A naturalistic multicenter study of intramuscular olanzapine in the treatment of acutely agitated manic or schizophrenic patients

Background

We conducted a naturalistic, multicenter, 24-hour, nonrandomized, observational study describing for the first time the effectiveness and safety of intramuscular (IM) olanzapine to control agitation and aggression in “real world” patients with psychosis. The data thus obtained was compared with that reported from randomized double-blind clinical trials.

Method

92 patients attending psychiatric emergency settings were enrolled. The study subjects were 44 male and 48 female patients with a mean age of 36.5 ± 12 years and DSM-IV-TR diagnoses of schizophrenia (48.9%), psychotic disorder not specified (23.9%) or bipolar disorder (27.2%). 10 mg IM olanzapine was administered to all patients. An optional second injection was permitted ≥ 2 hours later in line with hospital policy. Evaluations (PANSS-EC and CGI-S) were performed at baseline and 2 and 24 hours following the IM injection.

Results

Two hours after IM olanzapine was administered, a mean decrease of –9.6 in the PANSS-EC from a baseline score of 26.5 was recorded. At the 24-hour endpoint a statistically and clinically significant reduction in the PANSS-EC scores (11.6 ± 5.3) was observed as compared with values at study entry (26.5 ± 5.9) and at 2 hours endpoint (16.9 ± 9.3), which represent a mean decrease of –14.9 and –5.3, respectively.

Conclusion

The present naturalistic study provides naturalistic data on the effectiveness of IM olanzapine in the treatment of acute agitation in patients with schizophrenia or bipolar mania that is in line the data obtained in randomized double-blind clinical trials.

Non-adherence to oral antipsychotics in schizophrenia: Relapse and therapeutic strategies in a 12-month observational study

Introduction

Non-adherence influences schizophrenia prognosis.

Objectives

To describe the clinical profiles, modifications of the therapeutic strategies and relapse rate of patients with schizophrenia who are at risk of non-adherence to oral antipsychotic (AP) medication.

Methods

A cohort of 597 outpatients whose therapy was modified because of risk of non-adherence to oral AP was followed during 12 months. Authors used Cox regression to analyse the time to relapse.

Results

Patients’ mean (SD) age was 40.1 (11.1) and time since diagnosis was 15.2 (10.0) years; 64% were males. The clinical condition was at least moderate in most patients (CGI-S score ≥4 in 87%). Baseline AP medication was modified in 506 (85%) patients and non-pharmacological therapies in 190 (32%). In both cases, the main reason for modifications was insufficient efficacy. Concomitant medications were modified in 15%. The proportion of patients in AP monotherapy decreased in favour of polytherapy, and 15% started depot formulations.

During 12 months, 90 patients (15%) relapsed. Among relapsing patients, the proportion on monotherapy decreased to 42%, and the depot prescriptions rose to 28%. The risk of relapse was greater among patients with substance use disorder or familial psychiatric antecedents and lower in patients with poor attitude to AP medication or undergoing modifications of their non-pharmacological therapy at baseline.

Conclusions

Non-adherence management was focused on improving efficacy and consisted mainly of modifications of oral AP medication. The recognition and treatment, not necessarily pharmacological, of patients with a poor attitude to medication at baseline might explain their lower risk of relapse.

Rationale and design of the PLACID study: a randomised trial comparing the efficacy and safety of inhaled loxapine versus IM aripiprazole in acutely agitated patients with schizophrenia or bipolar disorder

BACKGROUND

The management of acute agitation manifesting in patients with schizophrenia or bipolar disorder requires swift pharmacological intervention to provide rapid symptomatic relief and prevent escalation to aggression and violence. Antipsychotic medications are widely used in this setting and the availability of an inhaled formulation with deep lung absorption of the antipsychotic loxapine has the potential to deliver a faster onset of therapeutic effect than the available intramuscular formulations of antipsychotics.

METHODS

The efficacy of inhaled loxapine and the alternative antipsychotic aripiprazole delivered via intramuscular (IM) injection will be compared in the Phase IIIb PLACID study. Adults (18-65 years) with a confirmed diagnosis of schizophrenia or bipolar I disorder presenting with acute agitation will be randomly assigned to open-label treatment in a 1:1 ratio. Clinical evaluation will be conducted by raters blinded to treatment assignment. The primary efficacy endpoint is time to response (defined as a Clinical Global Impression of Improvement [CGI-I] score of 1 [very much improved] or 2 [much improved]). Secondary endpoints will include the percentage of responders at different time points after dosing; the proportion of patients who receive 1 or 2 doses of study drug; time to second dose; time to rescue medication; satisfaction with study drug (evaluated using Item 14 of the Treatment Satisfaction Questionnaire for Medication); and safety and tolerability. Approximately 360 patients will be recruited with an interim analysis conducted once 180 patients have completed the study to decide whether to stop for futility or continue with or without an increase in the sample size up to additional 288 patients.

DISCUSSION

The PLACID trial will assess the efficacy and safety of inhaled loxapine with deep lung absorption compared with the IM antipsychotic, aripiprazole, in acutely agitated patients with schizophrenia or bipolar disorder. In the event that the median time to response of inhaled loxapine is significantly shorter than that of the intramuscular aripiprazole, the PLACID study has the potential to support the inhaled antipsychotic therapy as the standard of care in this setting.

TRIAL REGISTRATION

The study protocol was registered with the European Clinical Trials Database on the 31 October 2014 (EudraCT number 2014-000456-29 ).

Are women with a history of abuse more vulnerable to perinatal depressive symptoms? A systematic review

The objective of this paper is to examine the association between maternal lifetime abuse and perinatal depressive symptoms. Papers included in this review were identified through electronic searches of the following databases: Pubmed Medline and Ovid, EMBASE, PsycINFO, and the Cochrane Library. Each database was searched from its start date through 1 September 2011. Keywords such as "postpartum," "perinatal," "prenatal," "depression," "violence," "child abuse," and "partner abuse" were included in the purview of MeSH terms. Studies that examined the association between maternal lifetime abuse and perinatal depression were included. A total of 545 studies were included in the initial screening. Forty-three articles met criteria for inclusion and were incorporated in this review. Quality of articles was evaluated with the Newcastle-Ottawa-Scale (NOS). This systematic review indicates a positive association between maternal lifetime abuse and depressive symptoms in the perinatal period.

Clinical and serotonergic predictors of non-affective acute remitting psychosis in patients with a first-episode psychosis

OBJECTIVE

The study aimed to establish clinical predictors of non-affective acute remitting psychosis (NARP) and assess whether these patients showed a distinct serotonergic profile.

METHOD

First-episode never treated psychotic patients diagnosed of paranoid schizophrenia (n=35; 21 men and 14 women) or NARP (n=28; 15 men and 13 women) were included.

RESULTS

NARP patients showed significantly lower negative symptomatology, better premorbid adjustment, shorter duration of untreated psychosis, more depressive symptomatology and a lower number of 5-HT2A receptors than the paranoid schizophrenia patients. In the logistic regression, the four variables associated with the presence of NARP were: low number of 5-HT2A receptors; good premorbid adjustment; low score in the item 'hallucinatory behaviour' and reduced duration of untreated psychosis.

CONCLUSION

Our findings support the view that NARP is a highly distinctive condition different from either affective psychosis or other non-affective psychosis such as schizophrenia, and highlight the need for its validation.

[Effectiveness results of olanzapine in acute psychotic patients with agitation in the emergency room setting: results from NATURA study]

INTRODUCTION

Patterns of use of antipsychotics are not well described in emergency units. The objective of this study was to describe the effectiveness and safety of use of olanzapine in patients with acute psychosis and agitation in the emergency rooms.

METHODS

In this prospective observational study 278 patients with acute psychosis and agitation were consecutively admitted in 16 psychiatric emergency wards and treated with any oral psychopharmacology treatment, including olanzapine, according to investigators clinical criteria. Data were collected prospectively including demographics, diagnosis, concomitant medications, utilization of mechanical restraints, and severity of agitation. Clinical evolution during emergency room stay was assessed with PANSS-Excitement Component, CGI-S and Agitation and Calmness Evaluation Scale (ACES) at baseline, before any re-intervention (if needed) and at discharge from the emergency room. Safety was also evaluated.

RESULTS

Olanzapine alone was used in 148 (53.2%) patients. Most of them (77.7 %) were diagnosed of Schizophrenia and related psychoses. Up to 38 patients (25.7 %) required mechanical restraints. Mean change (confidence interval [CI] 95 %) from baseline to discharge was significant in all rating scales; PANSS-EC: -7.46 (-8.2, -6.7); CGI-S: -1.82 (-2, -1.6) ACES: 1.28 (1.1, 1.5). At discharge 70.3% of patients went to inpatient units. Five patients (3.4%) reported adverse events including: bradycardia, dry mouth, sedation, hypertension, hypotension, and orthostatic hypotension. None of them was serious.

CONCLUSIONS

The utilization of olanzapine alone decreased agitation in psychotic patients in emergency room settings. Incidence of adverse events was low and it was well tolerated.

[Course and prognosis of a case of central pontine myelinolysis in eating behavior disorder]

Central pontine myelinolysis (CPM) is a serious disorder that has been described in multiple diseases, generally involving important metabolic and hydroelectrolyte alterations. Although initially, its prognosis was usually fatal, there are a growing number of cases where the clinical symptoms begin abruptly and end after a short period, albeit with a persistence of the neuroimaging lesions. The case of a 22 year-old woman with a 6 year history of serious eating disorder with important physical deterioration and neurological and psychiatric symptoms suggestive of CPM is described. Despite the confirmation of the brain lesions through magnetic resonance imaging, neurological and psychiatric symptoms fully disappeared within a few weeks while the typical lesions of CPM remained. Although the risk of appearance of CPM exists during the course of an eating disorder, its prognosis does not seem to be as fatal as it was previously thought. Close monitoring of the clinical symptoms and neuroimaging findings should be carried out in these patients during the first months.

Lower weight gain with the orally disintegrating olanzapine than with standard tablets in first-episode never treated psychotic patients

OBJECTIVE

A post-hoc analysis of the data from a randomised clinical trial involving prescription of antipsychotic treatment to never treated first-onset psychotic patients was used to compare the weight change after 6-week olanzapine treatment (standard tablets vs. orally disintegrating formulation).

METHOD

In the subgroup of 38 patients randomised to olanzapine, standard olanzapine tablets were non-randomly and consecutively prescribed to the first 19 patients, with the orally disintegrating formulation being prescribed to the following 19 patients.

RESULTS

After 6-week treatment with olanzapine, a significant higher increase in weight was noted in those patients on standard tablets (mean weight increase 6.3 +/- 1.9 Kg) as compared to those on orally disintegrating olanzapine (mean weight increase 3.3 +/- 3.2 Kg) (F = 7.7; p = 0.009). BMI increase was also significantly higher in the olanzapine tablet group (mean increase of 2.1 Kg/m(2) as compared with 1.1 Kg/m(2) in the orally disintegrating group) (F = 4.7; p = 0.036). Substantial weight gain (SWG) (> or =7% increase from baseline weight) was noted in 84.2% (n = 16) of the olanzapine tablet patients and in 31.6% (n = 6) of the orally disintegrating olanzapine patients, with the olanzapine tablet group showing a significant increase in the mean percentage of weight gain (F = 4.0; p = 0.014).

CONCLUSIONS

Partial sublingual absorption occurring with orally disintegrating olanzapine may bypass gastrointestinal metabolisation and hence lead to differences in metabolite versus parent compound ratios. However, the need arises to replicate the present study with a longer follow-up.

Pharmacological Management of Acutely Agitated Schizophrenic Patients

Agitation is commonly seen in acute schizophrenic patients and core symptoms include a wide range of symptom. It requires rapid and effective treatment approaches in order to protect patient and caregiver from potential injury. Clinician's decision of pharmacological treatment should be individualized to the needs and circumstances of the patient. Benzodiazepines, typical antipsychotics, and combinations of typical antipsychotics and benzodiazepines have been widely used as treatment options. Atypical antipsychotics have clear advantages over the typical drugs as they generally show a much better safety and tolerability profile, particularly to EPS and related side effects, however clinical perception regarding efficacy in treating acutely agitated psychotic patient is controversial. New intramuscular atypical antipsychotic formulations offer evidence of being at least as effective as typical antipsychotics in controlling agitation. Therefore, they should be considered as first line therapy in agitated schizophrenic patients.

[Rhabdomyolysis due to polydipsia in a patient with psychotic disorder]

Polydipsia is a frequent clinical entity in psychiatric patients, especially in those with a psychotic disorder. Acute episodes of polydipsia can produce important metabolic alterations and even coma and death. Psychogenic polydipsia is a underestimated diagnosis, due to multiple causal factors and an etiology that has not been clearly established. We present the case of a patient with psychiatric background who was seen due to a clinical situation of severe acute renal failure by high rhabdomyolysis that needed hemodialysis, due to acute polydipsia. We also review some of the epidemiological and clinical factors and etiopathogeny of the polydipsia. It is considered necessary to keep in mind the in mind the diagnosis of polydipsia in any psychiatric patient showing acute symptoms of confusion.

[Combination therapy with reboxetine for major depression patients who are partial or nonresponders to serotonin selective reuptake inhibitors]

INTRODUCTION

Recent studies have confirmed the usefulness of the therapeutical combination of two antidepressants from different pharmacological families in patients with single drug therapy resistant depression.

METHODS

In this prospective 6 weeks open-labeled study, efficacy of combination strategy was evaluated. This included the addition of reboxetine to 34 outpatients with DSM-IV major depressive disorder, who had not responded previously, or who partially responded to conventional treatment in single drug therapy with serotonin selective reuptake inhibitors (SSRI). Data were analyzed on a intent-to-treat basis.

RESULTS

Mean decrease in the 21 item Hamilton depression rating scale (HDRS) score was 49.4% (from 26.9 to 13.6; p<0.0001) and in the clinical global impressions scale (CGI) was 40.4% (from 4.6 to 2.7; p < 0.0001). At the end of the treatment, 47.1% of the patients we re considered in remission (HDRS < or = 10), 55.9% evaluated as responders (HDRS < or = 50%) and 58.8% considered as having improvement (CGI<4). No serious side effects were observed during combination therapy, the most frequent being nervousness and the urinary hesitancy (5.9%).

CONCLUSIONS

The results of this study suggest that addition of reboxetine to SSRI may be an effective and well-tolerated strategy in treatment-resistant patients who have failed to adequately respond to single drug therapy with SSRI.

[Cannabis dependence: clinical implications. Based and one case]

Cannabis has been commonly regarded as an innocuous drug, and has been used for centuries due to its multiple therapeutic effects (analgesic, anticonvulsant, sedative, antidepressant, etc.). However, growing evidence in recent years highlights the risk of adverse effects secondary to dependence and withdrawal syndrome. We report a case of severe cannabis dependence, that led to a variety of psychopathological, cognitive and somatic symptoms. This is compared with the bibliography and we analyze the influence of a possible underlying psychiatric disease. The adverse effects include affective and eating disorders, and the possibility of seizure induction. A novel therapeutic strategy in cannabis dependence is reported. Key words: Cannabis. Mania. Bulimic behaviors.

Double-blind, placebo-controlled comparison of intramuscular olanzapine and intramuscular haloperidol in the treatment of acute agitation in schizophrenia

OBJECTIVE

The authors evaluated the comparative efficacy and safety of intramuscular olanzapine, intramuscular haloperidol, and intramuscular placebo for the treatment of acute agitation in schizophrenia.

METHOD

Hospitalized patients with schizophrenia received one to three injections of intramuscular olanzapine, 10 mg, intramuscular haloperidol, 7.5 mg, or intramuscular placebo over a 24-hour period. Agitation was measured with the excited component of the Positive and Negative Syndrome Scale and two additional scales.

RESULTS

According to scores on the excited component of the Positive and Negative Syndrome Scale, both intramuscular olanzapine and intramuscular haloperidol reduced agitation significantly more than intramuscular placebo 2 and 24 hours following the first injection. Intramuscular olanzapine reduced agitation significantly more than intramuscular haloperidol 15, 30, and 45 minutes following the first injection. No patients treated with intramuscular olanzapine experienced acute dystonia, compared with 7% of those who were treated with intramuscular haloperidol. No significant QT(c) interval changes were observed in any patients.

CONCLUSIONS

Intramuscular olanzapine represents a rapid, effective, and safe treatment for acute agitation in schizophrenia.

[Instruments of depression assessment in schizophrenia]

Lately, numerous reports have focused on the evaluation of depressive symptoms of schizophrenia. This assessment has been hampered by the temporal variability of the depressive symptoms and by their overlap with both the negative symptoms of schizophrenia and the extrapyramidal effects of the antipsychotic treatment. So far, classical assessment instruments such as the Hamilton Depression Rating Scale (HDRS) or the Montgomery-Asberg Rating Depression Scale (MARDS) have been used in those patients suffering from schizophrenia with depressive symptomatology, despite the important limitations concerning their use in subpopulations other than the one they have been developed for. New specific depression scales for schizophrenia such as the Calgary Depression Scale for Schizophrenics (CDSS) seems to have more efficiency and ability to distinguish between depression, negative and extrapyramidal symptoms. The present paper reviews the instruments used so far on the assessment of depressive symptomatology in schizophrenic patients.

[Genetic dysfunction of the serotonin receptor 5-HT2A in psychiatric disorders]

So far, there is increasing evidence of the active role of molecular biology in the psychiatric nosology as well as in the identification of psychiatric fenotypes. In this respect, the neurotransmitter serotonin (5-HT) has been involved in the etiopathogeny of multiple psychiatry conditions, such as affective disorder, schizophrenia, panic disorder, obsessive-compulsive disorder, alcoholism, eating disorder and personality disorder. The 5-HT2 receptor family includes the subtype 5-HT2A, a G protein coupled receptor whose activation leads to the stimulation of the enzyme phospholipase C and to the subsequent hydrolysis of the membrane located phosphoinositides, with the synthesis of the second messengers inositol triphosphate and diacylglicerol. This paper includes a review of the main findings concerning the polymorphism of the 5-HT2A in psychiatric disorders.

Altered 5-HT(2A) binding sites and second messenger inositol trisphosphate (IP(3)) levels in hippocampus but not in frontal cortex from depressed suicide victims

The binding parameters of 5-HT(2A) and levels of its second messenger, 1,4,5-trisphosphate (IP(3)), were simultaneously studied in frontal cortex and hippocampus from the brains of 18 control subjects and 18 depressed suicide victims. All suicides met DSM-III-R criteria for depressive symptoms, suffered a violent death and had not taken any antidepressant drugs for at least 6 months prior to death. A significant decrease in the number of 5-HT(2A) binding sites (154+/-22 vs. 254+/-36 fmol/mg), together with a significantly lower apparent affinity constant (1.02+/- 0.08 vs. 1. 36+/-0.09 nM), was detected in hippocampus but not in frontal cortex from the depressed suicides compared to the control subjects. Furthermore, IP(3) concentrations were significantly increased in hippocampus (3.2+/-0.3 vs. 2.1+/-0.3 pmol/g) but not in frontal cortex (1.3+/-0.3 vs. 2.7+/-0.5 pmol/g) from the suicide victims. The reported results may indicate a significant hypersensitivity of the 5-HT(2A) postsynaptic receptor located in the hippocampus from depressed suicide victims, giving rise to an enhancement of its intracellular signaling system with higher IP(3) production.

[Electroconvulsive therapy and serotonergic system]

Evidence from several studies supports the involvement of several neurotransmitter systems in the mechanism of action and the clinical efficacy of the electroconvulsive therapy (ECT). However, more recent studies have reported serotonin, through the activation of several receptors, to be the neurotransmitter most frequently altered in ECT. With regard to the serotonergic system, several levels of alteration can be targeted, that concerning serotonin and its metabolite concentrations, that concerning changes in the density of presynaptic and postsynaptic receptors located both in brain tissue or in platelets, and finally, alterations at the intracellular signalling system or second messenger level.

Human pharmacology of 3,4-methylenedioxymethamphetamine ("ecstasy"): psychomotor performance and subjective effects

3,4-Methylenedioxymethamphetamine (MDMA, "ecstasy") is a recreational drug of increasing use among youth because of its apparent entactogenic properties, such as euphoria, friendliness, closeness, and empathy. However, experimental studies have shown MDMA to be neurotoxic. Data on pharmacologic actions of MDMA in humans are limited. The authors conducted a randomized, double-blind, crossover, controlled trial to assess psychomotor performance and subjective effects in eight healthy male volunteers. MDMA was given in the same range of doses used for recreational purposes (75 and 125 mg). Amphetamine (40 mg) and placebo were used as reference compounds. For the digit-symbol substitution test (DSST), MDMA-125 produced a mild decrease in responses, and amphetamine produced a mild improvement. For the Maddox wing device, MDMA-125 induced esophoria compared with the other drug conditions. MDMA-125 and MDMA-75 produced increases in feelings of euphoria and well-being, as noted by increases in scores on the Addiction Research Center Inventory (ARCI) MBG and A scales, as well as scores of "stimulated," "good effects," "liking," and "high" on the visual analog scales. Amphetamine administration induced similar effects. At the same time, MDMA-125 enhanced sedation- and dysphoria-related effects (ARCI-PCAG and LSD, "confusion," "drunken," and Profile of Mood States Confusion scale). Mild changes in some body perception-related feelings were also reported after MDMA use, but hallucinations or psychoses were not present. In summary, the short-term administration of MDMA produced marked euphoria, a slight impairment in the performance of psychomotor tasks, and mild changes in body perceptions without hallucinations. These data support the abuse liability of MDMA.

Platelet serotonergic binding sites in alcohol-dependent patients

The serotonin (5-hydroxytryptamine, 5-HT) uptake sites assessed with both [3H]imipramine and [3H]paroxetine, and the 5-HT2A receptors were simultaneously measured in platelets from 24 male subjects meeting the American Psychiatric Association's DSM-IV criteria for alcohol dependence and admitted for inpatient detoxification. Blood samples from alcoholic patients were collected during acute alcohol intoxication (day 0), during withdrawal (day 1), and after 2 weeks of abstinence (day 14). All patients met the criteria for type II alcoholism. Alcohol misuse was found to be associated with an increased number and a lower affinity of [3H]paroxetine binding in comparison to the control values. Abstinence from alcohol for 2 weeks (day 14) resulted in a decrease in the number of 5-HT uptake sites labelled with [3H]paroxetine compared to normal values, together with a significant decrease in the number of 5-HT2A binding sites. The present data indicate that altered serotonergic function existing in alcoholic patients is a reversible phenomenon that normalizes after detoxification and withdrawal.

Immunological screening of drugs of abuse and gas chromatographic-mass spectrometric confirmation of opiates and cocaine in hair

The work presents an analytical strategy to detect drugs of abuse in hair. It involves two sequential steps: a screening by a simple enzyme-linked immunosorbent assay (ELISA) methodology to detect opiates, cocaine and its metabolites, and benzodiacepines, followed by confirmation of opiates and cocaine metabolites in positive samples by gas chromatography coupled to mass spectrometry (GC-MS). In the same GC-MS run other drugs for substitution therapy (e.g. methadone and its main metabolite) can also be detected. After a double washing of hair samples with dichloromethane, hair specimens were cut into small pieces and 10 mg samples were incubated in 2 ml of methanol-trifluoroacetic acid (9:1) mixture, overnight at 37 degrees C. Aliquots of the extract were then evaporated, reconstituted in buffer and analysed according to the ELISA procedure. Confirmation involved solid-phase extraction of another fraction of the extract kept at -20 degrees C, derivatization with heptafluorobutyric anhydride and hexafluoroisopropanol and detection of cocaine, benzoylecgonine, ecgonine methylester, cocaethylene, morphine, codeine, 6-monoacetylmorphine, methadone and 2-ethylidene-1.5-dimethyl-3,3-diphenylpirrolidine (methadone metabolite) by selective ion monitoring after gas chromatographic separation. During the development of the method it was verified that no more than 10% of cocaine, opiates and benzodiacepines were lost when dichloromethane was used to wash real samples. The results also confirmed the increase of extractability power of TFA when it was added to methanol: the recovery for the analytes (cocaine and its metabolites and opiates) added to methanol-TFA alone was of the order of 90% except for benzoylecgonine (75%), and the recovery for the analytes added to methanol-TFA extract of drug-free hair was about 90% for all analytes except for benzoylecgonine and 6-MAM (around 70%). Regarding the stability of labile compounds, only small amounts of ecgonine methylester (2.3%) and morphine (7.2%) were produced, from cocaine and 6-MAM respectively, after the whole extraction procedure and two weeks of storage of methanol-TFA extracts at -20 degrees C. Satisfactory results were obtained when the procedures were applied to the analysis of external proficiency testing hair samples and actual specimens from drug addicts.

Characterization of the 5-HT4 binding site in human brain

In this study, drug inhibition and saturation experiments on the binding of the highly selective 5-HT4 antagonist [3H]GR 113808 were performed in human brain membranes so as to better characterize this binding site. Drug competition studies were carried out by incubating 0.2 nM [3H]GR 113808 in the presence of increasing concentrations of six different drugs, i.e. 5-HT, 5-CT, ondansetron, tropisetron, BIMU 1 and BIMU 8 (mixed 5-HT3 and 5-HT4 agonists). The binding displaced by 5-HT showed a drug inhibition constant (Ki) value of 197nM. The use of 5-CT or ondansetron also showed the existence of single-site models albeit with Ki values in the micromolar range (11,5 microM). Tropisetron, BIMU 1 and BIMU 8 displaced bound [3H]GR 113808 according to a two-site binding model, with the high affinity component in the nanomolar range and the low affinity site in the micro or milimolar range. Saturation experiments revealed high binding densities in basal ganglia (187 fmol/mg in putamen, and 149 fmol/mg in caudate nucleus), while lower densities were observed in cortical regions (49 fmol/mg in temporal cortex, 45 fmol/mg in parietal cortex and 71 fmol/mg in cingulate cortex). The apparent affinity (Kd) was similar in the brain regions studied, ranging from 0.13 to 0.34 nmol/l. Despite the enrichment of 5-HT receptors in human brain, their functional correlate in brain diseases remains to be clarified.

Plasma methadone concentrations as an indicator of opioid withdrawal symptoms and heroin use in a methadone maintenance program

Plasma methadone concentrations and its main metabolite D,L-2-ethylidiene-1,5-dimethyl-3,5-diphenylpyrrolidine (EDDP) were determined in 93 patients under methadone maintenance treatment to assess their relationship with heroin use and opioid withdrawal symptoms. Neither plasma concentrations of methadone nor EDDP were significantly different when patients that used heroin in last 3 months were compared with those testing negative for this drug (methadone, 355 +/- 217 versus 369 +/- 216 ng/ml, t = 0.29, P = NS; EDDP, 49 +/- 28 versus 54 +/- 40 ng/ml, t = 0.51, P = NS). No correlation between opioid withdrawal scale scores and plasma concentrations of methadone (r = 0.02, P = NS) and EDDP (r = -0.14, P = NS) was found. Therapeutic drug monitoring during methadone maintenance seems to be useful for assessing compliance with treatment but not for predicting heroin use and subjective withdrawal symptoms.

Monitoring patterns of substance use in drug-dependent patients

Drug-addicted patients (N = 435) admitted for treatment in different clinical settings were studied. Patients were classified according to their self-report of consumed drugs and to the results of urine screening tests. Of the patients, 77.8% were active consumers, 9.6% were included in a methadone maintenance program, and 12.6% were abstinent. In the active consumer patients, positive urine screening results surpassed by far the information provided in the self-reports. Most patients tested positive to several drugs, while only 8.7% tested negative to all screened drugs. These results indicate that the information provided by drug-dependent patients lacks reliability when an analytical screening method is used simultaneously.

Use of the Nottingham Health Profile for measuring health status of patients in methadone maintenance treatment

This study was conducted to assess changes in health-related quality of life over a 3-year follow-up period in a cohort of 135 opioid dependent patients using the Nottingham Health Profile (NHP) questionnaires. Data obtained at 12 months from 80 patients retained in the programme are presented. In summary, opioid addicts in a methadone maintenance programme for a 12-month period experienced an early and substantial improvement in health-related quality of life. The use of the NHP questionnaire to monitor changes in the subjective health of opioid-dependent patients over time provides new insights in the assessment of treatment effectiveness of methadone maintenance programmes.

Clinical evaluation of the Triage analytic device for drugs-of-abuse testing

In the present clinical evaluation of Triage immunoassay for detection of drugs of abuse, we examined a possible connection between the laboratory skills of the personnel using it and the quality of analytical results; we also evaluated the degree of concordance between the Triage results and those obtained by an instrumented fluorescence polarization immunoassay (FPIA). Three groups of evaluators with different laboratory skills and two sets of urine samples from subjects with different rates of drug consumption prevalence were included in the study. Urines were analyzed by the Triage analytical device at the collection site. A second analysis was performed in a toxicology laboratory, and the results were compared with those obtained by FPIA. Nonconcordant results were confirmed by gas chromatography-mass spectrometry and HPLC. Results were independent of the laboratory skills of the evaluators. The agreement for each drug calculated for two populations with differences in prevalence of drug consumption was almost the same, except for benzodiazepines. No differences between Triage and FPIA results were observed for samples clearly over or under cutoff concentrations. Globally, the Triage device, in a clinical situation, demonstrated performance comparable with that of an instrument-based immunoassay and, in some cases (e.g., for benzodiazepines), the Triage performance was even better.

Clinical evaluation of the Triage analytic device for drugs-of-abuse testing

In the present clinical evaluation of Triage immunoassay for detection of drugs of abuse, we examined a possible connection between the laboratory skills of the personnel using it and the quality of analytical results; we also evaluated the degree of concordance between the Triage results and those obtained by an instrumented fluorescence polarization immunoassay (FPIA). Three groups of evaluators with different laboratory skills and two sets of urine samples from subjects with different rates of drug consumption prevalence were included in the study. Urines were analyzed by the Triage analytical device at the collection site. A second analysis was performed in a toxicology laboratory, and the results were compared with those obtained by FPIA. Nonconcordant results were confirmed by gas chromatography-mass spectrometry and HPLC. Results were independent of the laboratory skills of the evaluators. The agreement for each drug calculated for two populations with differences in prevalence of drug consumption was almost the same, except for benzodiazepines. No differences between Triage and FPIA results were observed for samples clearly over or under cutoff concentrations. Globally, the Triage device, in a clinical situation, demonstrated performance comparable with that of an instrument-based immunoassay and, in some cases (e.g., for benzodiazepines), the Triage performance was even better.

Efficacy of methadone versus methadone and guanfacine in the detoxification of heroin-addicted patients

In a randomized double-blind study, the clinical efficacy of methadone vs. methadone and guanfacine was assessed in terms of evolution of opioid withdrawal symptoms during inpatient detoxification. A total of 144 patients were included and randomly allocated to three different treatment groups: methadone alone, and two combined treatment schedules (methadone plus 3 or 4 mg of guanfacine). No differences were observed among the three groups with regard to retention rate throughout the study period. Both therapies, methadone and methadone plus guanfacine, determined a slight increase in withdrawal scores when methadone was discontinued. However, guanfacine was unable to effectively control methadone-associated withdrawal symptoms. These results indicate that guanfacine does not effectively reduce the opioid withdrawal symptoms.

Consumption of buprenorphine and other drugs among heroin addicts under ambulatory treatment: results from cross-sectional studies in 1988 and 1990

We assessed the prevalence of consumption of buprenorphine and other drugs among heroin addicts under ambulatory treatment in two cross-sectional studies conducted in 1988 (188 subjects) and in 1990 (197 subjects). Patients were enrolled in one of three different programmes: methadone maintenance programme (MMP), antagonist maintenance programme (AMP) and drug-free programme (DFP). Information given by participants was compared with results of urine screening for drugs. Urine samples were tested using enzyme immunoassay for the detection of heroin, cocaine, dextropropoxyphene, cannabis and benzodiazepines, and radioimmunoassay for buprenorphine. Sixty-six percent of patients in 1988 and 71% of patients in 1990 reported having consumed buprenorphine at some time during their history of drug dependence (period prevalence) and 5.9% and 6.1%, respectively, tested positive to the drug (point prevalence). In over 70% of these patients consumption was by the intravenous route. Consumption of cannabis, cocaine and benzodiazepines was also very high in the study population. Overall, patients in the DFP group consumed the largest number of the drugs tested, while those in the AMP group consumed the smallest number. Abuse of buprenorphine could be more widespread than previously reported.

Buprenorphine versus heroin dependence: comparison of toxicologic and psychopathologic characteristics

Sociodemographic, toxicologic, and psychopathologic characteristics of 22 buprenorphine addicts and 45 heroin addicts admitted for inpatient detoxification were compared. Although the buprenorphine addicts were older, clinically significant differences were not apparent. The availability of buprenorphine may be the main reason for its abuse.

Flunitrazepam consumption among heroin addicts admitted for in-patient detoxification

The use of benzodiazepines among 973 heroin addicts admitted for inpatient detoxification over a 10-year period was assessed in a cross-sectional study. A total of 780 (80.2%) patients had a history of benzodiazepine use; 666 (68.5%) were consuming benzodiazepines at the time of admission and 419 (43.1%) on an almost daily basis. Seventy-five (7.7%) patients fulfilled criteria for sedative-hypnotic abuse or dependence. Consumption of benzodiazepines began after subjects had become addicted to heroin. Flunitrazepam was ranked first by 68.4% of patients, followed by clorazepate (13%), and diazepam (12.4%). The prevalence of benzodiazepine use, in particular flunitrazepam, among heroin addicts is very high. Specific abuse liability studies are needed to determine whether pharmacologic reasons exist to explain heroin addicts' preference for this compound.

Hypercortisolism after opioid discontinuation in rapid detoxification of heroin addicts

Long-term opioid consumption can induce hypoadrenalism through impairment of the hypothalamic-pituitary-adrenal axis. Results of the present study showed that, in heroin addicts, saliva cortisol concentrations varied according to the amount of recently consumed heroin and the time elapsed since the last self-administration. Hypercortisolism was observed either after abrupt withdrawal of heroin or the last dose of methadone. Post-detoxification hypercortisolism was still present on day 16 after the last opioid consumption, whereas it was not observed in abstinent addicts for a mean period of 4 months. During detoxification treatment, mean AUC8-24 cortisol in saliva of clonidine or guanfacine-treated patients was significantly higher than that in methadone-treated patients. It may be hypothesized that elevated cortisol levels may account for untoward effects of adrenergic agonist therapy which, in turn, may represent an added risk factor for relapse during detoxification. Further studies are necessary to correlate the severity of withdrawal symptoms to cortisol levels in opioid addicts detoxified with alpha 2-adrenergic agonist substitution.

Assessment and management of opioid withdrawal symptoms in buprenorphine-dependent subjects

The spontaneous physical dependence of buprenorphine was assessed in opioid addicts who switched from heroin to sublingual or intravenous buprenorphine. Twenty-two patients were randomly assigned to double-blind administration of methadone (n = 11) or placebo (n = 11) for 13 days after abrupt withdrawal of buprenorphine. Methadone was administered according to four pre-established dosing schedules depending on the previous amount of daily consumed buprenorphine. No methadone-treated patient required modification of the therapeutic regimen, whereas eight of eleven placebo-treated patients needed treatment with methadone. Buprenorphine withdrawal syndrome was of opioid type, began somewhat more slowly, and showed a peak until day 5. The occurrence, time-course and characteristics of buprenorphine withdrawal syndrome make it necessary to reconsider the abuse potential of this analgesic.

Follow-up after a six-month maintenance period on naltrexone versus placebo in heroin addicts

Naltrexone and placebo as adjuvant treatment of opioid dependence were compared in a double-blind, controlled clinical trial in 50 heroin addicts. The overall efficacy was assessed by the degree of treatment acceptance, percentage of relapse in heroin consumption, presence of side effects, and overall retention on naltrexone. A total of 50 patients of both sexes, aged from 18 to 30 years, who fulfilled DSM-III-R criteria for opioid dependence were included in the study. All patients completed detoxification with clonidine on an inpatient basis for 2 weeks and subsequently, on an out-patient basis, received oral naltrexone (350 mg per week) for a month. At the beginning of the second month patients were randomly allocated to treatment with naltrexone (28 patients) or placebo (22 patients) until a 6-month treatment period in a double-blind fashion had been completed. During the study period (1 year) all patients followed the same therapeutic schedule. Patients in both groups were comparable in terms of socio-demographic data and toxicological history. The efficacy of naltrexone was not superior to that of placebo as there were no significant differences in acceptance of treatment, retention rates, opioid and other drug consumption, drug compliance or side effects.

Cocaine abuse among heroin addicts in Spain

Abuse of cocaine is becoming a major problem among heroin addicts in Spain. Between 1987 and 1988, 75% of patients admitted as inpatients for detoxification from opiate dependence had consumed cocaine during the 6 months prior to admission and 25% had abused cocaine daily or several times/week. These cocaine abusers showed more toxicologic and psychopathologic problems than opiate addicts who did not abuse cocaine. The opiate addicts who also abused cocaine had begun using illicit drugs earlier and showed a higher frequency of anti-HIV antibodies. They also had more antisocial personality disorders and persistence of depressive symptoms during opiate detoxification than heroin addicts who did not abuse cocaine. Based on these findings, we insist on the need to develop different treatments for detoxifying patients with this dual addiction.

Effect of ballet on immunity in young people

The peripheral blood samples obtained from 32 ballet students with a mean age of 17.5 years and 32 age-matched non- dancers who comprised a control group were analysed using the microdeterminations of lymphocyte blast transformation and mixture rosette forming cells. The percentage of lymphocyte blast transformation of ballet students was normal, but their percentage of E-rosette forming cells was lower than that of controls at rest. A significant increase in the percentage of zymosan-complement rosette forming cells was seen during dancing. The study suggests that a saving effect on expenditure of cellular immunofunction is exhibited in ballet students at rest and that intensive ballet-exercise induces an immediate humoral immune response change. However, the effect needs to be dynamically observed and the clinical implication of the response change remains to be proved.

Efficacy of clonidine, guanfacine and methadone in the rapid detoxification of heroin addicts: a controlled clinical trial

The efficacy of clonidine, methadone, and guanfacine in rapid detoxification of heroin inpatients was assessed in a randomized controlled clinical trial. Signs and symptoms of abstinence and of side effects were analysed in 90 heroin addicts successfully completing a 12-day inpatient trial. All patients fit DSM-III criteria for opioid dependence, the age range being 18 to 36 years. All three drugs were effective in controlling abstinence; however, the course of abstinence was different in the methadone group as compared to the adrenergic agonists, the latter showing limitations in their ability to suppress withdrawal manifestations. While mean number of withdrawal signs and symptoms was significantly lower during days 2 to 5 in the methadone group (p less than 0.01), adrenergic agonists were slightly more effective at the end of the trial. Incidence of side effects was closely related to the dose administered. Hypotensive action of adrenergic agonists was more marked in orthostatic position. The present results suggest that methadone is superior to adrenergic agonists. Between these drugs clonidine appears to be less effective than guanfacine in controlling some withdrawal manifestations, and causes more side effects, mainly of cardiovascular nature.

[Prevalence of buprenorphine use by heroin addicts undergoing treatment]

After buprenorphine was introduced as an analgesic, several clinical observations have stimulated the investigation of its potential abuse by heroin addicts. To evaluate the prevalence of buprenorphine use by a group of heroin abusers being treated on an outpatient basis, a cross-sectional study was carried out where the information given by the 188 subjects was verified by urine drug analyses. The patients had three different therapeutic modalities: methadone maintenance program (MMP), antagonist maintenance program (AMP), and drug-free program (DFP). The urine samples were analyzed with an enzyme immunoassay technique for the detection of heroin, methadone, dextropropoxyphene, cannabis and benzodiazepines. Buprenorphine was investigated with a radioimmunoassay technique. Overall 66% of the patients admitted having used buprenorphine throughout their toxicologic history (period prevalence) and 6.7% had positive urine controls for this drug (5% in the MMP group, 0% in the AMP group and 12% in the DFP group) (point prevalence). In 72% of the cases the drug was administered intravenously. In addition, a clinically statistically significant association was found between positivity for heroin and buprenorphine. The possible tolerance to the latter is suggested by the fact that the mean current dose was higher than the mean initial dose. In the study population, the use of cannabis and benzodiazepines was also very high. The results suggest that most patients had a previous history of buprenorphine use. This drug could have a higher potential for abuse than that found in previous experimental studies.

A multicentre study to introduce naltrexone for opiate dependence in Spain

A multicentre prospective study was performed in eight centres in Spain in order to assess the usefulness of naltrexone in the treatment of opiate dependents and abusers (113 dependents and 37 abusers) non-selected in terms of social class or professional skill. The fundamental criterion for evaluation of clinical outcome was the retention rate. At 6 months this parameter was 40%, i.e. higher than any previously reported for non-selected patients. The adverse effects were mild and did not lead to therapeutic failures. Non-pharmacological factors may have contributed to the good clinical results obtained.

Success and failure at inpatient heroin detoxification

Predictors of either detoxification success or failure were evaluated during an inpatient trial that compared the efficacy of methadone, clonidine and guanfacine for rapid heroin detoxification. The analysis of such predictors was stimulated by the fact that in order to achieve 90 patients who completed the study (30 in each group), a total of 170 patients had to be included. Of 80 detoxification failures, 10 occurred in the methadone group, 32 in the guanfacine group, and 38 in the clonidine group. Voluntary request for discontinuation of the detoxification schedule was the first cause of failure. There were not statistically significant differences with regard to sociodemographic characteristics and pattern of drug consumption among patients in the three groups who completed detoxification with success or failure. The treatment drug, the type of schedule and the score obtained from the Symptom Checklist-90/Revised (SCL-90/R) were the only predictors of either detoxification success or failure. Inpatient opioid detoxification would be a useful strategy for patients with more severe psychological symptoms.

Efficacy of clonidine and of methadone in the rapid detoxification of patients dependent on heroin

The efficacy of a rapid detoxification schedule (8 to 10 days) with clonidine or methadone was evaluated in 30 patients addicted to heroin. The dose of study drug was preestablished according to the subject's weight and the amount of opioid consumption, and the total daily dose was reduced by approximately 15% during the study. All subjects completed the detoxification program and stayed in the hospital for at least 12 days. Clonidine and methadone therapies proved to be highly effective. There was a marked reduction in anxiety during opioid detoxification, although subjects' experiences differed according to the drug used. On the day of discharge, subjects who had received methadone still had attenuated withdrawal symptoms, whereas there were no such symptoms in the clonidine group. Muscular aching, flatulence, and daily drowsiness were more common among subjects in the methadone group, while subjects in the clonidine group had more sleep disturbances and weeping. Syncopal episodes and bradycardia occurred more frequently in the clonidine group.