Neuropharmacologic and Behavioral Actions of Clonidine: Interactions With Central Neurotransmitters

The Cholinergic System as a Treatment Target for Opioid Use Disorder

Opioid overdoses recently became the leading cause of accidental death in the US, marking an increase in the severity of the opioid use disorder (OUD) epidemic that is impacting global health. Current treatment protocols for OUD are limited to opioid medications, including methadone, buprenorphine, and naltrexone. While these medications are effective in many cases, new treatments are required to more effectively address the rising societal and interpersonal costs associated with OUD. In this article, we review the opioid and cholinergic systems, and examine the potential of acetylcholine (ACh) as a treatment target for OUD. The cholinergic system includes enzymes that synthesize and degrade ACh and receptors that mediate the effects of ACh. ACh is involved in many central nervous system functions that are critical to the development and maintenance of OUD, such as reward and cognition. Medications that target the cholinergic system have been approved for the treatment of Alzheimer's disease, tobacco use disorder, and nausea. Clinical and preclinical studies suggest that medications such as cholinesterase inhibitors and scopolamine, which target components of the cholinergic system, show promise for the treatment of OUD and further investigations are warranted.

Pharmacological treatment for attention deficit hyperactivity disorder (ADHD) in children with comorbid tic disorders

BACKGROUND

This is an update of the original Cochrane Review published in Issue 4, 2011.Attention deficit hyperactivity disorder (ADHD) is the most prevalent of the comorbid psychiatric disorders that complicate tic disorders. Medications commonly used to treat ADHD symptoms include stimulants such as methylphenidate and amphetamine; non-stimulants, such as atomoxetine; tricyclic antidepressants; and alpha agonists. Alpha agonists are also used as a treatment for tics. Due to the impact of ADHD symptoms on the child with tic disorder, treatment of ADHD is often of greater priority than the medical management of tics. However, for many decades, clinicians have been reluctant to use stimulants to treat children with ADHD and tics for fear of worsening their tics.  OBJECTIVES: To assess the effects of pharmacological treatments for ADHD in children with comorbid tic disorders on symptoms of ADHD and tics.

SEARCH METHODS

In September 2017, we searched CENTRAL, MEDLINE, Embase, and 12 other databases. We also searched two trial registers and contacted experts in the field for any ongoing or unpublished studies.

SELECTION CRITERIA

We included randomized, double-blind, controlled trials of any pharmacological treatment for ADHD used specifically in children with comorbid tic disorders. We included both parallel-group and cross-over study designs.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures of Cochrane, in that two review authors independently selected studies, extracted data using standardized forms, assessed risk of bias, and graded the overall quality of the evidence by using the GRADE approach.

MAIN RESULTS

We included eight randomized controlled trials (four of which were cross-over trials) with 510 participants (443 boys, 67 girls) in this review. Participants in these studies were children with both ADHD and a chronic tic disorder. All studies took place in the USA and ranged from three to 22 weeks in duration. Five of the eight studies were funded by charitable organizations or government agencies, or both. One study was funded by the drug manufacturer. The other two studies did not specify the source of funding. Risk of bias of included studies was low for blinding; low or unclear for random sequence generation, allocation concealment, and attrition bias; and low or high for selective outcome reporting. We were unable to combine any of the studies in a meta-analysis due to important clinical heterogeneity and unit-of-analysis issues.Several of the trials assessed multiple agents. Medications assessed included methylphenidate, clonidine, desipramine, dextroamphetamine, guanfacine, atomoxetine, and deprenyl. There was low-quality evidence for methylphenidate, atomoxetine, and clonidine, and very low-quality evidence for desipramine, dextroamphetamine, guanfacine and deprenyl in the treatment of ADHD in children with tics. All studies, with the exception of a study using deprenyl, reported improvement in symptoms of ADHD. Tic symptoms also improved in children treated with guanfacine, desipramine, methylphenidate, clonidine, and a combination of methylphenidate and clonidine. In one study, tics limited further dosage increases of methylphenidate. High-dose dextroamphetamine appeared to worsen tics in one study, although the length of this study was limited to three weeks. There was appetite suppression or weight loss in association with methylphenidate, dextroamphetamine, atomoxetine, and desipramine. There was insomnia associated with methylphenidate and dextroamphetamine, and sedation associated with clonidine.

AUTHORS' CONCLUSIONS

Following an updated search of potentially relevant studies, we found no new studies that matched our inclusion criteria and thus our conclusions have not changed.Methylphenidate, clonidine, guanfacine, desipramine, and atomoxetine appear to reduce ADHD symptoms in children with tics though the quality of the available evidence was low to very low. Although stimulants have not been shown to worsen tics in most people with tic disorders, they may, nonetheless, exacerbate tics in individual cases. In these instances, treatment with alpha agonists or atomoxetine may be an alternative. Although there is evidence that desipramine may improve tics and ADHD in children, safety concerns will likely continue to limit its use in this population.

Effects of the α₂-adrenergic agonist clonidine on the pharmacodynamics and pharmacokinetics of 3,4-methylenedioxymethamphetamine in healthy volunteers

The mechanism of action of 3,4-methylenedioxymethamphetamine (MDMA; ecstasy) involves the carrier-mediated and potentially vesicular release of monoamines. We assessed the effects of the sympatholytic α₂-adrenergic receptor agonist clonidine (150 μg p.o.), which inhibits the neuronal vesicular release of norepinephrine, on the cardiovascular and psychotropic response to MDMA (125 mg p.o.) in 16 healthy subjects. The study used a randomized, double-blind, placebo-controlled crossover design with four experimental sessions. The administration of clonidine 1 h before MDMA reduced the MDMA-induced increases in plasma norepinephrine concentrations and blood pressure but only to the extent that clonidine lowered norepinephrine levels and blood pressure compared with placebo. Thus, no interaction was found between the cardiovascular effects of the two drugs. Clonidine did not affect the psychotropic effects or pharmacokinetics of MDMA. The lack of an interaction of the effects of clonidine and MDMA indicates that vesicular release of norepinephrine, which is inhibited by clonidine, does not critically contribute to the effects of MDMA in humans. Although clonidine may be used in the treatment of stimulant-induced hypertensive reactions, the present findings do not support a role for α₂-adrenergic receptor agonists in the prevention of psychostimulant dependence.

Pharmacological treatment for Attention Deficit Hyperactivity Disorder (ADHD) in children with comorbid tic disorders

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is the most prevalent of the comorbid psychiatric disorders that complicate tic disorders. Medications commonly used to treat ADHD symptoms include the stimulants methylphenidate and amphetamine; nonstimulants, such as atomoxetine; tricyclic antidepressants; and alpha agonists. Due to the impact of ADHD symptoms on the child with tic disorder, treatment of ADHD is often of greater priority than the medical management of tics. However, for many decades clinicians have been reluctant to use stimulants to treat children with ADHD and tics for fear of worsening their tics. 

OBJECTIVES

To assess the effects of pharmacological treatments for ADHD on ADHD symptoms and tic severity in children with ADHD and comorbid tic disorders. 

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library 2009, Issue 4), MEDLINE (1950 to July 2009), EMBASE (1980 to July 2009), CINAHL (1982 to July 2009), PsycINFO (1806 to July Week 4 2009) and BIOSIS Previews (1985 to July 2009). Dissertation Abstracts (searched via Dissertaation Express), and the metaRegister of Controlled Trials were searched (30 July 2009).

SELECTION CRITERIA

We included randomized, double-blind, controlled trials of any pharmacological treatment for ADHD used specifically in children with comorbid tic disorders. We included both parallel group and cross-over study designs.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data using standardized forms.

MAIN RESULTS

We included a total of eight randomized controlled studies in the review but were unable to combine any of these in meta-analysis. Several of the trials assessed multiple agents. Medications assessed included methylphenidate, clonidine, desipramine, dextroamphetamine, guanfacine, atomoxetine, and deprenyl. All treatments, with the exception of deprenyl, were efficacious in treating symptoms of ADHD. Tic symptoms improved in children treated with guanfacine, desipramine, methylphenidate, clonidine, and the combination of methylphenidate and clonidine. Fear of worsening tics limited dose increases of methylphenidate in one study. High dose dextroamphetamine appeared to worsen tics in one study, although the length of this study was limited.

AUTHORS' CONCLUSIONS

Methylphenidate, clonidine, guanfacine, desipramine and atomoxetine appear to reduce ADHD symptoms in children with tics. Although stimulants have not been shown to worsen tics in most people with tic disorders, they may nonetheless exacerbate tics in individual cases. In these instances, treatment with alpha agonists or atomoxetine may be an alternative. Although there is evidence that desipramine is effective for both tics and ADHD in children, safety concerns will likely continue to limit its use in this population.   

Multifunctional receptor-directed drugs for disorders of the central nervous system

The marked decline in FDA-approved new drug candidates in recent years suggests the possibility that the "low-hanging fruit" has been almost entirely harvested. This might be particularly applicable to drugs acting on the central nervous system. Fortunately, there are several examples extant for the utility of multifunctional drugs, compounds, or drug mixtures that act on multiple additive or synergistic targets. However, to exploit this approach may require the willingness to consider the possibility that drug targets might be addressed by molecules of rather low specificity and moderate potency. The expectation is that single target molecules with high specificity might not have access to complex interacting neural pathways, and that moderate potency could engender fewer off-target side effects. Though novel compounds might be developed by combining the active functional groups of two or more drug molecules, the approach still lends itself to high throughput screening of large chemical libraries. Multifunctional compounds might be designed with the ability to: 1) offer both palliative and disease modifying actions, 2) act on targets that produce additive or synergistic therapeutic responses, 3) simultaneously evoke a therapeutic response at the desired target and prevent an undesired response mediated by an alternate target, 4) allow one component to promote the drugable characteristics (e.g., brain penetration) of the therapeutic component, and 5) prolong the duration of effectiveness of one compound by contributing the pharmacodynamic actions of another. The author takes the liberty to include examples of the situations just mentioned from studies in his laboratory in the following discussion.

Pharmacotherapy of attention-deficit hyperactivity disorder in children and adolescents: update on new stimulant preparations, atomoxetine, and novel treatments

This article reviews data on the safety, tolerability, and efficacy of the extended-delivery stimulant preparations and atomoxetine, including nine methylphenidate formulations, five amphetamine formulations, and one norepinephrine reuptake inhibitor, now indicated for treatment of attention-deficit hyperactivity disorder (ADHD). Six of the nine methylphenidate formulations, three of the five compounds, and the norepinephrine reuptake inhibitor are long-acting, potentially once-daily agents. Data on treatment of common adverse events are described, and data on investigational treatments of ADHD are reviewed.

Opiate physical dependence and N-methyl-D-aspartate receptors

The present review focused the involvement of N-methyl-D-aspartate (NMDA) receptors in morphine physical dependence. The increased levels of extracellular glutamate, NMDA receptor zeta subunit (NR1) mRNA, NMDA receptor epsilon 1 subunit (NR2A) protein, phosphorylated Ca(2+)/calmodulin kinase II (p-CaMKII) protein, c-fos mRNA, c-Fos protein, are observed in the specific brain areas of mice and/or rats showing signs of naloxone-precipitated withdrawal. In preclinical and clinical studies, a variety of NMDA receptor antagonists and pretreatment with an antisense oligonucleotide of the NR1 have been reported to inhibit the development, expression and/or maintenance of opiate physical dependence. In contrast to data obtained in adult animals, NMDA receptor antagonists are neither effective in blocking the development of opiate dependence nor the expression of opiate withdrawal in neonatal rats. In the NMDA receptor-deficient mice, the NR2A knockout mice show the marked loss of typical withdrawal abstinence behaviors precipitated by naloxone. The rescue of NR2A protein by electroporation into the nucleus accumbens of NR2A knockout mice reverses the loss of abstinence behaviors. The activation of CaMKII and increased expression of c-Fos protein in the brain of animals with naloxone-precipitated withdrawal syndrome are prevented by NMDA receptor antagonists, whereas the increased levels of extracellular glutamate are not prevented by them. These findings indicate that glutamatergic neurotransmission at the NMDA receptor site contributes to the development, expression and maintenance of opiate dependence, and suggest that NMDA receptor antagonists may be a useful adjunct in the treatment of opiate dependence.

Changes in acetylcholinesterase activity and muscarinic receptor bindings in mu-opioid receptor knockout mice

Anatomical evidence indicates that cholinergic and opioidergic systems are co-localized and acting on the same neurons. However, the regulatory mechanisms between cholinergic and opioidergic system have not been well characterized. In the present study, we investigated whether there are compensatory changes of acetylcholinesterase activity and cholinergic receptors in mice lacking mu-opioid receptor gene. The acetylcholinesterase activity was determined by histochemistry assay. The cholinergic receptor binding was carried out by quantitative autoradiography using [3H]-quinuclidinyl benzilate (nonselective muscarinic receptors), N-[3H]-methylscopolamine (nonselective muscarinic receptors), [3H]-pirenzepine (M1 subtype muscarinic receptors) and [3H]-AF-DX384 (M2 subtype muscarinic receptors) in brain slices of wild-type and mu-opioid receptor knockout mice. The acetylcholinesterase activity of mu-opioid receptor knockout mice was higher than that of the wild-type in the striatal caudate putamen and nucleus accumbens, but not in the cortex and hippocampus areas. In addition, the bindings in N-[3H]-methylscopolamine and [3H]-AF-DX384 of mu-opioid receptor knockout mice were significantly lower when compared with that of the wild-type controls in the striatal caudate putamen and nucleus accumbens. However, there were no significant differences in bindings of [3H]-quinuclidinyl benzilate and [3H]-pirenzepine between mu-opioid receptor knockout and wild-type mice in the cortex, striatum and hippocampus. These data indicate that there are up-regulation of acetylcholinesterase activity and compensatory down-regulation of M2 muscarinic receptors in the striatal caudate putamen and nucleus accumbens of mu-opioid receptor knockout mice.

The Importance of Brainstem Cholinergic Neurons in the Pressor Response to Cocaine

After intracisternal injection, 140 nmol (48 microg) of cocaine (but not lidocaine or procaine) evoked an increase in mean arterial pressure (MAP) of 41 mm Hg. The increase in MAP began within 1 min after injection and lasted 10 to 15 min. The pressor response to intracisternal injection of cocaine was not mediated through central alpha-adrenergic receptors, but intracisternal pretreatment with D1 or D2 dopamine receptor antagonists shortened the duration of the response. Pretreatment with intracisternal injection of hemicholinium-3 to deplete medullary acetylcholine produced a dose-dependent inhibition of the pressor and tachycardic responses to intracisternal injection of cocaine. Central pretreatment with hemicholinium-3 also inhibited the pressor response to intravenous injection of 0.5 mg/kg cocaine. Atropine pretreatment was only partly effective in blocking the pressor and tachycardic responses to intracisternal injection of cocaine. However, a single intracisternal injection of the nicotinic ganglionic receptor blocker hexamethonium inhibited the pressor response to cocaine administered intracisternally 24 h later, and on each of the following 4 days. The blocking effect of hexamethonium was not mimicked by the alpha7 selective antagonist methyllycaconitine or by the alpha4beta2 subtype-preferring antagonist dihydro-beta-erythroidine. The data suggest that the pressor response to cocaine is mediated by medullary acetylcholine release on to nicotinic receptors of the ganglionic type, enhancing the output of bulbospinal sympathetic premotor neurons. Our results provide new evidence for the prolonged inactivation of relevant central nicotinic receptors by nicotinic receptor antagonists, and suggest that such compounds might be used safely for cocaine overdose, as well as for antiabuse issues without the concern for autonomic side effects.

Role of α7 Nicotinic Acetylcholine Receptors in the Pressor Response to Intracerebroventricular Injection of Choline: Blockade by Amyloid Peptide Aβ1-42

Systemic blood pressure and cardiac function have long been known to be under the control of central autonomic and hormonal pathways that, in part, use cholinergic neural systems. Recently choline, a precursor and product of acetylcholine metabolism, has been shown to serve as a selective endogenous agonist for the alpha7 subtype of the nicotinic acetylcholine receptor (alpha7nAChR). This receptor subtype mediates several responses to nicotine in animals, most notably, neuroprotection and enhanced cognition. The purpose of this study was to determine whether the cardiovascular changes induced by central injection of choline in rats also were mediated by alpha7nAChRs. Moreover, we sought to determine whether these cardiovascular changes to choline could be blocked by central pretreatment with amyloid beta peptide (1-42) (Abeta1-42), a neurotoxic component of cerebral amyloid that is known to bind with high affinity to alpha7nAChRs. Central, i.c.v. injection of choline (50, 100, or 150 microg) produced dose-dependent (10-15-min duration) pressor response of up to about 20 mm Hg. The most consistent change in heart rate included a brief increase (up to 40 beats/min) that lasted 2 to 3 min, followed by a prolonged decrease averaging 50 beats/min that lasted up to 30 min. Pretreatment (i.c.v.) with the selective alpha7nAChR antagonists alpha-bungarotoxin and methyllycaconitine significantly inhibited the pressor and heart rate responses to subsequent injection of choline. Pretreatment with the non-alpha7-preferring antagonist dihydro-beta-erythroidin was not effective. These findings suggested that the cardiovascular response to i.c.v. injection of choline was mediated at least in part through alpha7nAChRs. Pretreatment (30 min) with low doses (1-100 pmol) of amyloid peptide Abeta1-42 (but not with Abeta40-1) administered by the i.c.v. route significantly inhibited the choline-induced blood pressure increase as well as the choline-induced decrease in heart rate.

Potential cognitive actions of (n-propargly-(3r)-aminoindan-5-yl)-ethyl, methyl carbamate (tv3326), a novel neuroprotective agent, as assessed in old rhesus monkeys in their performance of versions of a delayed matching task

(N-propargyl-(3R)-aminoindan-5-yl)-ethyl, methyl carbamate (TV3326), a known neuroprotective agent exhibiting the properties of both an inhibitor of monoamine oxidase (brain selective) and an inhibitor of acetylcholinesterase was administered to seven old rhesus monkeys well trained to perform versions of a delayed matching-to-sample (DMTS) task. An increasing dose regimen of TV3326 was administered orally according to a schedule that allowed the animals to perform the standard DMTS task and a self-titrating version of the DMTS task each week during the study. A distractor version of the task was administered during two of the doses of TV3326. Under the conditions of this experiment TV3326 failed to significantly affect accuracy on the standard DMTS task; however, the drug was very effective in improving the ability of subjects to titrate to longer-duration delay intervals in the titrating version of the task. The maximal drug-induced extension of the self-titrated delay interval amounted to a 36.7% increase above baseline. This increase in maximum delay duration occurred without a significant change in overall task accuracy. TV3326 also significantly improved task accuracy during distractor (interference) sessions. The compound was effective enough to return group performance efficiency to standard DMTS vehicle levels of accuracy. These results were independent of whether trials were associated with a distractor or non-distractor delay interval, and they were independent of delay interval. The lack of delay selectivity in task improvement by TV3326 may not be consistent with a selective effect on attention. TV3326 was not associated with any obvious side effect or untoward reaction of the animals to the drug. Thus, TV3326 may be expected to offer a significant positive cognitive outcome in addition to its reported neuroprotective action.

The neurobiology and control of anxious states

Fear is an adaptive component of the acute "stress" response to potentially-dangerous (external and internal) stimuli which threaten to perturb homeostasis. However, when disproportional in intensity, chronic and/or irreversible, or not associated with any genuine risk, it may be symptomatic of a debilitating anxious state: for example, social phobia, panic attacks or generalized anxiety disorder. In view of the importance of guaranteeing an appropriate emotional response to aversive events, it is not surprising that a diversity of mechanisms are involved in the induction and inhibition of anxious states. Apart from conventional neurotransmitters, such as monoamines, gamma-amino-butyric acid (GABA) and glutamate, many other modulators have been implicated, including: adenosine, cannabinoids, numerous neuropeptides, hormones, neurotrophins, cytokines and several cellular mediators. Accordingly, though benzodiazepines (which reinforce transmission at GABA(A) receptors), serotonin (5-HT)(1A) receptor agonists and 5-HT reuptake inhibitors are currently the principle drugs employed in the management of anxiety disorders, there is considerable scope for the development of alternative therapies. In addition to cellular, anatomical and neurochemical strategies, behavioral models are indispensable for the characterization of anxious states and their modulation. Amongst diverse paradigms, conflict procedures--in which subjects experience opposing impulses of desire and fear--are of especial conceptual and therapeutic pertinence. For example, in the Vogel Conflict Test (VCT), the ability of drugs to release punishment-suppressed drinking behavior is evaluated. In reviewing the neurobiology of anxious states, the present article focuses in particular upon: the multifarious and complex roles of individual modulators, often as a function of the specific receptor type and neuronal substrate involved in their actions; novel targets for the management of anxiety disorders; the influence of neurotransmitters and other agents upon performance in the VCT; data acquired from complementary pharmacological and genetic strategies and, finally, several open questions likely to orientate future experimental- and clinical-research. In view of the recent proliferation of mechanisms implicated in the pathogenesis, modulation and, potentially, treatment of anxiety disorders, this is an opportune moment to survey their functional and pathophysiological significance, and to assess their influence upon performance in the VCT and other models of potential anxiolytic properties.

Opioid detoxification with buprenorphine, clonidine, or methadone in hospitalized heroin-dependent patients with HIV infection

With the growing role of intravenous drug use in the transmission of HIV infection, HIV-infected patients frequently present with comorbid opioid dependence. Yet, few empirical evaluations of the efficacy and consequences of opioid detoxification medications in medically ill HIV-infected patients have been reported. In a randomized, double-blind clinical trial, we evaluated the impact of three medications on the signs and symptoms of withdrawal and on the pain severity in heroin-dependent HIV-infected patients (N=55) hospitalized for medical reasons on an inpatient AIDS service. Patients received a 3-day pharmacologic taper with intramuscular buprenorphine (n=21), oral clonidine (n=16), or oral methadone (n=18), followed by a clonidine transdermal patch on the fourth day. Observed and self-reported measures of opioid withdrawal and pain were taken 1-3 times daily for up to 4 days. Opiate administration used as medically indicated for pain was also recorded. Observer- and subject-rated opiate withdrawal scores decreased significantly following the first dose of medication and overall during treatment. Among all 55 subjects, self-reported and observer-reported pain decreased after treatment (on average observer-rated opioid withdrawal scale (OOWS) scores declined 5.6 units and short opioid withdrawal scale (SOWS) declined 4.8 units, P<0.001, for both) with no indication of increased pain during medication taper. There were no significant differences of pain decline and other measures of withdrawal between the three treatment groups. During the intervention period, supplemental opiates were administered as medically indicated for pain to 45% of the patients; only 34% of men versus 62% of women received morphine (P<0.05). These findings suggest buprenorphine, clonidine, and methadone regimens each decrease opioid withdrawal in medically ill HIV-infected patients.

Nicotine applied by transdermal patch induced HSV-1 reactivation and ocular shedding in latently infected rabbits

The identification of factors involved in herpes virus latency and reactivation is critical to a better understanding of the mechanisms essential to viral neuroinvasiveness and neurovirulence. Recurrent episodes of ocular herpes infections cause irreversible corneal scarring and are the primary cause of loss of vision due to an infectious agent in industrialized countries. In this study, we examined the ability of nicotine, a compound known to be involved in stress-associated immunomodulation and recognized as one of the most frequently used addictive agents, to induce ocular shedding in rabbits latently infected with herpes simplex virus type 1 (HSV-1) strain McKrae. New Zealand white rabbits latently infected with HSV-1 at 3-4 weeks post-inoculation were randomly divided into two groups. The corneas of all rabbits were free of lesions as verified by slit lamp biomicroscopy. One group received nicotine by transdermal patch (21 mg/day) for 20 days and the other group served as the control. Reactivation data were obtained by detection of virus in tear film collected by ocular swabbing performed concurrently with the administration of nicotine. Compilation of data from three separate experiments demonstrated that 16.5% (258/1560) of the swabs taken from rabbits treated with nicotine were positive for virus, compared with 8.3% (53/639) of swabs taken from controls. Rabbits receiving nicotine exhibited a significantly (P < 0.0001) higher rate of ocular shedding than controls. The concentration of nicotine in the serum was determined at various times (0-24 hrs) after new patch replacement. Peak (average) serum level of nicotine was obtained 8 hours after patch replacement and exhibited a broad range of values (0.233 microg/mL-6.21 microg/mL). These results suggest that an initial systemic exposure to nicotine significantly increases HSV-1 reactivation. Further studies are needed to reveal any effects of nicotine dependency and nicotine withdrawal on herpesvirus reactivation.

Adaptive changes in M1 muscarinic receptors localized to specific rostral brain regions during and after morphine withdrawal

Morphine-dependent rats were allowed to undergo withdrawal by abrupt discontinuation of the drug. The regional expression of brain M1 muscarinic receptors was measured directly by autoradiographic determination with [(3)H] pirenzepine, and indirectly by quantifying the relative levels of M1 mRNA encoding the receptor protein. Patterns of receptor changes after morphine treatment were in general agreement using the two methods. Frontal cortical samples derived from morphine-dependent rats exhibited a 28% increase in M1 receptor mRNA measured at the end of the infusion. At the peak of the withdrawal, M1 mRNA levels for dependent rats were much lower (33.4%) than those for control rats. Hippocampal samples derived from morphine-dependent rats exhibited no changes in M1 mRNA levels after the morphine infusion. During the peak of withdrawal, however, hippocampal M1 mRNA levels were reduced (57%) compared with levels for controls. The M1 mRNA levels remained at this reduced degree of expression even after withdrawal symptoms had subsided. Addition of diisopropylflurophophate (DFP) to the morphine infusion schedule inhibited the adaptive changes in M1 mRNA levels induced by morphine. During the peak period of withdrawal, M1 mRNA levels in the hippocampus declined by only 18% as compared with 57% for the morphine control group. The adaptive decrease in hippocampal M1 receptors after withdrawal subsided may reflect prolonged heightened cholinergic activity in an area where such cholinergic innervation plays an important role in memory.

Prevention of precipitated withdrawal symptoms by activating central cholinergic systems during a dependence-producing schedule of morphine in rats

Previous studies in this and other laboratories have suggested an important role for central cholinergic neurons in the expression of morphine withdrawal symptoms. This study was designed to determine whether the symptoms of withdrawal could be mitigated by normalization of the effect of morphine on cholinergic neurons. Since this effect is generally inhibitory, we used centrally acting cholinergic agonists to augment central cholinergic tone during chronic morphine infusion. Rats were made dependent following the intra-arterial (i.a.) infusion of increasing concentrations (35-100 mg kg(-1) day(-1)) of morphine over 5 days. I.a. injection of 0.5 mg/kg of naloxone precipitated a profound withdrawal response that included a dramatic increase in mean arterial pressure (MAP) which was maintained over the 60-min observation period, a short duration increase in heart rate (HR), and characteristic opiate withdrawal symptoms. In separate groups of rats, non-toxic doses (50 and 250 microg/kg) of the acetylcholinesterase (AChE) inhibitor, diisopropylflurophosphate (DFP) were administered as single daily injections concomitant with the morphine infusion. DFP treated rats, exhibited significantly reduced expression of the naloxone-evoked pressor response. The apparent anti-withdrawal effect of DFP was not reproduced by the selective peripherally acting AChE inhibitor, echothiophate, although both compounds effectively reduced the expression of certain other withdrawal symptoms. The centrally acting muscarinic cholinergic receptor agonist, arecoline, resulted in an even more impressive suppression of withdrawal symptoms. While not all symptoms associated with morphine withdrawal are mediated via central cholinergic pathways, these results suggest that physical dependence on morphine can be suppressed to a significant degree by the augmentation of central cholinergic activity during morphine administration.

Adrenoceptor involvement in the cardiovascular responses to B-HT 920 in sinoaortic denervated rats

1. A study was made relating the involvement of alpha-adrenoceptors in the cardiovascular responses to intracerebroventricular (i.c.v.) injection of B-HT 920, a clonidine-type drug, in conscious sham-operated and sinoaortic-denervated rats. 2. Wistar rats were used, 7 days after the sham operation or sinoaortic denervation. For i.c.v. injection of drugs, a guide cannula had been previously implanted in the left lateral ventricle. 3. In sham-operated rats, cardiovascular responses to B-HT 920 (10-60 microg) were increased blood pressure and bradycardia; but, in sinoaortic-denervated rats, after the pressor response, a decrease in blood pressure also was seen. The responses to this agent were greater in sinoaortic-denervated rats than in sham-operated animals. Treatment with the alpha2-adrenoceptor antagonist yohimbine (30 microg), the imidazoline receptor antagonist idazoxan (15 microg) and the alpha1A-adrenoceptor antagonist 5-methylurapidil (15 microg) blocked the responses to B-HT 920 (30 microg). The alpha1-adrenoceptor antagonist prazosin (15 microg) and the alpha1B-adrenoceptor antagonist chloroethylclonidine (100 microg) did not modify the responses to agonist. 4. Sinoaortic denervation enhances the cardiovascular responses to B-HT 920. Moreover, the effects of i.c.v. administration of B-HT 920 could be mediated by several types of brain receptors: imidazoline receptors and alpha1A- and alpha2-adrenoceptors.

Antagonist precipitated clonidine withdrawal in rat: effects on locus coeruleus neurons, sympathetic nerves and cardiovascular parameters

The goal of the present study was to examine the effect of clonidine withdrawal on the neural control of blood pressure. Rats were treated for 7-13 days with clonidine via osmotic minipumps (200 microg kg(-1) day(-1), s.c.). Controls received saline or were sham operated. Withdrawal was precipitated by the alpha2-adrenergic receptor (alpha2-AR) antagonist atipamezole. Most experiments were done under halothane anesthesia. Chronic treatment with clonidine did not change mean arterial pressure (MAP) or heart rate (HR) but raised femoral artery resistance and the activity of locus coeruleus neurons slightly. Atipamezole given to rats treated chronically with clonidine produced the following effects: no change in MAP, severe tachycardia, sustained increase in splanchnic sympathetic nerve discharge (SND; +75 +/- 13%), transient increase in lumbar SND (+23 +/- 7%), ON-OFF activity pattern in the locus coeruleus (LC). The ON phase of LC activity was synchronized with upswings of SND and with small changes in MAP. A second alpha2-AR antagonist, methoxyidazoxan, produced effects identical to those of atipamezole. Atipamezole given to control rats produced no effect on MAP, HR, SND or LC activity. Atipamezole reversed the hypotension, sympathoinhibition and bradycardia produced by acute administration of clonidine. In awake rats treated chronically with clonidine, atipamezole did not change MAP but produced arterial pressure lability and tachycardia. In conclusion, under anesthesia, selective alpha2-AR antagonists elicit a clonidine withdrawal syndrome that displays autonomic characteristics reminiscent of the spontaneous withdrawal syndrome found in awake rats. The most prominent features of this syndrome are tachycardia, sympathoactivation, lack of hypertension and an oscillating activity pattern of brainstem neurons leading to abrupt changes in SND and in MAP.

Autoradiographic comparison of muscarinic M1 and M2 binding sites in the CNS of spontaneously hypertensive and normotensive rats

Spontaneously hypertensive rats (SHR) respond with exaggerated pressor responses of central origin in response to pharmacologic stimulation of brain muscarinic receptors when compared with those to normotensive Wistar Kyoto (WKY) rats. At least part of the enhanced response to central muscarinic stimulation may be due to alterations in the expression of one or more of the five subtypes of muscarinic receptors. SHR are also known to exhibit regional alterations in the levels of mRNA encoding the M1, M2 and M4 receptors. In this study, we estimated the number of specific muscarinic receptor binding sites in 12-week-old SHR and WKY by measuring the binding of M1- and M2-selective ligands. Using standard autoradiographic techniques, coronal sections obtained from 12-week-old SHR and WKY were incubated with [3H]pirenzepine or [3H]AFDX 384 to label M1 and M2 receptors, respectively. Although both strains exhibited similar distribution patterns for both binding sites, sections derived from SHR expressed a significant increase in the number of [3H]pirenzepine binding sites compared to normotensive WKY in caudate putamen, CA3 region of the hippocampus, cingulate cortex, substantia nigra, posterior hypothalamic area and tuberomammillary nucleus. An increased number of [3H]AFDX 384 binding sites in SHR were observed in the olfactory tubercle, nucleus accumbens, basolateral amygdaloid nucleus, rostroventrolateral medulla and nucleus paragigantocellularis. Decreases in the number of [3H]AFDX 384 binding sites in SHR were also observed in the parietal cortex, medial geniculate, and lateral hypothalamic area. Statistically significant site-selective differences in binding densities between strains ranged from 4.0% to 35.5% of WKY means. These alterations in the expression of M1 and M2 binding sites in cardiovascular regions may contribute to the strain's hyper-responsiveness to cholinergic drugs and possibly to the appearance of other autonomic or behavioral phenotypes exhibited by SHR, including the hypertensive state itself.

The role of alpha-2 adrenoceptors in the regulation of oxytocin neurones in the suckled rat

The role of alpha-2 adrenoceptors in the milk-ejection reflex was investigated by making electrophysiological recordings from oxytocin neurones in the supraoptic nucleus of urethane-anaesthetised rats. Systemic administration of the alpha-2 adrenoceptor antagonist. Idazoxan (0.5 mg/kg, i.v.), temporarily suppressed OT cell bursting activity, while having no consistent action on basal neuronal activity. Clonidine (25 micrograms/kg, i.v.) caused an immediate increase in the frequency and amplitude of oxytocin cell bursting, coincident with a fall in basal activity. A higher dose of clonidine (50 micrograms/kg, i.v.), inhibited both bursting and basal activity. These results indicate that alpha-2 adrenoceptors are essential for the normal functioning of the milk-ejection reflex and may be involved in the facilitatory and inhibitory regulation of suckling-evoked bursting in oxytocin neurones.

Effect of intrathecal pretreatment with the neurokinin receptor antagonist CP-99994 on the expression of naloxone-precipitated morphine withdrawal symptoms

In morphine-dependent rats pretreated with an intrathecal injection of saline (vehicle), intraarterial injection of 0.5 mg/kg of naloxone produced an immediate increase in blood pressure. Heart rate increased in most rats just after naloxone injection; however, the responses were transient, not lasting more than about 4 min after injection. Naloxone-precipitated behavioral changes were dominated by the appearance of body shakes and escape attempts that were strongly expressed during the first 10 min after naloxone. Pretreatment of morphine-dependent rats with an intrathecal injection of 100 nmol of the neurokinin-1 receptor antagonist CP-99994 significantly inhibited the magnitude and shortened the duration of the pressor response to naloxone. CP-99994 did ot reduce the expression of the associated withdrawal behaviors. Substance P significantly reversed the inhibitory effects of CP-99994 on the expression of the withdrawal-associated pressor response. Intrathecal pretreatment with CP-99994 also produced a dose-dependent inhibition of the expression of the pressor response to local spinal (intrathecal) injection of naloxone (60 micrograms) in morphine dependent rats without significant alteration of the expression of withdrawal-associated behaviors. These results indicate that spinal neurokinin-1 receptors mediate some of the cardiovascular signs of morphine withdrawal and suggest the possibility of developing a novel class of antiopiate withdrawal agents.

Elective mutism: an analysis of 100 cases

OBJECTIVE

An extended series of 100 children with elective mutism (EM) was clinically analyzed.

METHOD

The total sample included two subgroups of clinically referred children at different locations and a subgroup of nonreferred children with EM. The study was based on comprehensive item sheets and, in the nonreferred sample only, the Child Behavior Checklist.

RESULTS

EM is a rare disorder in the referred child psychiatric samples. It typically starts at preschool age, is more common in girls, and is seen in all social strata. A background of migration and early developmental risk factors is also quite common. Premorbid speech and language disorders play a role in one third of the clientele, and three quarters of children with EM had behavioral abnormalities during infancy and preschool age. School and unfamiliar people create the social context in which children with EM most frequently do not speak. Shyness and internalizing behavior problems are the most common personality features in EM, and comorbid diagnoses are quite frequent.

CONCLUSION

This large series of affected children has identified the most typical features of EM and thereby extends the limited knowledge of this rare disorder of childhood.

Altered thermoregulatory responses to clonidine in streptozotocin-diabetic rats

1. The effects of streptozotocin (STZ) treatment on alpha 2-adrenoceptor regulation of body temperature were studied by monitoring the response of colonic temperature to administration of clonidine. 2. A dose-dependent fall in colonic temperature occurred in control rats given clonidine challenge (0.05-2.0 mg kg-1, s.c.); this response was inhibited by prior administration of either yohimbine or idazoxan (2 mg kg-1, s.c.) but not by the peripherally-acting alpha 2-adrenoceptor antagonist L-659,066 (10 mg kg-1, s.c.). 3. In rats treated with STZ (65 mg kg-1, i.v.) administration of clonidine elicited a dose-independent hyperthermia (circa 1 degree C.); this effect was unaltered by prior administration of yohimbine or idazoxan. 4. Naloxone (5 mg kg-1, s.c.) elicited a small fall in temperature (< 1 degree C.) in both control and STZ-treated rats; naloxone pretreatment did not alter the temperature response to clonidine in either group. 5. Nicotinic acid (10 mg kg-1, s.c.) caused a similar small elevation in temperature in both groups. 6. Administration of replacement insulin to STZ-treated rats maintained weight gain and low blood glucose while the thermoregulatory response to clonidine slowly reverted to normal. 7. These results show that altered central temperature control is an element of the generalised abnormality of alpha 2-receptor function induced by STZ.

Spinal NMDA receptor--nitric oxide mediation of the expression of morphine withdrawal symptoms in the rat

Previous studies in this laboratory have demonstrated that cholinergic receptors within the spinal cord play an important role in the expression of naloxone-precipitated withdrawal symptoms in the morphine-dependent rat. Related cardiovascular studies in non-dependent animals have demonstrated that this spinal cholinergic system is linked to a glutamatergic, NMDA pressor pathway which also involves the participation of a nitric oxide (NO) generating system. The purpose of this study was to determine whether spinal NMDA receptors and/or NO are involved in the expression of morphine withdrawal symptoms. Rats bearing previously implanted intrathecal (IT) catheters were dependent on morphine following chronic i.a. infusion of increasing doses over 5 days. Naloxone (0.5 mg/kg) was administered via the i.a. line to precipitate withdrawal; and both cardiovascular and behavioral symptoms were recorded over 60 min. Pretreatment 20 min before naloxone with IT injection of either of the NMDA receptor antagonists, MK-801 or AP-7 (100-200 nmol), produced a significant reduction in the expression of both the cardiovascular and behavioral symptoms of up to about 60%. IT pretreatment with the NO synthase inhibitor L-NAME--a methyl ester derivative of L-arginine, also produced a dose-dependent, L-arginine reversible inhibition of the cardiovascular (mainly the pressor) component of withdrawal, but had no significant effect on the expression of behavioral signs. In contrast, IT pretreatment with L-NOARG and L-NMMA, non-ester analogs of L-arginine, significantly inhibited the expression of the behavioral signs of withdrawal but did not alter the pressor component. A combined pretreatment with L-NAME and L-NOARG resulted in suppression of both pressor and behavioral components of withdrawal. The anti-withdrawal actions of either class of NO synthase inhibitor could not be attributed to blockade of local muscarinic receptors. These findings are consistent with a role for both spinal NMDA receptors and a NO generating system in the expression of both the behavioral and autonomic components of naloxone-precipitated withdrawal. They also suggest that different structural analogs of L-arginine have different profiles of activity in this regard--opening the possibility that different isozymes of NO synthase located within the same spinal region mediate different physiological or behavioral functions.

Alterations in the expression of the genes encoding specific muscarinic receptor subtypes in the hypothalamus of spontaneously hypertensive rats

A significant body of evidence exists that is consistent with the possibility that heightened cholinergic activity in certain brain regions, such as the hypothalamus, leads to increased sympathetic tone and subsequent hypertension. The increase in cholinergic activity is mediated at least in part through enhanced sensitivity of muscarinic receptors. In this study, we used the technique of reverse transcriptase-polymerase chain reaction to estimate the relative levels of mRNA encoding the five known subtypes of muscarinic receptors within the hypothalamus of spontaneously hypertensive rats (SHR), a genetic model of the disease, and their normotensive counterparts (Wistar-Kyoto rats). SHR exhibited a significant increase (40% to 50%) in the excitatory M1 subtype (confirmed by receptor binding) and a decrease in the inhibitory M4 subtype of muscarinic receptors before and during the establishment of hypertension. Such alterations may form part of the genotypic profile of inherited hypertension.

The role of excitatory amino acids in the expression of precipitated acute and chronic clonidine withdrawal: an in vivo voltammetric study in the rat locus coeruleus

It has been previously shown that activation of excitatory amino acid (EAA) pathways contributes to hyperactivity of the locus coeruleus (LC) in antagonist precipitated opioid withdrawal. In this study, using differential normal pulse voltammetry to monitor catechol oxidation as an index of the activity of the LC, the role of EAA pathways in antagonist precipitated withdrawal after acute and chronic clonidine treatment was examined. Intracerebroventricular clonidine (10 micrograms i.c.v.) significantly reduced LC activity to 54.4 +/- 3.1% of baseline 45 minutes following the injection. Subsequent systemic injection of the selective alpha 2 receptor antagonist atipamezole (0.2 mg/kg i.v.) or yohimbine (0.5 mg/kg i.v.) resulted in a rapid reversal of the depressant effects and a significant increase in LC activity above baseline. Pretreatment with the non-selective EAA receptor antagonist gamma-D-glutamylglycine (DGG) (50 micrograms i.c.v.) attenuated the atipamezole-induced rebound response of the LC but not the reversal of clonidine action. However, both the yohimbine-induced rebound and reversal of clonidine effects were attenuated by DGG treated animals. In chronic clonidine treated animals (2, 5, 7, 10 micrograms/h i.c.v., 5 days), a challenge with atipamezole (0.2 mg/kg i.v.) produced an immediate increase in LC activity, blood pressure and heart rate. The magnitude of these responses was dependent on the dose of clonidine. The atipamezole-induced increase in LC activity and blood pressure was significantly attenuated by pretreatment with DGG (200 micrograms i.c.v.). These findings suggest that LC hyperactivity and blood pressure increases elicited during clonidine withdrawal are mediated in part by activation of EAA receptors. In this regard, the mechanisms underlying clonidine withdrawal closely resembles those underlying opioid withdrawal.

Localization of cholinergic neurons involved in the cardiovascular response to intrathecal injection of carbachol

Recent studies in this laboratory have demonstrated the ability of acetylcholine receptor agonists to produce systemic arterial pressor responses through stimulation of spinal muscarinic receptors. In urethane-anesthetized rats a new surgical procedure was employed to permit microinjection of drugs into the cerebrospinal fluid surrounding the medulla without significant redistribution to spinal sites and vice versa. Pretreatment with intracisternal (medullary level) injection of 10 micrograms of atropine significantly inhibited the expression of the pressor response produced by intrathecal injection of 5 micrograms of carbachol. This inhibition was due at least partly to the interruption of a medullary component of a spinobulbar pathway involving medullary muscarinic receptors. It was not due to redistribution of atropine from medullary to spinal sites since significant levels of atropine were not detected in the spinal cord after intracisternal injection of the drug. The remainder of the pressor response to intrathecal carbachol after medullary muscarinic receptor blockade was most likely due to interactions within the spinal cord itself.

Role of spinal and supraspinal muscarinic receptors in the expression of morphine withdrawal symptoms in the rat

Previous studies in this laboratory have demonstrated that prior intracerebroventricular (i.c.v.) administration of the muscarinic antagonist, 4-diphenylacetoxy-N-methylpiperidine methiodide (4-DAMP) in morphine dependent rats significantly attenuates the development of cardiovascular and certain behavioral responses precipitated by the opiate antagonist, naloxone. The purpose of this study was to determine whether both supraspinal and spinal cholinergic neurons are involved in the expression of withdrawal symptoms. Employing localized (i.c.v. or intrathecal, i.t.) infusions of muscarinic antagonists, it was determined that a significant antiwithdrawal action could be produced through both an inhibition of supraspinal and spinal cholinergic neurons. Pharmacological difference emerged regarding the antiwithdrawal potential of 4-DAMP and the partially M1 selective antagonist, pirenzepine. While our previous studies had revealed that pirenzepine had essentially no antiwithdrawal activity when administered by the i.c.v. route, in the present study, pirenzepine evoked a marked antiwithdrawal action by the i.t. route, significantly inhibiting both cardiovascular and behavioral signs of withdrawal. In contrast, 4-DAMP which was effective by the i.c.v. route (especially for the cardiovascular symptoms), elicited no antiwithdrawal action by the i.t. route. As a muscarinic antagonist (ability to block the pressor response to central injection of carbachol) 4-DAMP was equally active by i.c.v. or i.t. injection. However, pirenzepine was clearly more effective in this regard by the i.t. route. These results are consistent with ability of muscarinic antagonists to offer significant anti-morphine withdrawal activity at both supraspinal and spinal locations. They also suggest that different muscarinic systems, possibly different receptor subtypes, mediate the expression of morphine withdrawal symptoms within the two regions of the CNS.

Mechanism of the hypertensive response to central injection of nicotine in conscious rats

The purpose of this study was to examine the effects of nicotine administered directly into the CNS on mean arterial pressure (MAP) and heart rate to avoid the direct peripheral action of the drug. Also, because nicotine has been reported to enhance the release of endogenous brain acetylcholine, we sought to determine the role of this mechanism in mediating the cardiovascular response. Normotensive Wistar rats were previously implanted with indwelling intracerebroventricular (ICV) cannula guides and an arterial line (iliac artery) for central injection of drugs and measurement of MAP and heart rate, respectively. Rats received a series of increasing doses of nicotine (or saline vehicle) from 2-100 micrograms (in a 10 microliter volume) with each dose separated by at least 1 day. MAP increased immediately following all doses of nicotine; however, the maximal response was obtained following the 50 micrograms dose (higher doses actually produced lower responses). In general, the hypertensive response began immediately after injection, peaked within 2-3 min and returned to baseline within about 20 min. Heart rate changes were often not dramatic and highly variable. In order to examine the dependence of the pressor response to nicotine on brain acetylcholine, rats were pretreated with 20 micrograms (ICV) of hemicholinium-3 (HC-3) 1 h prior to nicotine to deplete endogenous acetylcholine. HC-3 pretreatment resulted in a significant reduction in the magnitude and duration of the pressor response to nicotine. Likewise, pretreatment with atropine inhibited the pressor response to subsequent injection of nicotine. Nicotine enhanced the release of [3H]acetylcholine from brain slices in vitro at concentrations likely achieved in the in vivo studies.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of concomitant cholinergic and adrenergic stimulation on learning and memory performance by primates

Physostigmine and other centrally-acting acetylcholinesterase inhibitors are currently being examined for their potential in the treatment of Alzheimer's Disease. The ability to employ this class of agents is limited by the potential for debilitating and dangerous side effects. Clonidine and related drugs have recently been demonstrated to enhance memory performance in monkeys. Clonidine also inhibits the function of cholinergic neurons in specific brain regions and reduces certain side effects of physostigmine. Seven adult macaque monkeys performing a delayed matching-to-sample (DMTS) task received regimens of increasing doses of clonidine and physostigmine on separate occasions to determine the 'best dose' of each agent in terms of enhanced memory performance. The best doses were combined as a single administration and performance compared to that using the two drugs alone. The combination regimen of clonidine and physostigmine was more effective than either drug alone in enhancing memory performance. Part of the benefit may have been due to the ability to employ significantly higher doses of physostigmine in the combination regimen. A single injection of the combination resulted in enhanced performance both on the day of administration as well as on the following day. These results are consistent with the ability of clonidine to limit the expression or intensity of certain physostigmine-induced autonomic side effects, while allowing the cognitive beneficial effects of the cholinesterase inhibitor.