinforcing doses for initiation and maintenance of nicotine self-administration, comparisons of the reinforcing effects of nicotine in adolescent versus adult subjects, investigations of gender differences in the reinforcing effects of nicotine, and studies of the abuse liability of non-nicotine tobacco product constituents and their ability to alter the reinforcing effects of nicotine will inform potential tobacco regulatory actions.

Measurement of food reinforcement in preschool children. Associations with food intake, BMI, and reward sensitivity

Progressive ratio (PR) schedules of reinforcement have been used to measure the relative reinforcing value (RRV) of food in humans as young as 8 years old; however, developmentally appropriate measures are needed to measure RRV of food earlier in life. Study objectives were to demonstrate the validity of the RRV of food task adapted for use among for preschool children (3-5 y), and examine individual differences in performance. Thirty-three children completed the RRV of food task in which they worked to access graham crackers. They also completed a snack task where they had free access these foods, liking and hunger assessments, and their heights and weights were measured. Parents reported on their child's reward sensitivity. Overall, children were willing work for palatable snack foods. Boys and older children made more responses in the task, while children with higher BMI z-scores and reward sensitivity responded at a faster rate. Children who worked harder in terms of total responses and response rates consumed more calories in the snack session. This study demonstrates that with slight modifications, the RRV of food task is a valid and developmentally appropriate measure for assessing individual differences in food reinforcement among very young children.

Effects of 14-day treatment with the schedule III anorectic phendimetrazine on choice between cocaine and food in rhesus monkeys

BACKGROUND

The clinical utility of monoamine releasers such as phenmetrazine or d-amphetamine as candidate agonist medications for cocaine dependence is hindered by their high abuse liability. Phendimetrazine is a clinically available schedule III anorectic that functions as a prodrug for phenmetrazine and thus may have lower abuse liability. This study determined the effects of continuous 14-day treatment with phendimetrazine on cocaine vs. food choice in rhesus monkeys (N=4).

METHODS

Responding was maintained under a concurrent schedule of food delivery (1-g pellets, fixed-ratio 100 schedule) and cocaine injections (0-0.1mg/kg/injection, fixed-ratio 10 schedule). Cocaine choice dose-effect curves were determined daily before and during 14-day periods of continuous intravenous treatment with saline or (+)-phendimetrazine (0.32-1.0mg/kg/h). Effects of 14-day treatment with (+)-phenmetrazine (0.1-0.32 mg/kg/h; N=5) and d-amphetamine (0.032-0.1mg/kg/h; N=6) were also examined for comparison.

RESULTS

During saline treatment, food was primarily chosen during availability of low cocaine doses (0, 0.0032, and 0.01 mg/kg/injection), and cocaine was primarily chosen during availability of higher cocaine doses (0.032 and 0.1mg/kg/injection). Phendimetrazine initially decreased overall responding without significantly altering cocaine choice. Over the course of 14 days, tolerance developed to rate decreasing effects, and phendimetrazine dose-dependently decreased cocaine choice (significant at 0.032 mg/kg/injection cocaine). Phenmetrazine and d-amphetamine produced qualitatively similar effects.

CONCLUSIONS

These results demonstrate that phendimetrazine can produce significant, though modest, reductions in cocaine choice in rhesus monkeys. Phendimetrazine may be especially suitable as a candidate medication for human studies because of its schedule III clinical availability.

Role of phenmetrazine as an active metabolite of phendimetrazine: evidence from studies of drug discrimination and pharmacokinetics in rhesus monkeys

BACKGROUND

Monoamine releasers such as d-amphetamine that selectively promote release of dopamine/norepinephrine versus serotonin are one class of candidate medications for treating cocaine dependence; however, their clinical utility is limited by undesirable effects such as abuse liability. Clinical utility of these compounds may be increased by development of prodrugs to reduce abuse potential by slowing onset of drug effects. This study examined the behavioral and pharmacokinetic profile of the Schedule III compound phendimetrazine, which may serve as a prodrug for the N-demethylated metabolite and potent dopamine/norepinephrine releaser phenmetrazine.

METHODS

Monkeys (n = 5) were trained in a two-key food-reinforced discrimination procedure to discriminate cocaine (0.32 mg/kg, IM) from saline, and the potency and time course of cocaine-like discriminative stimulus effects were determined for (+)-phenmetrazine, (-)-phenmetrazine, (+)-phendimetrazine, (-)-phendimetrazine, and (±)-phendimetrazine. Parallel pharmacokinetic studies in the same monkeys examined plasma phenmetrazine and phendimetrazine levels for correlation with cocaine-like discriminative stimulus effects.

RESULTS

Both isomers of phenmetrazine, and the racemate and both isomers of phendimetrazine, produced dose- and time-dependent substitution for the discriminative stimulus effects of cocaine, with greater potency residing in the (+) isomers. In general, plasma phenmetrazine levels increased to similar levels after administration of behaviorally active doses of either phenmetrazine or phendimetrazine.

CONCLUSIONS

These results support the hypothesis that phenmetrazine is an active metabolite that contributes to the effects of phendimetrazine. However, behavioral effects of phendimetrazine had a more rapid onset than would have been predicted by phenmetrazine levels alone, suggesting that other mechanisms may also contribute.

Agonist replacement therapy for cocaine dependence: a translational review

Cocaine use disorders are prevalent throughout the world. Agonist replacement therapy is among the most effective strategies for managing substance use disorders including nicotine and opioid dependence. This paper reviews the translational literature, including preclinical experiments, human laboratory studies and clinical trials, to determine whether agonist-replacement therapy is a viable strategy for managing cocaine dependence. Discussion is limited to transporter blockers (i.e., methylphenidate) and releasers (i.e., amphetamine analogs) that are available for use in humans in the hope of impacting clinical research and practice more quickly. The translational review suggests that agonist-replacement therapy, especially monoamine releasers, may be effective for managing cocaine dependence. Future directions for medications development are also discussed because the viability of agonist-replacement therapy for cocaine dependence may hinge on identifying novel compounds or formulations that have less abuse and diversion potential.

Caffeine use in children: what we know, what we have left to learn, and why we should worry

Caffeine is a widely used psychoactive substance in both adults and children that is legal, easy to obtain, and socially acceptable to consume. Although once relatively restricted to use among adults, caffeine-containing drinks are now consumed regularly by children. In addition, some caffeine-containing beverages are specifically marketed to children as young as 4 years of age. Unfortunately, our knowledge of the effects of caffeine use on behavior and physiology of children remains understudied and poorly understood. The purpose of this article is to review what is known about caffeine use in children and adolescents, to discuss why children and adolescents may be particularly vulnerable to the negative effects of caffeine, and to propose how caffeine consumption within this population may potentiate the rewarding properties of other substances. The following topics are reviewed: (1) tolerance and addiction to caffeine, (2) sensitization and cross-sensitization to the effects of caffeine, (3) caffeine self-administration and reinforcing value, and (4) conditioning of preferences for caffeine-containing beverages in both adults and children.

Critical assessment of how to study addiction and its treatment: human and non-human animal models

Laboratory models, both animal and human, have made enormous contributions to our understanding of addiction. For addictive disorders, animal models have the great advantage of possessing both face validity and a significant degree of predictive validity, already demonstrated. Another important advantage to this field is the ability of reciprocal interplay between preclinical and clinical experiments. These models have made important contributions to the development of medications to treat addictive disorders and will likely result in even more advances in the future. Human laboratory models have gone beyond data obtained from patient histories and enabled investigators to make direct observations of human drug self-administration and test the effects of putative medications on this behavior. This review examines in detail some animal and human models that have led not only to important theories of addiction mechanisms but also to medications shown to be effective in the clinic.

Pharmacotherapy of obesity

The growing recognition of the health risks of obesity coupled with the difficulties in treating it successfully by lifestyle modification predicates a need for effective drug treatment. The history of drug treatment in the second half of the 20th century is, however, one of disappointment and concern over drug toxicity. However, the advances in our understanding of the mechanism of weight control, together with improved ways of evaluating anti-obesity drugs, has resulted in two effective compounds, sibutramine and orlistat, becoming available for clinical use. Sibutramine has actions on both energy intake and expenditure and had been shown to enhance weight loss and weight maintenance achieved by diet, in simple obesity as well as when accompanied by complications of diabetes or hypertension. About 50-80% of patients can achieve a >5% loss, significantly more than if patients receive the same lifestyle intervention with placebo. Orlistat, which acts peripherally to block the absorption of dietary fat, has had similar results in clinical trials; a recent study (XENDOS) has just reported results which show that the enhanced, albeit modest, weight loss achieved with orlistat delays the development of diabetes over a 4-year period. A number of other compounds are expected to complete or enter clinical trials over the next decade. There is considerable optimism that we will soon have the pharmacological tools needed to make the treatment of obesity feasible.

Amphetamine-type central nervous system stimulants release norepinephrine more potently than they release dopamine and serotonin

A large body of evidence supports the hypothesis that mesolimbic dopamine (DA) mediates, in animal models, the reinforcing effects of central nervous system stimulants such as cocaine and amphetamine. The role DA plays in mediating amphetamine-type subjective effects of stimulants in humans remains to be established. Both amphetamine and cocaine increase norepinephrine (NE) via stimulation of release and inhibition of reuptake, respectively. If increases in NE mediate amphetamine-type subjective effects of stimulants in humans, then one would predict that stimulant medications that produce amphetamine-type subjective effects in humans should share the ability to increase NE. To test this hypothesis, we determined, using in vitro methods, the neurochemical mechanism of action of amphetamine, 3,4-methylenedioxymethamphetamine (MDMA), (+)-methamphetamine, ephedrine, phentermine, and aminorex. As expected, their rank order of potency for DA release was similar to their rank order of potency in published self-administration studies. Interestingly, the results demonstrated that the most potent effect of these stimulants is to release NE. Importantly, the oral dose of these stimulants, which produce amphetamine-type subjective effects in humans, correlated with the their potency in releasing NE, not DA, and did not decrease plasma prolactin, an effect mediated by DA release. These results suggest that NE may contribute to the amphetamine-type subjective effects of stimulants in humans.

Are we dependent upon coffee and caffeine? A review on human and animal data

Caffeine is the most widely used psychoactive substance and has been considered occasionally as a drug of abuse. The present paper reviews available data on caffeine dependence, tolerance, reinforcement and withdrawal. After sudden caffeine cessation, withdrawal symptoms develop in a small portion of the population but are moderate and transient. Tolerance to caffeine-induced stimulation of locomotor activity has been shown in animals. In humans, tolerance to some subjective effects of caffeine seems to occur, but most of the time complete tolerance to many effects of caffeine on the central nervous system does not occur. In animals, caffeine can act as a reinforcer, but only in a more limited range of conditions than with classical drugs of dependence. In humans, the reinforcing stimuli functions of caffeine are limited to low or rather moderate doses while high doses are usually avoided. The classical drugs of abuse lead to quite specific increases in cerebral functional activity and dopamine release in the shell of the nucleus accumbens, the key structure for reward, motivation and addiction. However, caffeine doses that reflect the daily human consumption, do not induce a release of dopamine in the shell of the nucleus accumbens but lead to a release of dopamine in the prefrontal cortex, which is consistent with caffeine reinforcing properties. Moreover, caffeine increases glucose utilization in the shell of the nucleus accumbens only at rather high doses that stimulate most brain structures, non-specifically, and likely reflect the side effects linked to high caffeine ingestion. That dose is also 5-10-fold higher than the one necessary to stimulate the caudate nucleus, which mediates motor activity and the structures regulating the sleep-wake cycle, the two functions the most sensitive to caffeine. In conclusion, it appears that although caffeine fulfils some of the criteria for drug dependence and shares with amphetamines and cocaine a certain specificity of action on the cerebral dopaminergic system, the methylxanthine does not act on the dopaminergic structures related to reward, motivation and addiction.

The role of dopamine in the behavioral effects of caffeine in animals and humans

Dopamine has been proposed to mediate some of the behavioral effects of caffeine. This review discusses cellular mechanisms of action that could explain the role of dopamine in the behavioral effects of caffeine and summarizes the results of behavioral studies in both animals and humans that provide evidence for a role of dopamine in these effects. Caffeine is a competitive antagonist at adenosine receptors and produces a range of central and physiological effects that are opposite those of adenosine. Recently, caffeine has been shown to enhance dopaminergic activity, presumably by competitive antagonism at adenosine receptors that are colocalized and interact functionally with dopamine receptors. Thus, caffeine, as a competitive antagonist at adenosine receptors, may produce its behavioral effects by removing the negative modulatory effects of adenosine from dopamine receptors, thus stimulating dopaminergic activity. Consistent with this interpretation, preclinical behavioral studies show that caffeine produces behavioral effects similar to classic dopaminergically mediated stimulants such as cocaine and amphetamine, including increased locomotor activity, increased turning behavior in 6-hydroxydopamine-lesioned animals, stimulant-like discriminative stimulus effects, and self-administration. Furthermore, caffeine potentiates the effects of dopamine-mediated drugs on these same behaviors, and some of caffeine's effects on these behaviors can be blocked by dopamine receptor antagonists. Although more limited in scope, human studies also show that caffeine produces subjective, discriminative stimulus and reinforcing effects that have some similarities to those produced by cocaine and amphetamine.

Dose-effect functions for cocaine self-administration: effects of schedule and dosing procedure

Research related to determining how procedural variables can alter dose-effect functions for cocaine self-administration is limited. Toward clarifying the role of procedural variables, responding was maintained in rats under either variable-interval (VI) or fixed-ratio (FR) schedules of cocaine infusion. In addition to free-operant FR schedules, discrete-trial FR schedules were evaluated. The dose-effect functions were obtained by either substituting a dose for the usual daily dose, instituting a particular dose for several sessions, or making all doses available within a session. Dose-effect functions for response rate (or number of trials with infusions for the discrete-trial FR) were bitonic for the VI and discrete-trial FR schedules but tended to be strictly decreasing for the free-operant FR schedules. Responding was maintained under FR schedules by a low dose (0.083 mg/infusion) if the dose was substituted for a higher daily dose but not when made available daily. Rate of response was higher under ratio schedules at 0.17 mg/infusion when this dose occurred within the context of other higher doses within a session than when the dose was simply substituted for a higher daily dose. These data indicate that procedural variables can alter dose-response curves for cocaine self-administration.

Use of drugs in the treatment of obesity

Obesity has become an epidemic in the United States and in many other countries of the world. Obesity is a chronic disease, not a failure of willpower. Diet, exercise, and behavioral modification of lifestyle are rarely successful over the long term. Medications have been used sparingly, because of concerns about addiction and ineffectiveness, but used chronically, obesity drugs are effective. The two main categories of obesity drugs are centrally active adrenergic and serotonergic agents. These drugs reduce appetite, enhance satiety, and increase energy expenditure. Use of single agents produces modest weight loss and use of combinations increases loss, but few patients reach their goal weight. Co-morbidities associated with obesity resolve or are reduced in severity with weight loss. Adverse events of major concern are changes in brain biochemistry and primary pulmonary hypertension. Published guidelines for use of obesity medications recommend they be used only for medically significant obesity.

Conditions sufficient for the production of oral cocaine or lidocaine self-administration in preference to water

Groups of rats were given a chronic history of drinking cocaine solutions of different concentrations in daily, 3-h schedule induced polydipsia sessions. Animals failed to develop a preference for cocaine solution to concurrently presented water. Schedule-induction conditions were maintained, and the animals were divided into separate groups, drinking either cocaine or lidocaine placed in a highly acceptable vehicle (glucose-saccharin solution). Animals preferred their respective drug solutions to concurrently presented water, and these preferences remained stable after the glucose-saccharin vehicle was gradually faded to water, leaving only cocaine or lidocaine, respectively, in the solution. Thus a stable preference for drug solution to water could be instituted in rats for either cocaine or lidocaine solution (putative reinforcing and nonreinforcing agents, respectively) given an appropriate associative history, with high intakes maintained by schedule-induction. Conditions sufficient for the initiation of an oral preference and high intake for a putatively reinforcing drug cannot be assumed to occur owing to the drug's reinforcing property in the absence of demonstrating the ineffectiveness of an appropriate negative control substance.

Combined drug treatment of obesity

Pharmacological treatment of obesity has been neglected as a viable therapeutic option for many years. Recent long term studies with combinations of obesity drugs gives promise that drugs may play a role in weight maintenance, which classically has been the most difficult aspect of treating obesity. Currently available obesity drugs include centrally acting adrenergic agents and serotonin agonists. Drugs still in development include a lipase inhibitor that produces fat malabsorption, a combined adrenergic-serotonergic reuptake inhibitor, various gut-central nervous system peptides, and a number of beta-3 agonists. Any of these obesity drugs given alone produces modest weight loss, and for most, weight loss continues for as long as medication is given. The most successful drug regimens to date are combinations of phentermine and fenfluramine or of ephedrine, caffeine, and/or aspirin. The former combination produces reduction in body weight and complications of obesity for 2 to almost 4 years in clinical trials to date. More research is needed to document long term efficacy and particularly the long term safety of these and other combinations.

Abuse of "BRON": a Japanese OTC cough suppressant solution containing methylephedrine, codeine, caffeine and chlorpheniramine

1. The paper describes the mental disturbances of 44 abusive cases of "BRON," an over-the-counter (OTC) cough suppressant solution containing methylephedrine, codeine, caffeine, and chlorpheniramine. 2. Major psychiatric symptoms observed included hallucinatory-paranoid state and affective disorder. There also were groups which exhibited a combination of the two states and abuse only. 3. The hallucinatory-paranoid state group had a relatively small BRON usage amount, short usage term and few withdrawal symptoms. The affective disorder group, in contrast, had large usage amount, longer usage term, and showed significant autonomic nerve disorders during withdrawal. These tendencies were seen more clearly in the mixed state group. 4. The hallucinatory-paranoid state group showed little or no physical dependence, while that of the affective disorder group was thought to be firmly established. Thus, in the former group, methylephedrine was considered the major behavior modifying drug, while in the latter, it was thought to be codeine.

Obesity: basic considerations and clinical approaches

Obesity, defined as an excess of body fat, can be measured with a variety of techniques, but in most epidemiologic studies it is estimated from height and weight or from skinfold thickness. The "gold standard" for body fat is the body density from which fat and fat-free body mass can be calculated. The new technique of bioelectric impedance analysis may substantially improve the estimation of total body fat. For estimating regional fat distribution, either waist to hip circumference ratio or subscapular skinfold have been most useful. Using the body mass index, defined as weight in kilograms divided by the square of the height in meters (kilogram per square meter), the National Health and Nutrition Examination Survey estimated that 26%, or 34 million, adult Americans aged 20 to 75 were overweight. The prevalence of severe overweight (a body mass index above 30 kg/m2) is higher in the United States and Canada than in Great Britain, the Netherlands, or Australia. Obesity results from an increase in energy intake relative to expenditure. Total daily energy expenditure includes energy used during resting metabolism, energy associated with the ingestion of food, and energy needed for physical activity. The obese are often observed to be less active, but since carrying a heavier load requires more energy, their total energy expenditure may not be low. A low resting metabolic rate has been suggested as a predictor of future risk of becoming obese. Adipose tissue is the major site for fat storage and may contain more than 90% of total energy stores. The increase in body mass index or degree of body weight is associated with an increased risk of heart disease, hypertension, gall bladder disease, and diabetes mellitus. When fat is centrally located in either males or females, the risk for these diseases is also increased, and may be a more important risk factor than total overweight itself. Genetic factors form the background from which obesity develops. The best estimates suggest that these genetic factors may be of less importance than environmental events in determination of total body fat and its distribution. Obesity can be classified on the basis of the total number of fat cells and regional fat distribution by using the etiological factors which caused the obesity or by determining the age at which the obesity began. Regardless of the cause, treatment for obesity should be based on an evaluation of the individual's risk from obesity as compared with the risk of the treatment under consideration. (ABSTRACT TRUNCATED AT 400 WORDS)

Drug treatment of obesity

Use of drugs for the treatment of obesity is regarded more skeptically than drug use in other chronic disease; this view, however, may be inappropriate. Anorexiant drugs, the major class of drugs currently available for treating obesity, differ in several important ways, including whether they act on noradrenergic or serotonergic systems and in their potential for abuse. New approaches to drug treatment of obesity include thermogenic agents and drugs acting on the digestive system and hormones.

Amantadine: evaluation of reinforcing properties and effect on cocaine self-injection in baboons

The ability of amantadine to maintain self-injection behavior and to alter self-administration of cocaine was examined in baboons using a standard intravenous cocaine self-injection procedure. Responding was maintained under a FR 80- or 160-response schedule of intravenous cocaine delivery (0.32 mg/kg per injection). Each drug injection was followed by a 3-h time-out allowing a maximum of 8 injections/day. Vehicle or amantadine doses were substituted for cocaine for a period of 15 or more days. Evaluation of a wide range of amantadine doses (0.32-32 mg/kg per injection) showed that this compound did not maintain self-administration behavior above vehicle control levels. In another experiment using the cocaine self-injection baseline, amantadine (10 or 32 mg/kg per day) was administered via a chronic intravenous infusion. Cocaine self-injection behavior was maintained and re-initiated during chronic amantadine exposure, suggesting that the reinforcing efficacy of cocaine was not modified by chronic amantadine administration.

Cocaine receptors on dopamine transporters are related to self-administration of cocaine

Although cocaine binds to several sites in the brain, the biochemical receptor mechanism or mechanisms associated with its dependence producing properties are unknown. It is shown here that the potencies of cocaine-like drugs in self-administration studies correlate with their potencies in inhibiting [3H]mazindol binding to the dopamine transporters in the rat striatum, but not with their potencies in binding to a large number of other presynaptic and postsynaptic binding sites. Thus, the cocaine receptor related to substance abuse is proposed to be the one associated with dopamine uptake inhibition.

Abuse potential evaluation of inhalants

Although inhalant abuse remains an important worldwide drug abuse problem, little is known about the relative abuse liability of specific inhalant compounds. This paper reviews approaches which might be used to investigate the abuse potential of inhalants in the laboratory, focusing primarily on animal studies. The principal approaches considered are inhalant self-administration and discrimination studies. A need is identified for further investigations of the abuse potential of inhalants to provide data which should be useful in shaping a more effective public health response to inhalant abuse.

Food deprivation fails to potentiate intravenous self-administration of fenfluramine in naive rats

Recent findings show that in animals, i.v. self-administration of D-amphetamine, cocaine and phentermine, which act predominantly upon catecholamine (CA) containing neurons, is potentiated following chronic restricted feeding. The objective in this experiment was to determine whether food deprivation would potentiate self-administration of fenfluramine, an anorectic compound which acts predominantly upon serotonin (5HT) containing neurons. When saline and five doses of fenfluramine were made available for i.v. self-administration to naive free-feeding (FF) rats or food-restricted (FR) rats at 80% free-feeding weight, the rate of fenfluramine-reinforced responding did not differ significantly from saline-reinforced responding at any dose or deprivation state. These data suggest that the potentiation of responding which occurs under conditions of chronic restricted feeding is specific to compounds which act predominantly upon CA containing neurons.