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Journal of Psychopharmacology (Oxford, England) SAGE Publications

Amphetamine, past and present a pharmacological and clinical perspective

David J Heal, Sharon L Smith, [...], and David J Nutt Additional article information

Abstract
Amphetamine was discovered over 100 years ago. Since then, it has transformed from a drug that was freely available without prescription as a panacea for a broad range of disorders into a highly restricted Controlled Drug with therapeutic applications restricted to attention deficit hyperactivity disorder (ADHD) and narcolepsy. This review describes the relationship between chemical structure and pharmacology of amphetamine and its congeners. Amphetamines diverse pharmacological actions translate not only into therapeutic efficacy, but also into the production of adverse events and liability for recreational abuse. Accordingly, the balance of benefit/risk is the key challenge for its clinical use. The review charts advances in pharmaceutical development from the introduction of once-daily formulations of amphetamine through to lisdexamfetamine, which is the first d-amphetamine prodrug approved for the management of ADHD in children, adolescents and adults. The unusual metabolic route for lisdexamfetamine to deliver d-amphetamine makes an important contribution to its pharmacology. How lisdexamfetamines distinctive pharmacokinetic/pharmacodynamic profile translates into sustained efficacy as a treatment for ADHD and its reduced potential for recreational abuse is also discussed. Keywords: Abuse liability, amphetamine, attention deficit hyperactivity disorder (ADHD), drug formulations, lisdexamfetamine, microdialysis

A short history of amphetamine

Although racemic -methylphenethylamine (amphetamine) was discovered by Barger and Dale in 1910, it was not until 1927 that this molecule was first synthesised by the chemist, G. A. Alles, whilst he was searching for a less costly and more easily synthesised substitute for ephedrine. Experiments performed in animals and human subjects by Alles and others unequivocally revealed -methylphenethylamines ability to reverse drug-induced anaesthesia and produce arousal and insomnia (see reviews by Bett, 1946; Guttmann and Sargent, 1937). The trade name Benzedrine for racemic -

methylphenethylamine was registered by the pharmaceutical company, Smith, Kline and French. Amphetamine, which is the generic name for Benzedrine devised by the Council on Pharmacy and Chemistry of the American Medical Association, was not adopted until many years later. It is the reason why the name Benzedrine, not amphetamine, appears in all of the early publications (see Bett, 1946). Smith, Kline and French introduced Benzedrine onto the market in 1935 as a treatment for narcolepsy (for which it is still used today), mild depression, post-encephalitic Parkinsonism and a raft of other disorders (see Bett, 1946; Guttmann and Sargent, 1937; Tidy, 1938). As a molecule with a single chiral centre, amphetamine exists in two optically active forms, i.e. the dextro- (or d-) and levo- (or l-) isomers or enantiomers (Figure 1). Smith, Kline and French synthesised both isomers, and in 1937 commenced marketing of damphetamine, which was the more potent of the two isomers, under the trade name of Dexedrine. Sales of Benzedrine and Dexedrine in chemist stores were unrestricted until 1939, when these drugs could only be obtained either on prescription from a registered medical practitioner or by signing the Poison Register (Bett, 1946). The cognitiveenhancing properties of amphetamine were quickly recognised, with reports of Benzedrine producing improvements in intelligence tests leading to its widespread use to reduce stress and improve concentration and intellectual performance by academics, students and medical professionals (see Guttmann and Sargent, 1937; Tidy, 1938). In his 1946 review, Bett commented on the widespread use of energy pills by the allied forces in World War II, estimating that 150 million Benzedrine tablets were supplied to British and American service personnel during the course of the global conflict. In spite of considerable coverage in the medical literature and the popular press describing the powerful central effects of these new drugs, the addictive potential of amphetamine was largely dismissed (see Bett, 1946; Guttmann and Sargent, 1937; Tidy, 1938).

Figure 1. Chemical structures of various biologically active -phenylethylamines. It was Bradley (1937) who first reported the beneficial effects of Benzedrine in treating children with severe behavioural problems, who would now be diagnosed as suffering from attention deficit/hyperactivity disorder (ADHD) (American Psychiatric Association, 1994). Bradley treated 30 subjects for a week, and in approximately half of them he observed remarkable improvements in their school performance, behaviour and demeanour. These therapeutic benefits unequivocally derived from the drug because they were apparent from the first day of Benzedrine treatment and disappeared as soon as it was discontinued. Although l-amphetamine (Cydril) achieved far less attention than either the racemate or d-isomer, clinical trials conducted in the 1970s demonstrated that

both isomers of amphetamine were clinically effective in treating ADHD (Arnold et al., 1972, 1973, 1976). The use of Benzedrine to treat ADHD declined dramatically after Gross (1976) reported that the racemate was significantly less clinically effective than Dexedrine. Currently, the only use of l-amphetamine in ADHD medications is in mixed salts/mixed enantiomers amphetamine (MES-amphetamine), which consists of a 3:1 enantiomeric mixture d-amphetamine:l-amphetamine salts that is available in both immediate-release (Adderall, generic) and extended-release (Adderall XR, generic) formulations. A recent development in the amphetamine field is the introduction of an amphetamine prodrug, lisdexamfetamine dimesylate (Vyvanse). Lisdexamfetamine comprises the naturally occurring amino acid, L-lysine, covalently bound to damphetamine via an amide linking group. It has been approved for the management of ADHD in children (age 612), adolescents and adults in the USA and Canada. It is currently being developed for clinical use in treating ADHD in a number of European countries. The metabolic route of lisdexamfetamine is unusual because after absorption into the bloodstream it is metabolised by red blood cells to yield d-amphetamine and the natural amino acid, L-lysine, by rate- limited, enzymatic hydrolysis (Pennick, 2010). An overview of amphetamine-based medications is provided in Table 1.

Table 1. Amphetamines past and present.

A clinical perspective on the use of amphetamine in the treatment of ADHD

ADHD is arguably the most under-diagnosed and treated of all psychiatric disorders, especially in adults (Kooij et al., 2010). The most recent European data suggest that about 5% of the population suffer from ADHD in any one year, with a total of about 3 million patients in Europe (Wittchen et al., 2011). Further estimates put the cost of each patient at about 5000 per year in the UK (Gustavsson et al., 2011). Of the total just over half are direct treatment costs and the rest indirect costs, for example lost productivity, social harm, negative impact on family life, increased incidence of accidents and costs associated with criminality and legal intervention. The impact in terms of lost quality of life (days lived with disability) puts ADHD in the top 10 disorders of the brain in Europe. Treatment of ADHD is generally inadequate, with estimates suggesting that, at best, less than one-third of patients with the diagnosis get appropriate treatment (Gustavsson et al., 2011).

Although amphetamine has been established as an effective treatment for ADHD, as well as other central nervous system (CNS) disorders such as narcolepsy for decades, its use in the UK (and in the wider European context) has been rather limited in comparison with its widespread use in the USA. The reasons for this are complex and relate to social and medical attitudes to the condition of ADHD, pharmaceutical industry marketing policies, as well as to concerns regarding the use of drugs in paediatric indications which are perceived to have a high potential for recreational abuse and to cause addiction. ADHD has long suffered from being considered an American diagnosis, and for many decades there was a concerted attempt by some experts in child psychiatry to deny, or at least minimise, its existence in the UK. On top of this, on the rare occasions when the disorder was identified, the preferred treatment option was psychotherapy because it fitted with the background of the child psychiatrists and psychologists who were responsible for managing these patients. It was left to certain paediatricians to develop the requisite expertise in the use of stimulants for treating children with ADHD, which many did quite successfully. In recent years, child psychiatrists have begun to assume a prescribing role as well, largely using methylphenidate preparations. Amphetamines, i.e. racemic amphetamine, d-amphetamine and methamphetamine, were widely used to promote wakefulness in World War II, which in turn led to a large increase in production that resulted in large surpluses of these drugs after the war. Much of these stocks got into the black market, and in the 1950s d-amphetamine abuse became recognised. In a classic study of that period, Connell from the Institute of Psychiatry reported a group of heavy d-amphetamine users who had become paranoid (Connell, 1966). This flagged up the potential psychiatric dangers of this drug and may have encouraged prescribers away from d-amphetamine and on to methylphenidate. Another factor was the use of d-amphetamine as an antidepressant in the 1950s before the discovery of the tricyclic monoamine reuptake inhibitors. There were cases of misuse by patients, and also a significant degree of diversion of the prescribed drug into youth misuse and/or abuse that may also have contributed to wariness by prescribers regarding its clinical use. In later years, local outbreaks of d-amphetamine abuse have occurred in various parts of the UK, often using locally synthesised d-amphetamine; again, this will have made doctors shy away from prescribing d-amphetamine lest it contributes to its misuse. In the USA, d-amphetamine-containing medications, especially MESamphetamine, have been very widely used as treatments for ADHD. Familiarity with prescribed amphetamines together with the increased availability of more and more tamper-deterrent drug formulations to reduce the potential for abuse, for example Adderall XR, have created a situation where in the USA the abuse risk of damphetamine is perceived as being similar to that of methylphenidate. This fact, along with the perception that d-amphetamine is much safer than the more potent and enduring stimulant methamphetamine, which is now widely abused, has resulted in a more relaxed attitude of physicians in the USA to the prescribing of d-amphetamine. Luckily, for reasons that are obscure, the recreational abuse methamphetamine has never really caught on in Europe, and almost all illegal use of the amphetamines is confined to damphetamine as the sulphate salt.

The pharmacology of amphetamine

The chemical structure, particularly the 3-dimensional (3-D) structure of amphetamine, is critical in determining the pharmacological effects that underpin its considerable therapeutic benefits and also its liability for recreational abuse. Amphetamine belongs to the class of drugs called the -phenylethylamines. Although it was synthesised many decades before the discovery that the monoamines, i.e. noradrenaline (norepinephrine), dopamine and 5-hydroxytryptamine (5-HT; serotonin), were major neurotransmitters in the central and peripheral nervous systems, part of the rationale for synthesising racemic amphetamine was its structural similarity to the biologically active molecule, ephedrine. As shown in Figure 1, the similarity between the chemical structures of the catecholamine neurotransmitters, noradrenaline and dopamine, and the isomers of amphetamine is abundantly clear. The 3-D structures of the catecholamines and amphetamine molecules reveal the long planar conformation that is common to all of these compounds. For amphetamines isomers, it is their planar conformation, molecular size that is similar to the monoamines, the presence of an aromatic ring and a nitrogen on the aryl side-chain which are the prerequisite physico-chemical properties of a competitive substrate for the monoamine reuptake transporters, i.e. NET (noradrenaline transporter), DAT (dopamine transporter) and SERT (5-HT transporter). Figure 2 illustrates the mechanism responsible for the uptake transport of monoamines and amphetamine into presynaptic nerve terminals. One molecule of monoamine neurotransmitter or amphetamine associates with two Na+ and one Cl- ion, and the resulting molecular complex is actively transported into the presynaptic terminal by the relevant monoamine reuptake transporter. The motive power for this active transport mechanism is a Na+ ion concentration gradient (high Na+ on the outside of the nerve terminal/low Na+ on the inside). The Na+ concentration gradient is maintained by Na+/K+ ATPase that pumps two Na+ ions out of the cell whilst simultaneously pumping in one K+ ion. There are two pools of monoamine neurotransmitter within each type of nerve terminal: the cytosolic pool that holds newly synthesised monoamines, and the vesicular pool that stores the monoamines and from which they are released when neurones fire action potentials.

Figure 2. Actions comprising the pharmacological mechanism of amphetamine. Although the concentration of a monoamine neurotransmitter in the cytosol of the presynaptic nerve terminal is regulated, controlled by its rates of synthesis, release, reuptake and catabolism, it is now recognised that transport of the monoamine into the vesicular storage granules has a critically important role to play in this process.

Translocation of monoamines from the cytosolic pool into the storage pool is performed by a similar active transporter system, the vesicular monoamine transporter 2 (VMAT2) (Fei et al., 2008; Fleckenstein et al., 2009; Ramamoorthy et al., 2011). Since amphetamine competes with the endogenous monoamines for transport into the nerve terminals via NET, DAT or SERT, the higher the concentration of amphetamine present in the synapse, the greater the number of amphetamine molecules transported relative to every molecule of monoamine (see Figure 3). Once inside the presynaptic terminal, amphetamine displaces monoamines from the cytosolic pool. Furthermore, because amphetamine also has affinity for VMAT2 (Teng et al., 1998), it prevents the translocation of monoamines into the intraneuronal storage vesicles. The outcome of these actions is that the direction of the reuptake transporter reverses, so that instead of pumping neurotransmitter from the synapse into the nerve terminal, it pumps neurotransmitter out of neurones into the synapse. This process is called reverse transport or retro-transport (Robertson et al., 2009).

Figure 3. Different mechanisms leading to a 50% reduction in monoamine reuptake produced by a classical reuptake inhibitor versus a competitive substrate (releasing agent). Consistent with the mechanism described above, in vitro experiments have unequivocally demonstrated that amphetamines d- and l-isomers non-selectively release [3H]monoamines from preloaded slices or synaptosomes prepared from rat brain. There are experimental reports stating that d-amphetamine releases [3H] noradrenaline, dopamine and 5-HT from synaptosomes (Holmes and Rutledge, 1976; Rothman et al., 2001) and brain slices (Heal et al., 1998). l-Amphetamine releases noradrenaline, dopamine and 5-HT from synaptosomes (Heikkila et al., 1975; Holmes and Rutledge, 1976) and noradrenaline and dopamine from rat brain slices (Easton et al., 2007). Comparing the relative potencies of d- and l-amphetamine, Heikkila et al. (1975) and Easton et al. (2007) reported that the d-isomer was approximately fourfold more potent than the l-isomer as a releaser of [3H]dopamine. In contrast, l-amphetamine was either as potent, or more so, than d-amphetamine as a releaser of [3H]noradrenaline (Easton et al., 2007; Heikkila et al., 1975). The monoamine transporters are not particularly selective in terms of which monoamines they transport, and this lack of selectivity is explained by the close structural similarity between them (Figure 1). Furthermore, this structural similarity between the monoamine neurotransmitters and amphetamine explains why the latter has promiscuous actions to release the important CNS monoamines (noradrenaline, dopamine and 5-HT). Amphetamine also releases adrenaline from the peripheral sympathetic nervous system, an action linked to its cardiovascular side effects. Although most of these experiments have looked at the effects of amphetamine isomers on basal [3H]monoamine release from synaptosomes or slices, amphetamine also augments electrically stimulated efflux (Easton et al., 2007). This action indicates that its retro-

transport mechanism can act both co-operatively with, and independently of, neuronal firing. Although the pharmacological effect of amphetamine is predominantly mediated by monoamine release, this mechanism is complemented by reuptake inhibition and probably also inhibition of monoamine oxidase (MAO) that combine additively or synergistically to augment synaptic monoamine concentrations. The description of amphetamine as a monoamine reuptake inhibitor often causes some confusion, and the difference between the mechanisms of amphetamine, which is a competitive reuptake transport substrate, and classical reuptake inhibitors is illustrated in Figure 3. The potency of amphetamines isomers as monoamine reuptake inhibitors is summarised in Table 2 and they are compared against some highly potent classical reuptake inhibitors. dAmphetamine is generally accepted to be a weak dopamine reuptake inhibitor with a Ki value of ~100 nM, a moderately potent inhibitor of noradrenaline reuptake (Ki = 4050 nM) and a very weak inhibitor of 5-HT reuptake (Ki = 1.4-3.8 M). Comparisons of the isomers of amphetamine reveal that l-amphetamine is 3.27-fold less potent than damphetamine as a dopamine reuptake inhibitor (Easton et al., 2007; Kula and Baldessarini, 1991; Richelson and Pfenning, 1984), but it is only 1.8-fold less potent against noradrenaline (Richelson and Pfenning, 1984). Its potency is so low that lamphetamine would not be considered to be a 5-HT reuptake inhibitor.

Table 2. Inhibition of [3H]monoamine uptake into rat brain synaptosomes by amphetamines enantiomers in vitro. Finally, excess monoamines within the nerve terminal are catabolised by the mitochondrial-bound enzyme, MAO. Inhibition of MAO would further augment the quantity of neurotransmitter that is available for retro-transport into the synapse. Amphetamines isomers have long been known to be inhibitors of this important catabolising enzyme (Mantle et al., 1976; Miller et al., 1980; Robinson, 1985). Although this mechanism is often discounted because amphetamine is a relatively weak inhibitor of MAO, in the situation where amphetamine is concentrated in presynaptic nerve terminals, shown in Figure 3, it is probable that some inhibition of this enzyme would occur. Although in vitro experiments provide a good insight into individual mechanisms, the efficacy of amphetamine relative to other indirect monoamine agonists, for example classical reuptake inhibitors, can only be estimated from in vivo experiments. We have used dual-probe intracerebral microdialysis to explore the in vivo effects of d- and lamphetamine in the spontaneously hypertensive rat (SHR), which has been proposed as a

rodent model of ADHD (Heal et al., 2008; Sagvolden, 2000; Sagvolden et al., 2005, 2009; see review by Wickens et al., 2011). Both isomers of amphetamine dose-dependently increased the extracellular concentrations of noradrenaline in the prefrontal cortex (PFC) and dopamine in the striatum. The pharmacodynamics of their effects are typical of those reported for monoamine releasing agents, i.e. a fast onset of action with peak increases of noradrenaline and dopamine efflux occurring at 3045 min, large effects (400450% of baseline for noradrenaline and 7001500% of baseline for dopamine), with a relatively rapid decline after the maximum (Figure 4). Although no comparative results have been included in this review, the magnitude of the increases produced by amphetamines isomers are greater than those reported for classical reuptake inhibitors such as atomoxetine or bupropion, and there is no dose-effect ceiling to amphetamines actions (Bymaster et al., 2002; Nomikos et al., 1989, 1990; Swanson et al., 2006; see also Heal et al., 2009, 2012). When comparing the effects of drugs on the efflux of catecholamines in the PFC it is important to take into account the highly unusual neuroanatomy of this brain region. The density of DAT sites on PFC dopaminergic neurones is very low (Hitri et al., 1991), and as a consequence, most dopamine that is released is sequestered via NET into noradrenergic neurones (Mazei et al., 2002; Morn et al., 2002; Stahl, 2003). In spite of the fact that there are few DAT sites on PFC dopaminergic neurones, their reuptake capacity is sufficient for amphetamine to evoke substantial dopamine release from them (Maisonneuve et al., 1990; Pum et al., 2007; Shoblock et al., 2003), though it has been suggested that much of the release of dopamine in the PFC comes from noradrenergic neurones (Shoblock et al., 2004).

Figure 4. A comparison of the effects of the d- and l-isomers of amphetamine on noradrenaline and dopamine efflux in the brains of freely moving rats. When the in vivo pharmacological profiles of amphetamines isomers are compared, damphetamine is three to fivefold more potent than l-amphetamine (Figure 4). Moreover, an analysis of the relative effects of amphetamines isomers on individual catecholamines reveals d-amphetamine has greater effects on dopamine than noradrenaline, whereas lamphetamine has a more balanced action to increase both dopaminergic than noradrenergic neurotransmission (Figure 4). Although the effects of amphetamines isomers shown in Figure 4 were obtained in one particular rat strain predisposed to hypertension (SHRs), similar effects of d- and l-amphetamine have been reported from experiments performed in the PFC and striatum of non-hypertensive strains (Cadoni et al., 1995; Granton et al., 2003; Kuczenski et al., 1995; Nomikos et al., 1990; Pum et al., 2007; Figure 5). Kuczenski et al. (1995) determined the effects of both amphetamine enantiomers on caudate 5-HT release. The effect was considerably smaller than found for dopamine and there was a smaller potency separation between the two isomers.

Figure 5. The effects of administration of d-amphetamine and lisdexamfetamine on the extracellular concentration of dopamine in the striatum and locomotor activity of freely moving rats. Earlier in the review, we described the formulation of MES-amphetamine. In vivo experiments have also been performed to explore the interaction between the 3:1 ratio of d- and l-isomers in this formulation (Glaser et al., 2005; Joyce et al., 2007). The experiments were performed in anaesthetised rats using in vivo voltammetry to determine the extracellular concentration of dopamine in the striatum and nucleus accumbens. Using this technique, Joyce et al. (2007) demonstrated that the dynamics of damphetamine on dopamine efflux were not altered by the presence of the l-isomer in the 1:1 ratio present in the racemate, but as the 3:1 d- to l-isomer mixture, l-amphetamine significantly enhanced and prolonged the efflux of dopamine in the rat striatum produced by d-amphetamine. The authors hypothesised that l-amphetamine in MES-amphetamine modulates the activity of DAT so that the actions of the d-isomer are prolonged (Joyce et al., 2007). An alternative explanation for the observed prolongation of pharmacological effect is that the 3:1 ratio of d- to l-isomers in the MES-amphetamine formulation is serendipitously optimised so that entry of the d-isomer into catecholaminergic nerve terminals is modulated by competition for DAT by the l-isomer, thereby prolonging the neurotransmitter-releasing action of the more potent d-isomer.

Clinical implications
The primary action of amphetamine is to increase synaptic concentrations of monoamine neurotransmitters, thereby indirectly enhancing noradrenergic, dopaminergic neurotransmission in the CNS. Although amphetamines isomers are also powerful 5-HTreleasing agents in vivo (Heal et al., 1998; Kuczenski et al., 1995), this action does not appear to contribute to their efficacy in treating ADHD. This opinion is based on clinical experience with fenfluramine, which is a chemical analogue of amphetamine and a powerful releasing agent with a preferential action on 5-HT (Baumann et al., 2000; Gundlah et al., 1997; Tao et al., 2002). Donnelly et al. (1989) reported that fenfluramine was not effective in treating the disruptive and overactive behaviours in ADHD; nor did it ameliorate the conduct disorder that was present in about half of the subjects. However, it is possible that the actions of amphetamine to increase serotonergic drive may have a beneficial effect on anxiety or depression that is often comorbid with ADHD. Thus, enhanced catecholaminergic signalling is the primary mediator of amphetamines efficacy in ADHD and narcolepsy. On the negative side, the same pharmacology is also responsible for amphetamines major side effects and also its liability for recreational abuse. Therefore, optimising therapeutic efficacy whilst simultaneously maintaining side

effects at an acceptable level is a difficult balance requiring careful dose titration in the patient.

Efficacy
It has long been accepted that in ADHD there is dysregulation of the brain catecholaminergic systems in the PFC and its connections to subcortical regions including the striatum (Arnsten and Dudley, 2005; Durston, 2003; Russell et al., 2005). Neuroimaging studies in subjects with ADHD have revealed anatomical alterations and functional changes consistent with reduced dopaminergic function in various dopaminerich areas of the brain including the frontal cortex, striatum and globus pallidus (Castellanos, 2001; Castellanos et al., 1996; Ernst et al., 1998; Sieg et al., 1995). Based on observations that the isomers of amphetamine evoke very large and rapid increases in the efflux of dopamine and noradrenaline in the PFC and dopamine in the striatum, it was predicted that these drugs would be highly effective in the treatment of ADHD. This was confirmed by reports of efficacy in ADHD with d-amphetamine (Arnold et al., 1972, 1973; Gross, 1976; Huestis et al., 1975; James et al., 2001; Winsberg et al., 1974), l-amphetamine (Arnold et al., 1972, 1973), racemic amphetamine (Gross, 1976) and MES-amphetamine (Greenhill et al., 2003; James et al., 2001; Pelham et al., 1999). It is generally accepted that the efficacy of the amphetamines is not different from that of methylphenidate (Faraone et al., 2006; James et al., 2001; Pelham et al., 2005), which is the other major stimulant used to treat ADHD. However, a meta-analysis by Faraone and Buitelaar (2010) did show moderately greater efficacy for amphetamine medications. This agrees with preclinical findings that methylphenidate also markedly enhances catecholaminergic drive in the PFC and striatum (see Heal et al., 2009, 2012). On the other hand, several trials have reported the superior efficacy of amphetamine in the treatment of ADHD in comparison with the non-stimulant, selective noradrenaline reuptake inhibitor, atomoxetine (Strattera) (Biederman et al., 2006; Faraone et al., 2007; Wigal et al., 2005). This finding fits well with results from in vivo microdialysis experiments that have shown atomoxetine can produce moderate increases in extracellular noradrenaline and dopamine in the PFC as a result of blocking the entry of both catecholamine neurotransmitters into noradrenergic neurones via NET sites, but as a selective noradrenaline reuptake inhibitor it is without effect in other brain regions, such as striatum and nucleus accumbens, where synaptic dopamine concentrations are regulated by DAT sites (Swanson et al., 2006; see also Heal et al., 2009, 2012).

Safety and adverse events

With clinical applications of amphetamine as a drug to combat fatigue, an appetite suppressant and a treatment of narcolepsy, adverse effects such as anorexia, weight loss and insomnia are predictable and frequent adverse events associated with the use of amphetamine-based medications in the management of ADHD. These side effects have been reported for d-amphetamine (James et al., 2001; Pelham et al., 1990; Winsberg et al., 1974) MES-amphetamine (Goodman et al., 2005; James et al., 2001; Pelham et al.,

1999; Wigal et al., 2005) and lisdexamfetamine (Adler et al., 2008; Biederman et al., 2007a,b; Findling et al., 2008; Weisler et al., 2009). Other adverse events evoked by the amphetamines include nausea, vomiting, abdominal cramps, increases in blood pressure and heart rate and possibly also the exacerbation of motor tics (Adler et al., 2008; Biederman et al., 2007a,b; Findling et al., 2008; Goodman et al., 2005; James et al., 2001; Pelham et al., 1990, 1999; Weisler et al., 2009; Wigal et al., 2005; Winsberg et al., 1974).

Abuse liability
Stimulants have a tendency to be liked by a certain proportion of the population, though not by everyone by any means. There is some evidence that basal dopamine tone determines this, with people who have a higher number of dopamine D2 receptors as measured by [11C]-raclopride positron emission tomography (PET) finding the stimulants aversive rather than pleasurable (Volkow et al., 1999a). However, a pleasurable experience from d-amphetamine can lead to excessive use of it as a prescribed drug by the patient and the (mis)use of the prescription by others (diversion). For these reasons, all current amphetamine-type stimulant treatments are Controlled Drugs under the UK Misuse of Drugs Act 1971, with all members of being placed in Class B except methamphetamine, which was recently placed into Class A because of fears of an explosion of recreational abuse similar to that seen in the USA and Thailand. In reality, there is little abuse of these drugs by patients with ADHD (Merkel and Kuchibhatla, 2009), and in most cases the challenge for the prescribing doctor is to keep the patients taking their medication rather than limiting its use. Many teenage patients stop using despite the drugs having clear benefits for their school performance; they cite reasons such as feeling too controlled, wanting empowerment from medication, etc. For these reasons, observations of dependence and abuse of prescription d-amphetamine are rare in clinical practice, and this stimulant can even be prescribed to people with a history of drug abuse provided certain controls, such as daily pick-ups of prescriptions, are put in place (Jasinski and Krishnan, 2009b). It is well known that recreational drug abusers and dependent users generally administer psychostimulants at doses several-fold higher than those stipulated for therapeutic use. Furthermore, to achieve its greatest pharmacological effect, the maximum quantity of drug must be delivered into the CNS in the shortest possible time. It is this imperative which causes drug abusers to progress from relatively safe methods of selfadministration, such as oral ingestion, onto increasingly dangerous routes, for example snorting cocaine, smoking (crack cocaine or crystal meth) or intravenous injection. Another less well-recognised factor in drug abuse is a desire of users for instant gratification. Thus, the appeal of a particular drug as a recreational substance of abuse is to a large extent determined by its ability to produce its desired effects within minutes, for example the cocaine rush. The kinetics of d-amphetamine when taken orally make it less rewarding (pleasurable) than cocaine or methamphetamine. Cocaine, whether snorted or smoked as crack in particular, enters the brain very quickly, and appears even to be concentrated in the brain

relative to plasma; this explains the high rewarding potential of this drug: faster brain entry leads to a greater high. Methamphetamine enters more slowly and its peak effects are delayed by 1015 min compared with cocaine (Fowler et al., 2008). Although damphetamine sulphate has not been studied in an exactly comparable way, we can predict from its physico-chemical properties that after oral ingestion d-amphetamine would have even slower rate of uptake into the brain than methamphetamine. Having said that, the abuse of d-amphetamine is not a cause for complacency. Although amphetamine abuse peaked in the 1960s (Rasmussen, 2008), the misuse of amphetamine is a persistent social, legal and medical problem (Das-Douglas et al., 2008). The intravenous use of damphetamine and other stimulants still pose major safety risks to the individuals indulging in this practice (Charnaud and Griffiths, 1998; Das-Douglas et al., 2008; Kll and Olin, 1990; Leino et al., 1997). Some of this intravenous abuse is derived from the diversion of ampoules of d-amphetamine, which are still occasionally prescribed in the UK for the control of severe narcolepsy and other disorders of excessive sedation. However, most intravenous d-amphetamine use is from local illicit production. Some abusers will use solvents to extract the active ingredient from tablets or capsules, which can then be concentrated and injected intravenously. The development of tamperdeterrent d-amphetamine formulations has been a major objective of the pharmaceutical industry to prevent this type of abuse. Several new once-daily d-amphetamine-containing prescription drugs have emerged that have a high degree of tamper deterrence, for example Adderall XR. In addition, lisdexamfetamine as a prodrug of d-amphetamine, is a further advance in reducing diversion risk since it provides a more gradual increase in brain drug concentration, thereby further reducing the pleasurable effects of the damphetamine. These topics will be revisited later in this review. Volkow and colleagues have performed an enormous body of research using PET and other brain imaging techniques to explore the relationship between DAT occupancy, synaptic dopamine concentration and dopamine D2 receptor occupancy for psychostimulant drugs of abuse. Although the dopamine release hypothesis of drug reinforcement proposed by Di Chiara and Imperato (1988) based on experiments performed in rats and then extended in humans by Volkow and colleagues (1997, 1999a) has its limitations, it is now well accepted that euphoria, psychostimulation and reinforcement produced by stimulant drugs occur when there are rapid and substantial increases in the synaptic concentrations of dopamine in the basal striatum and mesolimbic system of the human brain. These researchers have also demonstrated that the rate of DAT occupancy by drugs such as cocaine and methylphenidate is critical to their ability to produce highs in human subjects (Volkow and Swanson, 2003; Volkow et al., 1996a,b, 1997, 1999a,b). Although d-amphetamine is a competitive substrate for DAT rather than a classical reuptake inhibitor, these same principles apply to its pharmacological action. Thus, the rate and magnitude of neuronal dopamine release produced by amphetamine is absolutely dependent on the rate and concentration of drug that reaches DAT sites in the brain (Heal et al., 2008, 2009). There has been little research conducted in humans on this kinetic course using brain imaging, but it seems likely that the same rules apply.

Consistent with the findings in microdialysis experiments, d-amphetamine has greater potency than l-amphetamine to evoke stimulant-like subjective effects in rats (Schechter, 1978) and behavioural activation in primates (Scraggs and Ridley, 1978). Crossgeneralisation occurs between the subjective cues evoked by amphetamines d- and lisomers, indicating a common neurochemical mechanism (Schechter, 1978). Both amphetamine isomers have been shown to serve as positive reinforcers in animals (i.e. animals will work to get more of the drug) (Gilbert and Cooper, 1983; Risner, 1975; Yokel and Pickens, 1973). The same is true for human subjects (Smith and Davis, 1977; Van Kammen and Murphy, 1975), with the d-isomer once again being two to threefold more potent than the l-isomer (Risner, 1975; Smith and Davis, 1977; Van Kammen and Murphy, 1975; Yokel and Pickens, 1973). On the basis that the subjective and reinforcing effects of amphetamines isomers translate well from animals to humans, and with the assumption that the neurochemical mediators are similarly consistent across species, we can employ the findings from the microdialysis experiments to draw some conclusions on this subject. The results in Figure 4, which reveal that both isomers are equally potent noradrenaline releasers, but d-amphetamine is around threefold more potent than lamphetamine as a dopamine releaser, point to dopamine as the primary neurochemical mediator of amphetamines stimulant and euphoriant properties. As indicated above, it is the combination of the rapid rate of increase and magnitude of effect that accounts for the powerful stimulant effects of amphetamine. Although l-amphetamine is the less potent of the two isomers, its pharmacological efficacy should not be underestimated. Cheetham et al. (2007) reported that both isomers were capable of increasing striatal dopamine efflux by >5000% of baseline values, with these effects reaching a maximum within around 45 min. In contrast, the maximum increases in dopamine efflux achieved by classical dopamine reuptake inhibitors (e.g. bupropion and GBR 12909) are five to tenfold smaller, and often take longer than an hour to reach their peak (Bredeloux et al., 2007; Desai et al., 2010; Nomikos et al., 1989; Sidhpura et al., 2007; Westerink et al., 1987). The importance of the rate of increase of synaptic dopamine concentrations to the induction of stimulation and euphoria is exemplified by the observation that bupropion and GBR 12909 were not experienced as stimulant or euphoriant by normal volunteers (Hamilton et al., 1983; Peck et al., 1979; Sgaard et al., 1990) or experienced recreational stimulant users (Griffith et al., 1983; Miller and Griffith, 1983). In those bupropion and GBR 12909 trials where damphetamine was employed as the positive control, its stimulant, energising and reinforcing effects were unequivocally recognised by normal subjects and recreational drug users (Hamilton et al., 1983; Griffith et al., 1983; Miller and Griffith, 1983; Peck et al., 1979).

Once-daily formulations
In previous reviews, we have extensively described the efficacy and safety of stimulant and non-stimulant drugs used in the management of ADHD and compared the relative merits of each (Heal et al., 2009, 2012). This analysis has revealed that the stimulants, including amphetamine, are still accepted to be the most efficacious drugs available. Some attempts to introduce new medications, for example guanfacine XR (Intuniv)

have been successful, but many other new pharmacological approaches have failed (see Heal et al., 2012). On the other hand, the innovations in formulation technology and drug delivery systems have made significant strides forward in improving the clinical management of ADHD. All of the stimulants have biological half-lives that require at least twice-daily dosing to deliver efficacy over 1214 h. ADHD is characterised by inattention, distractibility, working memory deficits and impulsivity, and as such, subjects with this disorder are particularly unsuited to compliance with rigid dosing schedules. Since amphetamine has a high liability for recreational abuse, placing medicines in the hands of children increases the risk of diversion/abuse, whilst the alternative approach of putting the drugs into the care of the school authorities carries with it the requirement for appropriate facilities for the storage of Controlled Drugs. Administering a once-daily stimulant medication to a child or adolescent first thing in the morning under parental supervision relieves him/her of the requirement to take additional medication outside of the home, and it also eliminates the need for the patient to take additional medication within strict time-windows. One of the additional benefits of these new formulations is their tamper deterrence, making it difficult for abusers to extract amphetamine for self-administration by hazardous routes, such as smoking, snorting or intravenous injection. Examples of once-daily amphetamine medications include MESamphetamine XR and the d-amphetamine prodrug, lisdexamfetamine.

Lisdexamfetamine
As briefly discussed earlier in the review, lisdexamfetamine is the first amphetamine prodrug to have been approved for use in treating ADHD. Lisdexamfetamine has no affinity for a wide panel of transporters including DAT and NET (Vyvanse, US Product Label) or receptors, ion channels, allosteric binding sites and enzymes (Table 3). This profile is consistent with lisdexamfetamine being pharmacologically inactive. Although there is no definitive information on the subject, the large molecular size and polar characteristics of lisdexamfetamine predict that the parent molecule is unlikely to cross the bloodbrain barrier. In vitro experiments revealed that the metabolism of lisdexamfetamine to d-amphetamine occurs in red blood cells by rate-limited enzymatic hydrolysis (Pennick, 2010).

Table 3. Lack of affinity of lisdexamfetamine for a portfolio of abuse-related molecular targets The pharmacokinetic/pharmacodynamic (PK/PD) relationships of lisdexamfetamine and immediate-release (IR) d-amphetamine sulphate have been explored in rats, where automated blood sampling was combined with striatal microdialysate sampling. The

locomotor activity of the rats was also simultaneously monitored. After administration of equivalent doses of lisdexamfetamine and IR d-amphetamine (1.5 mg/kg ip as damphetamine base), the observed plasma PK profiles for the pharmacologically active moiety, d-amphetamine, were very different. The AUC0-480 min values were identical, but the maximum concentration reached in plasma (the Cmax) was 50% lower after administration of lisdexamfetamine and the time to Cmax (the tmax) was doubled (Jackson et al., 2011). These observations are entirely consistent with the postulated rate-limited enzymatic conversion of lisdexamfetamine to d-amphetamine. This difference in PK characteristics had a profound impact on the pharmacological effects of these two compounds in rats (Figure 5). Lisdexamfetamine produced a gradual and sustained increase in striatal dopamine efflux, whereas the increase produced by IR d-amphetamine was faster in onset, reaching a peak at 30 min, and it subsequently declined more rapidly (Figure 5). d-Amphetamines effects on striatal dopamine efflux and locomotor activity are superimposable (Figure 5), that is, the rapid release of dopamine translates directly into an immediate and substantial increase of locomotor activity. In the case of lisdexamfetamine, the more gradual and sustained increase in dopamine efflux was associated with a much smaller and visibly delayed locomotor response. Using a hysteresis analysis to define the relationship between the ascending and descending components of a concentration-time curve for extracellular dopamine concentration in the striatum and the functional response (locomotor activity), the relationship was anticlockwise for lisdexamfetamine, but clockwise for IR d-amphetamine (p < 0.05) (Rowley et al., 2011). Using the hysteresis analysis in a more conventional way to explore the relationship between the plasma concentration of d-amphetamine and the functional response, there was a clear difference between the two compounds with an anticlockwise hysteresis for lisdexamfetamine and no hysteresis for IR d-amphetamine (Rowley et al., 2011). The anticlockwise hysteresis shows that the functional effect of lisdexamfetamine was greater as the plasma concentration of d-amphetamine was falling, whilst the lack of hysteresis with IR d-amphetamine demonstrates that as soon as the plasma concentration of the drug starts to decline, so does its pharmacological effect. The clinical importance of these findings will be discussed in the following section.

Implications of pharmacokinetics of lisdexamfetamine for efficacy, safety and recreational abuse liability
The efficacy of lisdexamfetamine has been demonstrated in a number of randomised, double-blind, placebo-controlled clinical trials in ADHD in children, adolescents (Biederman et al., 2007a,b; Lopez et al., 2008; Wigal et al., 2009) and adults (Adler et al., 2008, 2009; Wigal et al., 2010a). Since lisdexamfetamine has been the subject of several reviews (Dew and Kollins, 2010; Heal et al., 2009, 2012; Howland, 2008; Madaan, 2008; Mattingly, 2010; Najib, 2009), we will focus on the probable contribution of lisdexamfetamines special PK/PD profile to its efficacy as a treatment for ADHD and its potential for lower recreational abuse/dependence than amphetamine.

Biederman et al. (2007a) published results from the only clinical trial where the efficacy and safety of lisdexamfetamine in ADHD was compared directly against another clinically proven drug, MES-amphetamine XR. Following a 3-week, open-label run-in period where the dose of MES-amphetamine XR was optimised to 10, 20 or 30 mg once a day, subjects were then randomised into a 3-way double-blind, placebo-controlled crossover trial. They received their optimal dose of MES-amphetamine XR, an equivalent dose of lisdexamfetamine in terms of d-amphetamine base, or placebo. On the primary and secondary efficacy variables of behaviour, attention and problem solving, lisdexamfetamine delivered equivalent or better efficacy than MES-amphetamine XR with both drugs being maximally effective at 2 h post-dose (Biederman et al., 2007a). However, on the problem-solving endpoints, it was also evident that lisdexamfetamine maintained its maximum effect for at least 12 h, whereas the effect of MES-amphetamine XR showed a clear decline after 68 h (Biederman et al., 2007a). An exceptionally long duration of effect of lisdexamfetamine was observed by Wigal et al. (2009, 2010b), who reported that significant improvements in deportment and attention in children with ADHD were observed as early as 1 h after lisdexamfetamine administration, with its efficacy on behaviour, attention and problem solving maintained for up to 13 h. A posthoc analysis of the data also showed that the sex and age of the subjects had no significant influence on the efficacy of lisdexamfetamine (Wigal et al., 2010b). These observations fit well with the PD profile of lisdexamfetamine in the microdialysis experiments. Thus, a dose of lisdexamfetamine that produced only a small increase in locomotor activity evoked >500% enhancement of striatal dopamine efflux that was maintained for at least 6 h (Figure 5). PK studies in human subjects have revealed the tmax of plasma d-amphetamine occurs around 3 h after taking lisdexamfetamine; thereafter, plasma d-amphetamine declines such that at 12 h its concentration has fallen to around 60% of the Cmax (Krishnan and Stark, 2008; Krishnan et al., 2008). The maintenance of therapeutic effect in ADHD when plasma d-amphetamine concentrations are declining indicates that the anticlockwise hysteresis observed in the preclinical PK/PD experiments probably also applies to its clinical efficacy. Another way to produce a more gentle increase of brain dopamine is to bind damphetamine to a support. MES-amphetamine XR employs a bead technology to deliver two bolus doses of amphetamine, the first immediately and the second approximately 4 h later, giving a Cmax for amphetamines d- and l-isomers 68 h (Adderall XR, US Product Label). Therefore, the maximum therapeutic effect of MES-amphetamine XR (Biederman et al., 2007a) coincided almost exactly with the tmax for plasma damphetamine (Adderall XR, US Product Label). These findings are also consistent with the preclinical PK/PD relationship for IR d-amphetamine that found a lack of hysteresis between plasma d-amphetamine concentration and the functional response, that is, locomotor activity. Another factor that almost certainly contributes to the consistently high level of therapeutic efficacy observed with lisdexamfetamine treatment is the very low inter- and intra-subject variability in the plasma concentration of d-amphetamine observed after administration of the prodrug compared with traditionally formulated stimulants,

including beaded and osmotic-release formulations. Once again, the reproducible pharmacokinetics of its active metabolite, d-amphetamine, are probably due to the ratelimited, enzymatic cleavage of the precursor molecule that occurs primarily in red blood cells (Ermer et al., 2010). In two earlier published studies, Jasinski and Krishnan compared the subjective effects of lisdexamfetamine and IR d-amphetamine in drug-experienced human volunteers when these compounds were administered intravenously (Jasinski and Krishnan, 2009a) and orally (Jasinski and Krishnan, 2009b). In the trial where they compared these compounds after oral administration, IR d-amphetamine (40 mg (29.6 mg d-amphetamine base)) evoked a statistically significant increase relative to placebo in Drug liking on the Drug Rating Questionnaire Subject (DQRS) scale, whereas the equivalent dose of lisdexamfetamine (100 mg, oral) did not (Jasinski and Krishnan, 2009b). Furthermore, the time of lisdexamfetamines peak pharmacological effect was substantially delayed compared with IR d-amphetamine, at 3.0 h versus 1.52.0 h. When lisdexamfetamine was given at an increased dose of 150 mg, it significantly increased the DQRS Drug liking score to an equivalent extent to IR d-amphetamine (40 mg oral). However, the peak effect of the higher dose of lisdexamfetamine was even more delayed, at 4.0 h. When the intravenous route was explored, IR d-amphetamine (20 mg intravenous) produced a peak Drug liking score 20 min after dosing, which coincided with plasma Cmax (Jasinsky and Krishnan, 2009b). In contrast, the equivalent dose of lisdexamfetamine (50 mg intravenous) did not significantly increase Dug liking relative to placebo, and the Cmax of plasma d-amphetamine occurred considerably later at 2.0 h (Jasinski and Krishnan, 2009b). Both compounds yielded equivalent AUC0-24h values, but compared with the equivalent dose of IR d-amphetamine, the Cmax for plasma d-amphetamine was threefold smaller for lisdexamfetamine and the tmax was threefold greater (Jasinski and Krishnan, 2009b). These differences in the PK and PD characteristics of IR damphetamine and lisdexamfetamine observed in humans by Jasinski and Krishnan (2009b) are very similar to the results from the rat PK/PD study that are described earlier in this review (Jackson et al., 2011; Rowley et al., 2011). From these results, it can be concluded that although in terms of d-amphetamine base equivalents lisdexamfetamine is clearly less potent than IR d-amphetamine, it does nonetheless produce d-amphetamine-like subjective effects in man. It is also reasonable to assume that if the intravenous dose of lisdexamfetamine had been increased, its Drug liking effect would have separated from placebo. However, when considering any drugs potential for recreational abuse, the time required for it to produce its peak response is likely to be as important as its magnitude. In the case of IR d-amphetamine, its maximum subjective effect occurred much earlier than lisdexamfetamine, and switching to the intravenous route speeded up IR d-amphetamines onset of action and increased its potency. Although increasing the dose of lisdexamfetamine enhanced its efficacy, it also progressively delayed its time of peak effect. Furthermore, switching to the intravenous route for lisdexamfetamine appeared to have relatively little influence on the abuse potential of the prodrug.

To explore this possibility further, we performed a post-hoc analysis on the data in the original clinical study reports (Jasinski, 2005, NRP104.A02; Jasinski, 2006, NRP104.A03) to compare pharmacodynamics and pharmacokinetics of lisdexamfetamine when given by the clinical route (oral) versus one of those favoured by recreational abusers (intravenous). This topic is of particular importance because lisdexamfetamine has very high aqueous solubility, making the prodrug very easy to extract. In fact, breaking the capsule open and dissolving the contents in water is stated as a dosing route for patients who are unable to swallow capsules (Vyvanse, US Product Label). As shown in Table 4, the average maximum scores on the DQRS and Drug Rating Questionnaire Observer (DRQO) scales for Liking, Feel drug effect, and Disliking reveal that the subjective effects of lisdexamfetamine (50 mg) were not significantly different when the prodrug was administered orally or intravenously. This result shows that the subjective effects of lisdexamfetamine were not enhanced when the drug was given intravenously. Blood pressure measurements are useful objective measures of the PD effects of sympathomimetic drugs. Compared with placebo, 50 mg lisdexamfetamine significantly increased the peak systolic blood pressure when administered both orally and intravenously and diastolic blood pressure when given orally (Figure 6). What is also evident from the data in Figure 6 is that the magnitude of increases in systolic and diastolic blood pressures was not statistically different after oral or intravenous administration of lisdexamfetamine.

Table 4. A comparison of the pharmacodynamics and pharmacokinetics of orally versus intravenously administered 50 mg lisdexamfetamine.

Figure 6. A comparison of the mean peak increases in systolic and diastolic blood pressure produced by intravenous versus oral administration of 50 mg lisdexamfetamine. The PK parameters for plasma d-amphetamine observed after oral versus intravenous administration of lisdexamfetamine (50 mg) are also summarised in Table 4. The AUC0infinity shows that the overall drug exposure was identical irrespective of the route of administration. Importantly, intravenous injection of lisdexamfetamine did not either significantly increase the Cmax of d-amphetamine, nor did it significantly reduce its tmax. Although the AUC0-1.0h indicated that early exposure to d-amphetamine was reduced after

oral administration of lisdexamfetamine, this difference is probably explained by the fact that intravenous dosing route bypasses the time taken for the prodrug to be absorbed from the gut into the bloodstream prior enzymatic hydrolysis by red blood cells. These findings strengthen the view that the unusual mechanism for metabolic conversion of lisdexamfetamine to d-amphetamine has important implications for its liability for recreational abuse. The subjective effects of a 50 mg dose of lisdexamfetamine were identical in magnitude when the prodrug was administered orally or by intravenous injection, demonstrating that intravenous injection did not enhance the pharmacological potency of lisdexamfetamine in the CNS. The increases in systolic and diastolic blood pressures after oral or by intravenous administration of lisdexamfetamine were also identical, confirming by objective and quantifiable physiological measures that the intravenous injection route did not enhance its pharmacological potency. These conclusions were supported by the PK results showing that the AUC, Cmax and tmax were not influenced by lisdexamfetamines route of administration. These results are complemented by those of Ermer et al. (2011), who reported that the PK profiles were identical when lisdexamfetamine was administered intranasally or orally, indicating that attempts to increase its potential for recreational abuse by snorting would similarly be futile. Although the findings do not demonstrate that lisdexamfetamine lacks any potential for recreational abuse, they do indicate that its attractiveness to abusers will be reduced compared with IR d-amphetamine. Based on these data, the likelihood that lisdexamfetamine will be widely abused by the intravenous or nasal route is very low.

Conclusions
It is now just over a hundred years since amphetamine was first discovered. In that period amphetamine has transformed from a drug that was widely available without prescription for the treatment of a broad range of disorders to being highly restricted Controlled Drugs that, in Europe at least, have all but disappeared from the formularies in many countries. The very clear links between molecular structure and pharmacological mode of action and, in turn, efficacy and safety in humans, makes amphetamine a textbook example of translational validity. The primary pharmacology of these drugs is not only responsible for providing efficacy in disorders such as ADHD and narcolepsy, but also for their spectrum of adverse events and liability for recreational abuse, making the balance of benefit/risk the key challenge in their clinical use. Amphetamine ranks alongside methylphenidate as the most effective drugs available for the management of ADHD, and the advances that have been made in developing genuine once-daily medications have addressed some of the problems of therapeutic coverage, whilst at the same time reducing the risk of diversion and recreational abuse.

Acknowledgments
The authors wish to thank Shire Pharmaceuticals for their support funding a portion of the writers time for the literature review and writing of this manuscript. The authors

wish to state that the material presented in this review reflect only their views and not necessarily those of the Shire Pharmaceuticals.

Footnotes
Conflict of interest: The authors declare that there are no conflict of interest. Funding: Part of this research was funded by Shire Pharmaceuticals.

Article information
J Psychopharmacol. 2013 June; 27(6): 479496. doi: 10.1177/0269881113482532 PMCID: PMC3666194 David J Heal,1 Sharon L Smith,1 Jane Gosden,1 and David J Nutt2 1 RenaSci Limited, Biocity, Nottingham, UK 2 Department of Neuropsychopharmacology and Molecular Imaging, Division of Neuroscience & Mental Health, Imperial College London, London, UK David J Heal, RenaSci Limited, Biocity, Pennyfoot Street, Nottingham NG1 1GF, UK. Email: david.heal/at/renasci.co.uk Copyright The Author(s) 2013 This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Articles from SAGE Choice are provided here courtesy of SAGE Publications

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Persistent reversal of enhanced amphetamine intake by transient CaMKII inhibition

Jessica A. Loweth, Dongdong Li, [...], and Paul Vezina Additional article information

Abstract
Amphetamine exposure transiently increases CaMKII expression in the nucleus accumbens (NAcc) shell and this persistently increases local GluA1 S831 phosphorylation and enhances behavioral responding to the drug. Here we assessed whether transiently interfering with CaMKII signaling using a dominant-negative CaMKII mutant delivered to the NAcc shell with herpes simplex viral (HSV) vectors could reverse these long-lasting biochemical and behavioral effects observed following exposure to amphetamine. As expected, transient expression of CaMKII K42M in the NAcc shell produced a corresponding transient increase in CaMKII and decrease in pCaMKII (T286) protein levels in this site. Remarkably, this transient inhibition of CaMKII activity produced a long-lasting reversal of the increased GluA1 S831 phosphorylation levels in NAcc shell and persistently blocked the enhanced locomotor response to and self-administration of amphetamine normally observed in rats previously exposed to the drug. Together, these results indicate that even transient interference with CaMKII signaling may confer long-lasting benefits in drug sensitized individuals and point to CaMKII and its downstream pathways as attractive therapeutic targets for the treatment of stimulant addiction. Keywords: Addiction, amphetamine, CaMKII, GluA1, self-administration, sensitization, substance abuse, therapeutics

INTRODUCTION
Previous exposure to psychostimulants such as amphetamine and cocaine enhances subsequent neurochemical and behavioral responding to the drug. These phenomena are thought to contribute to the transition from casual drug use to addiction (Robinson and Berridge, 1993; Vezina, 2004). A brain area prominently linked to the generation of addictive behaviors is the nucleus accumbens (NAcc) shell (Anderson et al., 2008). We recently showed that amphetamine exposure transiently increases expression of the Ca2+/calmodulin-dependent protein kinase II (CaMKII) isoform in this site and that transient viral overexpression of CaMKII mimics the behavioral effects of amphetamine exposure in rats (Loweth et al., 2010). Conversely, NAcc shell infusion of a CaMKII inhibitor (KN93) prevents cocaine-induced reinstatement of drug seeking (Anderson et

al., 2008) as well as the expression of enhanced NAcc dopamine (DA) overflow (Pierce and Kalivas, 1997), cocaine-induced locomotion (Pierce et a., 1998) and amphetamine self-administration (Loweth et al., 2008) normally observed in sensitized rats. However, KN93 affects not only CaMKII and other protein kinases, but also L-type Ca2+-channels (Li et al., 1992; Gao et al., 2006), and an inhibitor of these channels produces the same biochemical (Pierce and Kalivas, 1997) and behavioral effects (Pierce et al., 1998; Anderson et al., 2008) as KN93. Furthermore, these studies did not directly assess the possibility that transient NAcc shell CaMKII inhibition could have long-lasting effects on behavioral responding to psychostimulants, a possibility suggested by our earlier work showing that transient increases in CaMKII in this region lead to long-lasting neuroadaptations that contribute to the maintenance of sensitization (Loweth et al., 2010). Thus, in the present study, we used a CaMKII- and brain-region-specific transient inhibition strategy to determine whether interfering directly with endogenous CaMKII signaling within the NAcc shell could persistently reverse long-lasting behavioral manifestations of amphetamine sensitization.

METHODS
Strategy for CaMKII inhibition by viral-mediated expression of a K42M mutant
Replication-deficient herpes simplex virus (HSV) viral vectors were constructed and packaged as previously described by us (Neve et al., 1997; Loweth et al., 2010). These vectors were used because they produce transient overexpression of the transgene that peaks 34 days post-infection and returns to baseline by day 8 post-infection (Neve et al., 1997; Carlezon and Neve, 2003; Loweth et al., 2010). In addition, local viral infection permits functional testing of specific groups of neurons in specific brain areas (here the NAcc shell). We chose to transiently express a CaMKII K42M mutant which is kinase dead due to impaired ATP binding. Such kinase dead mutants are commonly used as dominant-negative mutants to interfere with endogenous kinase functions and this has been described for CaMKII (e.g., Khl et al., 2000; Xiao et al., 2005; Garic et al., 2011). Dominant-negative effects can be exerted by competition with endogenous kinase for upstream activators, downstream substrates, or subcellular targeting modules. In the case of CaMKII, which forms dodecameric holoenzymes, dominant-negative effects can also be exerted by the formation of heteromeric holoenzymes, which interferes with the intraholoenzyme inter-subunit autophosphorylation at T286 that generates Ca2+-independent autonomous CaMKII activity (for reviews, see Coultrap and Bayer, 2012; Lisman et al., 2012). In addition, the K42M mutant interferes with the targeting of holoenzymes to the NMDA-type glutamate receptor subunit GluN2 (Bayer et al., 2006; OLeary et al., 2011), which is regulated by nucleotide binding to CaMKII (OLeary et al., 2011) and also generates autonomous activity (Bayer et al., 2001; Bayer et al., 2006). Thus, the K42M mutant of CaMKII has even greater dominant-negative potential than the kinase dead mutants of most other kinases. The regulation of CaMKII is rather complex (Coultrap and Bayer, 2012), but it should be noted that some cellular functions that simply require Ca2+/calmodulin-stimulated CaMKII activity may or may not be affected by the presence of additional kinase dead mutant. Thus, the designation as a dominant

negative mutant (as done here) is always linked to a specific cellular function; for other functions, a particular kinase dead mutant may or may not act in a dominant negative fashion (for further discussion, see Wayman et al., 2011).

Subjects and Surgery

Male Sprague-Dawley (locomotion experiments) and Long-Evans rats (selfadministration experiments) weighing 250275 g on arrival were purchased from Harlan Sprague-Dawley (Madison, WI) and housed individually with food and water freely available. They were implanted with chronic bilateral guide cannulae as described previously (Loweth et al., 2010). For the amphetamine self-administration studies, rats were also implanted with i.v. catheters as described previously (Suto et al., 2004). All surgical procedures were conducted using aseptic techniques according to an approved Institutional Animal Care and Use Committee protocol.

Design and Procedure

Rats in different groups were exposed to repeated intermittent injections of amphetamine or saline and 23 weeks later, infused intracranially into the NAcc shell with HSV-K42M CaMKII or a control infusion (mock) consisting of HSV-LacZ or 10% sucrose vehicle. Rats in one experiment were tested for their locomotor response to a systemic amphetamine injection 4 days and again 8 days following infection. Rats in a second experiment were tested for their self-administration of amphetamine before and after HSV infection. Rats in additional groups were sacrificed 4 or 8 days following HSV infection to determine the expression pattern of the transgene and assess its effect on phosphorylation of the AMPA receptor GluA1 subunit at S831, a CaMKII residue. In these cases, brain sections were harvested and subsequently assessed using immunoblotting.

Exposure Injections
Exposure injections (5 1.5 mg/kg amphetamine or 1.0 ml/kg saline) were administered every 23 days as described previously (Vezina et al., 2002; Suto et al., 2004). S(+)amphetamine sulfate was obtained from Sigma-Aldrich and dissolved in sterile saline. Doses refer to the weight of the salt.

Viral-mediated gene transfer in the NAcc shell

The following HSV vector constructs were used: CaMKII K42M and a control vector, LacZ, which encodes the protein -galactosidase. LacZ and 10% sucrose vehicle were used interchangeably for mock-infection control infusions as they have consistently been found to be without effect (Loweth et al., 2010; Singer et al., 2010). Rats were transported to a biosafety level 2 facility where, as described previously (Loweth et al., 2010; Singer et al., 2010) and according to an approved Institutional Biosafety Committee protocol, they were administered bilateral intracranial microinjections into the

NAcc shell of their respective viral vectors or mock control vehicle. Rats were returned to the colony room 24 hours later.

Locomotor Testing
To assess the effect of transient expression of CaMKII K42M in NAcc shell neurons on sensitized locomotor responding to amphetamine, rats were assigned randomly to different groups based on exposure (systemic amphetamine or saline) and infection (NAcc shell HSV-K42M CaMKII or mock). Thus, four groups were tested: amphetamine-mock, amphetamine-K42M, saline-mock, and saline-K42M. 23 weeks after the exposure regimen, rats received their respective NAcc shell microinjections and were tested for their locomotor response to amphetamine (1.0 mg/kg, i.p.) 4 and 8 days later. On each test day, locomotor activity was measured 1 hour before and 2 hours after the amphetamine challenge injection using a bank of 12 activity boxes as described previously (Vezina et al., 2002).

Self-Administration Training and Testing

To assess the effects of transient expression of CaMKII K42M on enhanced amphetamine self-administration, separate rats were assigned randomly to one of four groups based on exposure and infection as described above for locomotor testing. 23 weeks after the last exposure injection, rats were trained to self-administer amphetamine on fixed ratio (FR) schedules of reinforcement and then tested under a progressive ratio (PR) schedule for 4 days pre-infection to visualize enhanced work output and drug intake in amphetamine-exposed rats (Vezina et al., 2002). The following day, rats were transported to the biosafety facility and administered their respective NAcc shell microinjections. PR self-administration testing resumed the next day and continued for 12 days post-infection as described previously (Loweth et al., 2010). Reinforced lever presses delivered an infusion of amphetamine (200 g/kg/infusion) through the i.v. catheter. 6 rats did not satisfy the FR training criteria and were excluded from the study. The daily PR test sessions were terminated after 3 hr or after 1 hr elapsed without a drug infusion.

Immunoblotting and Immunohistochemistry

Brains were removed rapidly and flash-frozen on dry ice. Sections (1mm thick) were obtained with a brain matrix and 2 mm diameter punches taken bilaterally around the injection cannula tips. Tissue punches were processed, loaded (20g/lane), run using SDS-PAGE electrophoresis and developed. The following primary antibodies were used: CaMKII (1:2,000), pCaMKII (T286; 1:1,000), GluA1 (1:1,000), pGluA1(S831;1:500), and -Actin (1:2,000) or Tubulin (1:100,000) as a loading control. All antibodies were obtained from Millipore except for -Actin (Sigma-Aldrich). Additional rats were used in immunohistochemistry studies (infection with HSV-LacZ) to visualize the pattern of infection as described previously (Carlezon and Neve, 2003).

Histology

After the completion of the behavioral experiments, rats were deeply anesthetized and perfused transcardially with 0.9% saline and 10% formalin and brains were removed and stained with cresyl violet to identify rats with injection cannula tips located bilaterally in the NAcc shell. Only rats with both cannula tips in the targeted region were retained for statistical analyses and their number subsequently indicated as n/group in the appropriate figure legends. The number of rats that failed to meet this criterion for the locomotor and self-administration studies was as follows: amphetamine-mock, 7; amphetamine-K42M, 5; saline-mock, 2; saline-K42M, 3.

Data Analysis
Immunoblot, locomotor and self-administration data were analyzed with 2-way between ANOVA with Exposure (amphetamine and saline) and Infection (HSV-CaMKII K42M and mock) as the between factors. Post-hoc comparisons were made using the Least Significant Difference (LSD) test. For locomotion, the data analyzed were the total locomotor counts obtained following the amphetamine challenge (2-hr) on each test day. For self-administration, the data analyzed were the total number of infusions obtained on day -1 pre-infection, on day 4 post-infection (when expression of the transgene was maximal), and averaged over days 812 post infection (when the transgene was no longer expressed).

RESULTS
Transient CaMKII inhibition persistently reverses increased GluA1 S831 phosphorylation in the NAcc shell of amphetamine exposed rats
Herpes simplex viral (HSV) vectors were used to transiently overexpress an inactive mutant of CaMKII (K42M) in NAcc shell neurons (Fig. 1e) as we have previously described for active CaMKII (Loweth et al., 2010). 23 weeks after exposure to amphetamine or saline, rats received bilateral NAcc shell microinjections of HSVCaMKII K42M or mock-infection control infusions. CaMKII protein and T286phosphorylation levels were assessed on day 4 and day 8 post-infection (Fig. 1bc). Consistent with previous findings (Loweth et al., 2010), no changes in either CaMKII protein or T286-phosphorylation levels were detected 23 weeks after exposure to amphetamine as displayed in the mock-infected rats. Subsequent infection with HSVCaMKII K42M transiently increased total CaMKII protein levels in both amphetamine and saline treated rats; these returned to baseline levels by day 8 post-infection (Fig. 1b). In contrast, T286-phosphorylation was transiently decreased, both in absolute terms (data not shown) and as a ratio of phospho-T286 to total CaMKII (Fig. 1c), confirming that expression of CaMKII K42M interfered with endogenous CaMKII signaling. This effect was also transient and no longer evident by day 8 post-infection (Fig. 1c). The ANOVA conducted on CaMKII levels and the ratio of pCaMKII/CaMKII showed significant effects of Infection only on day 4 post-infection (F1,19=20.12, p<0.001 and F1,19=15.90 p<0.001, respectively). No other effects, including on day 8 post-infection, were statistically significant. Thus, transient viral expression of CaMKII K42M transiently

interfered with autonomy-inducing CaMKII T286 phosphorylation, which was back to control levels on day 8 post-infection.

Figure 1 HSV-CaMKII K42M transiently reduces CaMKII T286 autophosphorylation but persistently reverses the increased phosphorylation of GluA1 at S831 in NAcc shell of amphetamine exposed rats As exposure to a sensitizing amphetamine regimen leads to a long-lasting increase in phosphorylation of GluA1 at S831 in the NAcc shell (Loweth et al., 2010), we then assessed the effect of transiently inhibiting CaMKII signaling in this site on phosphorylation of this GluA1 residue. Again, a sustained increase in GluA1 S831 phosphorylation was detected in the NAcc shell of mock-infected rats 23 weeks after exposure to amphetamine. This increase in phospho-S831 was reversed by CaMKII K42M expression on day 4 (Infection, F1,17=5.70, p<0.05), and, remarkably, remained attenuated on day 8 post-infection (Exposure, F1,18=10.99, p<0.01) when both CaMKII expression and T286 phosphorylation had returned to baseline levels. No other effects were statistically significant. These findings were again observed both in absolute terms (data not shown) and as a ratio of phospho-S831 to total GluA1 (Fig. 1d).

Transient CaMKII inhibition in the NAcc shell of amphetamine exposed rats persistently reverses their enhanced locomotor response to and selfadministration of the drug
As expected, rats exposed to amphetamine 23 weeks earlier showed a greater locomotor response to a systemic amphetamine challenge (1.0 mg/kg, i.p.) compared to salineexposed controls (Vezina, 2004; Fig. 2). Remarkably, transient CaMKII inhibition in the NAcc shell persistently reversed this expression of locomotor sensitization by amphetamine. The enhanced locomotor response was completely abolished in the HSVCaMKII K42M infected animals, not only on day 4 (Fig. 2a) but also on day 8 postinfection (Fig. 2b), again a time point when both CaMKII expression and T286phosphorylation had returned to baseline levels (Fig. 1bc). Significant effects of Exposure (day 4, F1,21=6.30, p<0.05; day 8, F1,21=4.15, p=0.054) and Infection (day 4, F1,21=9.20, p<0.01; day 8, F1,21=4.43, p<0.05) were detected on both test days. Thus, we next assessed the effect of transient CaMKII inhibition on the enhanced amphetamine intake observed following amphetamine exposure (Vezina, 2004; Vezina et al., 2002). Rats were again randomly assigned to four groups based on condition of exposure (amphetamine or saline) and infection (bilateral NAcc shell HSV-CaMKII K42M or mock-infection). As expected (Vezina et al., 2002), rats exposed to amphetamine and

given the opportunity to self-administer the drug i.v. worked significantly more and as a result obtained more infusions compared to saline-exposed controls (Fig. 3; day -1 preinfection, Exposure, F1,28=5.41, p<0.05). However, the day following infection through to day 4 post-infection when expression of the transgene was maximal, amphetamineexposed rats infected with HSV-CaMKII K42M no longer displayed enhanced amphetamine intake, obtaining the same number of infusions as saline-exposed rats and significantly fewer than mock-infected amphetamine-exposed rats (Fig. 3; day 4 postinfection, Exposure, F1,28=3.58, p=0.07; E I, F1,28=6.69, p<0.05). Importantly, this reversal of enhanced amphetamine self-administration was maintained for the full 12 days of testing post-infection and thus again outlasted the transient interference with CaMKII signaling achieved by HSV-CaMKII K42M (Fig. 3; days 812 post-infection, E I, F1,25=4.09, p=0.05).

Figure 2 Transient NAcc shell CaMKII K42M expression persistently reverses amphetamine-induced locomotor sensitization

Figure 3 Transient CaMKII inhibition in the NAcc shell of amphetamine exposed rats persistently reverses enhanced amphetamine self-administration

DISCUSSION
Expressing a dominant negative form of CaMKII (K42M) that transiently inhibits CaMKII activity in NAcc shell neurons persistently blocked the expression of two major manifestations of sensitization by amphetamine. As expected, previously exposing rats to amphetamine led to sensitized locomotor responding to a challenge injection of the drug and, in a separate group of rats, enhanced drug intake under a progressive ratio (PR) schedule of reinforcement (Vezina et al., 2002; Vezina, 2004). Transiently inhibiting CaMKII activity in the NAcc shell of these rats blocked these manifestations of sensitization and continued to do so long after expression of the transgene had dissipated, indicating that continued uninterrupted CaMKII activation is necessary for their maintenance. Previous studies suggested that CaMKII activity in the NAcc shell is required for the expression of stimulant sensitization (Pierce and Kalivas, 1997; Pierce et al., 1998; Loweth et al., 2008) and cocaine-induced reinstatement (Anderson et al., 2008). However, these previous studies tested the pharmacological inhibitor KN-93 that is known to affect not only CaMKII and other protein kinases but also to inhibit L-type Ca2+ channels, rendering an interpretation of results that focuses specifically on CaMKII

difficult. The use of HSV mediated delivery of a CaMKII mutant in the present experiments circumvented these shortfalls. Importantly, the present study is the first to unequivocally demonstrate that transiently inhibiting CaMKII activity in the NAcc shell can lead to the persistent and selective reversal of enhanced behavioral responding to amphetamine. Thus, the evidence reported here identifies CaMKII and the signaling pathways it initiates as attractive therapeutic targets for the treatment of substance abuse. CaMKII regulates long-term potentiation (LTP) of synaptic strength, a form of neuronal plasticity thought to underlie both physiological and addiction-related maladaptive learning and memory (Loweth et al., 2010; Coultrap and Bayer, 2012). Transient interference with CaMKII signaling has been shown to persistently reverse LTP when it specifically disrupts the CaMKII/NMDA-type glutamate receptor complex (Buard et al., 2010; Sanhueza et al., 2011). CaMKII mediates LTP by increasing both the number and the conductance of synaptic AMPA-type glutamate receptors (Coultrap and Bayer, 2012), the latter by phosphorylating their GluA1 subunit at S831 (Derkach et al., 1999; Kristensen et al., 2011). As normal LTP and LTP-induced GluA1 S831 phosphorylation require NMDA receptor-bound CaMKII (Barria and Malinow, 2005; Halt et al., 2012) and the CaMKII K42M mutation disrupts this binding (O'Leary et al., 2011), we examined the GluA1 S831 phosphorylation state in our animals. Indeed, previous exposure to amphetamine produced a sustained increase in GluA1 S831 phosphorylation in the NAcc shell, as reported previously (Loweth et al., 2010), and it was persistently reversed by transient CaMKII K42M expression in this site. Thus, while the interference with CaMKII signaling was transient, its effect on at least one important downstream mediator persisted, which may have contributed to the persistent reduction in the enhanced behavioral output normally observed in amphetamine sensitized rats. While GluA1 S831A mutant mice do not show impairments in hippocampal LTP or LTD (Lee et al., 2010), they do show deficits in responding for a conditioned reinforcer (Crombag et al., 2008). Alternatively, an AMPA receptor independent effect of CaMKII on A-type potassium currents was recently proposed to also contribute to behavioral sensitization by cocaine (Kourrich et al., 2012). Notably, CaMKII inhibition affected only the enhanced locomotor response and selfadministration observed in rats previously exposed to amphetamine. HSV-CaMKII K42M and mock-infected rats previously exposed to saline showed the same basal levels of amphetamine-induced locomotion and amphetamine intake throughout testing. These results indicate that continued uninterrupted CaMKII signaling in the NAcc shell is necessary specifically to maintain enhanced drug intake observed in individuals that have been repeatedly exposed to the drug but not for the initial basal intake seen before drug exposure. Although further characterization of the molecular mechanisms underlying these effects awaits further study, the results reported here clearly demonstrate that transient inhibition of CaMKII provides a viable therapeutic strategy to persistently reverse addiction-related behaviors.

Acknowledgments

This study was supported by grants from the Peter F. McManus Charitable Trust (P.V.) as well as National Institutes of Health grants R01 DA09397 (P.V.), R01 NS052644 (K.U.B.), T32 DA07255 (J.J.C. and O.J.) and F31 DA022834 (J.A.L).

Footnotes
The authors declare no competing financial interests.

Article information
J Neurosci. Author manuscript; available in PMC 2013 July 23. Published in final edited form as: J Neurosci. 2013 January 23; 33(4): 14111416. doi: 10.1523/JNEUROSCI.4386-13.2013 PMCID: PMC3710147 NIHMSID: NIHMS438832 Jessica A. Loweth,1,2 Dongdong Li,2 James J. Cortright,2 Georgia Wilke,2 Okunola Jeyifous,3 Rachael L. Neve,4 K. Ulrich Bayer,5 and Paul Vezina1,2 1 Committee on Neurobiology, The University of Chicago, Chicago, IL 60637 2 Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, IL 60637 3 Department of Neurobiology, The University of Chicago, Chicago, IL 60637 4 Massachusetts Institute of Technology, Cambridge, MA 02139 5 Department of Pharmacology, University of Colorado Denver, Aurora, CO 80045 Correspondence: Paul Vezina, Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, 5841 South Maryland Avenue, MC 3077, Chicago, IL 60637, TEL: (773) 702-2890, FAX: (773) 702-0857, Email: pvezina/at/yoda.bsd.uchicago.edu For information regarding CaMKII mutant biochemistry: K. Ulrich Bayer, ulli.bayer/at/ucdenver.edu Copyright notice and Disclaimer The publisher's final edited version of this article is available free at J Neurosci See other articles in PMC that cite the published article.

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The Journal of neuroscience : the official journal of the Society for Neuroscience Author Manuscript NIH Public Access

Persistent reversal of enhanced amphetamine intake by transient CaMKII inhibition

Jessica A. Loweth, Dongdong Li, [...], and Paul Vezina Additional article information

Abstract
Amphetamine exposure transiently increases CaMKII expression in the nucleus accumbens (NAcc) shell and this persistently increases local GluA1 S831 phosphorylation and enhances behavioral responding to the drug. Here we assessed whether transiently interfering with CaMKII signaling using a dominant-negative CaMKII mutant delivered to the NAcc shell with herpes simplex viral (HSV) vectors could reverse these long-lasting biochemical and behavioral effects observed following exposure to amphetamine. As expected, transient expression of CaMKII K42M in the NAcc shell produced a corresponding transient increase in CaMKII and decrease in pCaMKII (T286) protein levels in this site. Remarkably, this transient inhibition of CaMKII activity produced a long-lasting reversal of the increased GluA1 S831 phosphorylation levels in NAcc shell and persistently blocked the enhanced locomotor response to and self-administration of amphetamine normally observed in rats previously exposed to the drug. Together, these results indicate that even transient interference with CaMKII signaling may confer long-lasting benefits in drug sensitized individuals and point to CaMKII and its downstream pathways as attractive therapeutic targets for the treatment of stimulant addiction. Keywords: Addiction, amphetamine, CaMKII, GluA1, self-administration, sensitization, substance abuse, therapeutics

INTRODUCTION
Previous exposure to psychostimulants such as amphetamine and cocaine enhances subsequent neurochemical and behavioral responding to the drug. These phenomena are

thought to contribute to the transition from casual drug use to addiction (Robinson and Berridge, 1993; Vezina, 2004). A brain area prominently linked to the generation of addictive behaviors is the nucleus accumbens (NAcc) shell (Anderson et al., 2008). We recently showed that amphetamine exposure transiently increases expression of the Ca2+/calmodulin-dependent protein kinase II (CaMKII) isoform in this site and that transient viral overexpression of CaMKII mimics the behavioral effects of amphetamine exposure in rats (Loweth et al., 2010). Conversely, NAcc shell infusion of a CaMKII inhibitor (KN93) prevents cocaine-induced reinstatement of drug seeking (Anderson et al., 2008) as well as the expression of enhanced NAcc dopamine (DA) overflow (Pierce and Kalivas, 1997), cocaine-induced locomotion (Pierce et a., 1998) and amphetamine self-administration (Loweth et al., 2008) normally observed in sensitized rats. However, KN93 affects not only CaMKII and other protein kinases, but also L-type Ca2+-channels (Li et al., 1992; Gao et al., 2006), and an inhibitor of these channels produces the same biochemical (Pierce and Kalivas, 1997) and behavioral effects (Pierce et al., 1998; Anderson et al., 2008) as KN93. Furthermore, these studies did not directly assess the possibility that transient NAcc shell CaMKII inhibition could have long-lasting effects on behavioral responding to psychostimulants, a possibility suggested by our earlier work showing that transient increases in CaMKII in this region lead to long-lasting neuroadaptations that contribute to the maintenance of sensitization (Loweth et al., 2010). Thus, in the present study, we used a CaMKII- and brain-region-specific transient inhibition strategy to determine whether interfering directly with endogenous CaMKII signaling within the NAcc shell could persistently reverse long-lasting behavioral manifestations of amphetamine sensitization.

METHODS
Strategy for CaMKII inhibition by viral-mediated expression of a K42M mutant
Replication-deficient herpes simplex virus (HSV) viral vectors were constructed and packaged as previously described by us (Neve et al., 1997; Loweth et al., 2010). These vectors were used because they produce transient overexpression of the transgene that peaks 34 days post-infection and returns to baseline by day 8 post-infection (Neve et al., 1997; Carlezon and Neve, 2003; Loweth et al., 2010). In addition, local viral infection permits functional testing of specific groups of neurons in specific brain areas (here the NAcc shell). We chose to transiently express a CaMKII K42M mutant which is kinase dead due to impaired ATP binding. Such kinase dead mutants are commonly used as dominant-negative mutants to interfere with endogenous kinase functions and this has been described for CaMKII (e.g., Khl et al., 2000; Xiao et al., 2005; Garic et al., 2011). Dominant-negative effects can be exerted by competition with endogenous kinase for upstream activators, downstream substrates, or subcellular targeting modules. In the case of CaMKII, which forms dodecameric holoenzymes, dominant-negative effects can also be exerted by the formation of heteromeric holoenzymes, which interferes with the intraholoenzyme inter-subunit autophosphorylation at T286 that generates Ca2+-independent autonomous CaMKII activity (for reviews, see Coultrap and Bayer, 2012; Lisman et al., 2012). In addition, the K42M mutant interferes with the targeting of holoenzymes to

the NMDA-type glutamate receptor subunit GluN2 (Bayer et al., 2006; OLeary et al., 2011), which is regulated by nucleotide binding to CaMKII (OLeary et al., 2011) and also generates autonomous activity (Bayer et al., 2001; Bayer et al., 2006). Thus, the K42M mutant of CaMKII has even greater dominant-negative potential than the kinase dead mutants of most other kinases. The regulation of CaMKII is rather complex (Coultrap and Bayer, 2012), but it should be noted that some cellular functions that simply require Ca2+/calmodulin-stimulated CaMKII activity may or may not be affected by the presence of additional kinase dead mutant. Thus, the designation as a dominant negative mutant (as done here) is always linked to a specific cellular function; for other functions, a particular kinase dead mutant may or may not act in a dominant negative fashion (for further discussion, see Wayman et al., 2011).

Subjects and Surgery

Male Sprague-Dawley (locomotion experiments) and Long-Evans rats (selfadministration experiments) weighing 250275 g on arrival were purchased from Harlan Sprague-Dawley (Madison, WI) and housed individually with food and water freely available. They were implanted with chronic bilateral guide cannulae as described previously (Loweth et al., 2010). For the amphetamine self-administration studies, rats were also implanted with i.v. catheters as described previously (Suto et al., 2004). All surgical procedures were conducted using aseptic techniques according to an approved Institutional Animal Care and Use Committee protocol.

Design and Procedure

Rats in different groups were exposed to repeated intermittent injections of amphetamine or saline and 23 weeks later, infused intracranially into the NAcc shell with HSV-K42M CaMKII or a control infusion (mock) consisting of HSV-LacZ or 10% sucrose vehicle. Rats in one experiment were tested for their locomotor response to a systemic amphetamine injection 4 days and again 8 days following infection. Rats in a second experiment were tested for their self-administration of amphetamine before and after HSV infection. Rats in additional groups were sacrificed 4 or 8 days following HSV infection to determine the expression pattern of the transgene and assess its effect on phosphorylation of the AMPA receptor GluA1 subunit at S831, a CaMKII residue. In these cases, brain sections were harvested and subsequently assessed using immunoblotting.

Exposure Injections
Exposure injections (5 1.5 mg/kg amphetamine or 1.0 ml/kg saline) were administered every 23 days as described previously (Vezina et al., 2002; Suto et al., 2004). S(+)amphetamine sulfate was obtained from Sigma-Aldrich and dissolved in sterile saline. Doses refer to the weight of the salt.

Viral-mediated gene transfer in the NAcc shell

The following HSV vector constructs were used: CaMKII K42M and a control vector, LacZ, which encodes the protein -galactosidase. LacZ and 10% sucrose vehicle were used interchangeably for mock-infection control infusions as they have consistently been found to be without effect (Loweth et al., 2010; Singer et al., 2010). Rats were transported to a biosafety level 2 facility where, as described previously (Loweth et al., 2010; Singer et al., 2010) and according to an approved Institutional Biosafety Committee protocol, they were administered bilateral intracranial microinjections into the NAcc shell of their respective viral vectors or mock control vehicle. Rats were returned to the colony room 24 hours later.

Locomotor Testing
To assess the effect of transient expression of CaMKII K42M in NAcc shell neurons on sensitized locomotor responding to amphetamine, rats were assigned randomly to different groups based on exposure (systemic amphetamine or saline) and infection (NAcc shell HSV-K42M CaMKII or mock). Thus, four groups were tested: amphetamine-mock, amphetamine-K42M, saline-mock, and saline-K42M. 23 weeks after the exposure regimen, rats received their respective NAcc shell microinjections and were tested for their locomotor response to amphetamine (1.0 mg/kg, i.p.) 4 and 8 days later. On each test day, locomotor activity was measured 1 hour before and 2 hours after the amphetamine challenge injection using a bank of 12 activity boxes as described previously (Vezina et al., 2002).

Self-Administration Training and Testing

To assess the effects of transient expression of CaMKII K42M on enhanced amphetamine self-administration, separate rats were assigned randomly to one of four groups based on exposure and infection as described above for locomotor testing. 23 weeks after the last exposure injection, rats were trained to self-administer amphetamine on fixed ratio (FR) schedules of reinforcement and then tested under a progressive ratio (PR) schedule for 4 days pre-infection to visualize enhanced work output and drug intake in amphetamine-exposed rats (Vezina et al., 2002). The following day, rats were transported to the biosafety facility and administered their respective NAcc shell microinjections. PR self-administration testing resumed the next day and continued for 12 days post-infection as described previously (Loweth et al., 2010). Reinforced lever presses delivered an infusion of amphetamine (200 g/kg/infusion) through the i.v. catheter. 6 rats did not satisfy the FR training criteria and were excluded from the study. The daily PR test sessions were terminated after 3 hr or after 1 hr elapsed without a drug infusion.

Immunoblotting and Immunohistochemistry

Brains were removed rapidly and flash-frozen on dry ice. Sections (1mm thick) were obtained with a brain matrix and 2 mm diameter punches taken bilaterally around the injection cannula tips. Tissue punches were processed, loaded (20g/lane), run using SDS-PAGE electrophoresis and developed. The following primary antibodies were used:

CaMKII (1:2,000), pCaMKII (T286; 1:1,000), GluA1 (1:1,000), pGluA1(S831;1:500), and -Actin (1:2,000) or Tubulin (1:100,000) as a loading control. All antibodies were obtained from Millipore except for -Actin (Sigma-Aldrich). Additional rats were used in immunohistochemistry studies (infection with HSV-LacZ) to visualize the pattern of infection as described previously (Carlezon and Neve, 2003).

Histology
After the completion of the behavioral experiments, rats were deeply anesthetized and perfused transcardially with 0.9% saline and 10% formalin and brains were removed and stained with cresyl violet to identify rats with injection cannula tips located bilaterally in the NAcc shell. Only rats with both cannula tips in the targeted region were retained for statistical analyses and their number subsequently indicated as n/group in the appropriate figure legends. The number of rats that failed to meet this criterion for the locomotor and self-administration studies was as follows: amphetamine-mock, 7; amphetamine-K42M, 5; saline-mock, 2; saline-K42M, 3.

Data Analysis
Immunoblot, locomotor and self-administration data were analyzed with 2-way between ANOVA with Exposure (amphetamine and saline) and Infection (HSV-CaMKII K42M and mock) as the between factors. Post-hoc comparisons were made using the Least Significant Difference (LSD) test. For locomotion, the data analyzed were the total locomotor counts obtained following the amphetamine challenge (2-hr) on each test day. For self-administration, the data analyzed were the total number of infusions obtained on day -1 pre-infection, on day 4 post-infection (when expression of the transgene was maximal), and averaged over days 812 post infection (when the transgene was no longer expressed).

RESULTS
Transient CaMKII inhibition persistently reverses increased GluA1 S831 phosphorylation in the NAcc shell of amphetamine exposed rats
Herpes simplex viral (HSV) vectors were used to transiently overexpress an inactive mutant of CaMKII (K42M) in NAcc shell neurons (Fig. 1e) as we have previously described for active CaMKII (Loweth et al., 2010). 23 weeks after exposure to amphetamine or saline, rats received bilateral NAcc shell microinjections of HSVCaMKII K42M or mock-infection control infusions. CaMKII protein and T286phosphorylation levels were assessed on day 4 and day 8 post-infection (Fig. 1bc). Consistent with previous findings (Loweth et al., 2010), no changes in either CaMKII protein or T286-phosphorylation levels were detected 23 weeks after exposure to amphetamine as displayed in the mock-infected rats. Subsequent infection with HSVCaMKII K42M transiently increased total CaMKII protein levels in both amphetamine and saline treated rats; these returned to baseline levels by day 8 post-infection (Fig. 1b).

In contrast, T286-phosphorylation was transiently decreased, both in absolute terms (data not shown) and as a ratio of phospho-T286 to total CaMKII (Fig. 1c), confirming that expression of CaMKII K42M interfered with endogenous CaMKII signaling. This effect was also transient and no longer evident by day 8 post-infection (Fig. 1c). The ANOVA conducted on CaMKII levels and the ratio of pCaMKII/CaMKII showed significant effects of Infection only on day 4 post-infection (F1,19=20.12, p<0.001 and F1,19=15.90 p<0.001, respectively). No other effects, including on day 8 post-infection, were statistically significant. Thus, transient viral expression of CaMKII K42M transiently interfered with autonomy-inducing CaMKII T286 phosphorylation, which was back to control levels on day 8 post-infection.

Figure 1 HSV-CaMKII K42M transiently reduces CaMKII T286 autophosphorylation but persistently reverses the increased phosphorylation of GluA1 at S831 in NAcc shell of amphetamine exposed rats As exposure to a sensitizing amphetamine regimen leads to a long-lasting increase in phosphorylation of GluA1 at S831 in the NAcc shell (Loweth et al., 2010), we then assessed the effect of transiently inhibiting CaMKII signaling in this site on phosphorylation of this GluA1 residue. Again, a sustained increase in GluA1 S831 phosphorylation was detected in the NAcc shell of mock-infected rats 23 weeks after exposure to amphetamine. This increase in phospho-S831 was reversed by CaMKII K42M expression on day 4 (Infection, F1,17=5.70, p<0.05), and, remarkably, remained attenuated on day 8 post-infection (Exposure, F1,18=10.99, p<0.01) when both CaMKII expression and T286 phosphorylation had returned to baseline levels. No other effects were statistically significant. These findings were again observed both in absolute terms (data not shown) and as a ratio of phospho-S831 to total GluA1 (Fig. 1d).

Transient CaMKII inhibition in the NAcc shell of amphetamine exposed rats persistently reverses their enhanced locomotor response to and selfadministration of the drug
As expected, rats exposed to amphetamine 23 weeks earlier showed a greater locomotor response to a systemic amphetamine challenge (1.0 mg/kg, i.p.) compared to salineexposed controls (Vezina, 2004; Fig. 2). Remarkably, transient CaMKII inhibition in the NAcc shell persistently reversed this expression of locomotor sensitization by amphetamine. The enhanced locomotor response was completely abolished in the HSVCaMKII K42M infected animals, not only on day 4 (Fig. 2a) but also on day 8 postinfection (Fig. 2b), again a time point when both CaMKII expression and T286-

phosphorylation had returned to baseline levels (Fig. 1bc). Significant effects of Exposure (day 4, F1,21=6.30, p<0.05; day 8, F1,21=4.15, p=0.054) and Infection (day 4, F1,21=9.20, p<0.01; day 8, F1,21=4.43, p<0.05) were detected on both test days. Thus, we next assessed the effect of transient CaMKII inhibition on the enhanced amphetamine intake observed following amphetamine exposure (Vezina, 2004; Vezina et al., 2002). Rats were again randomly assigned to four groups based on condition of exposure (amphetamine or saline) and infection (bilateral NAcc shell HSV-CaMKII K42M or mock-infection). As expected (Vezina et al., 2002), rats exposed to amphetamine and given the opportunity to self-administer the drug i.v. worked significantly more and as a result obtained more infusions compared to saline-exposed controls (Fig. 3; day -1 preinfection, Exposure, F1,28=5.41, p<0.05). However, the day following infection through to day 4 post-infection when expression of the transgene was maximal, amphetamineexposed rats infected with HSV-CaMKII K42M no longer displayed enhanced amphetamine intake, obtaining the same number of infusions as saline-exposed rats and significantly fewer than mock-infected amphetamine-exposed rats (Fig. 3; day 4 postinfection, Exposure, F1,28=3.58, p=0.07; E I, F1,28=6.69, p<0.05). Importantly, this reversal of enhanced amphetamine self-administration was maintained for the full 12 days of testing post-infection and thus again outlasted the transient interference with CaMKII signaling achieved by HSV-CaMKII K42M (Fig. 3; days 812 post-infection, E I, F1,25=4.09, p=0.05).

Figure 2 Transient NAcc shell CaMKII K42M expression persistently reverses amphetamine-induced locomotor sensitization

Figure 3 Transient CaMKII inhibition in the NAcc shell of amphetamine exposed rats persistently reverses enhanced amphetamine self-administration

DISCUSSION
Expressing a dominant negative form of CaMKII (K42M) that transiently inhibits CaMKII activity in NAcc shell neurons persistently blocked the expression of two major manifestations of sensitization by amphetamine. As expected, previously exposing rats to amphetamine led to sensitized locomotor responding to a challenge injection of the drug and, in a separate group of rats, enhanced drug intake under a progressive ratio (PR) schedule of reinforcement (Vezina et al., 2002; Vezina, 2004). Transiently inhibiting CaMKII activity in the NAcc shell of these rats blocked these manifestations of

sensitization and continued to do so long after expression of the transgene had dissipated, indicating that continued uninterrupted CaMKII activation is necessary for their maintenance. Previous studies suggested that CaMKII activity in the NAcc shell is required for the expression of stimulant sensitization (Pierce and Kalivas, 1997; Pierce et al., 1998; Loweth et al., 2008) and cocaine-induced reinstatement (Anderson et al., 2008). However, these previous studies tested the pharmacological inhibitor KN-93 that is known to affect not only CaMKII and other protein kinases but also to inhibit L-type Ca2+ channels, rendering an interpretation of results that focuses specifically on CaMKII difficult. The use of HSV mediated delivery of a CaMKII mutant in the present experiments circumvented these shortfalls. Importantly, the present study is the first to unequivocally demonstrate that transiently inhibiting CaMKII activity in the NAcc shell can lead to the persistent and selective reversal of enhanced behavioral responding to amphetamine. Thus, the evidence reported here identifies CaMKII and the signaling pathways it initiates as attractive therapeutic targets for the treatment of substance abuse. CaMKII regulates long-term potentiation (LTP) of synaptic strength, a form of neuronal plasticity thought to underlie both physiological and addiction-related maladaptive learning and memory (Loweth et al., 2010; Coultrap and Bayer, 2012). Transient interference with CaMKII signaling has been shown to persistently reverse LTP when it specifically disrupts the CaMKII/NMDA-type glutamate receptor complex (Buard et al., 2010; Sanhueza et al., 2011). CaMKII mediates LTP by increasing both the number and the conductance of synaptic AMPA-type glutamate receptors (Coultrap and Bayer, 2012), the latter by phosphorylating their GluA1 subunit at S831 (Derkach et al., 1999; Kristensen et al., 2011). As normal LTP and LTP-induced GluA1 S831 phosphorylation require NMDA receptor-bound CaMKII (Barria and Malinow, 2005; Halt et al., 2012) and the CaMKII K42M mutation disrupts this binding (O'Leary et al., 2011), we examined the GluA1 S831 phosphorylation state in our animals. Indeed, previous exposure to amphetamine produced a sustained increase in GluA1 S831 phosphorylation in the NAcc shell, as reported previously (Loweth et al., 2010), and it was persistently reversed by transient CaMKII K42M expression in this site. Thus, while the interference with CaMKII signaling was transient, its effect on at least one important downstream mediator persisted, which may have contributed to the persistent reduction in the enhanced behavioral output normally observed in amphetamine sensitized rats. While GluA1 S831A mutant mice do not show impairments in hippocampal LTP or LTD (Lee et al., 2010), they do show deficits in responding for a conditioned reinforcer (Crombag et al., 2008). Alternatively, an AMPA receptor independent effect of CaMKII on A-type potassium currents was recently proposed to also contribute to behavioral sensitization by cocaine (Kourrich et al., 2012). Notably, CaMKII inhibition affected only the enhanced locomotor response and selfadministration observed in rats previously exposed to amphetamine. HSV-CaMKII K42M and mock-infected rats previously exposed to saline showed the same basal levels of amphetamine-induced locomotion and amphetamine intake throughout testing. These results indicate that continued uninterrupted CaMKII signaling in the NAcc shell is necessary specifically to maintain enhanced drug intake observed in individuals that have been repeatedly exposed to the drug but not for the initial basal intake seen before drug

exposure. Although further characterization of the molecular mechanisms underlying these effects awaits further study, the results reported here clearly demonstrate that transient inhibition of CaMKII provides a viable therapeutic strategy to persistently reverse addiction-related behaviors.

Acknowledgments
This study was supported by grants from the Peter F. McManus Charitable Trust (P.V.) as well as National Institutes of Health grants R01 DA09397 (P.V.), R01 NS052644 (K.U.B.), T32 DA07255 (J.J.C. and O.J.) and F31 DA022834 (J.A.L).

Footnotes
The authors declare no competing financial interests.

Article information
J Neurosci. Author manuscript; available in PMC 2013 July 23. Published in final edited form as: J Neurosci. 2013 January 23; 33(4): 14111416. doi: 10.1523/JNEUROSCI.4386-13.2013 PMCID: PMC3710147 NIHMSID: NIHMS438832 Jessica A. Loweth,1,2 Dongdong Li,2 James J. Cortright,2 Georgia Wilke,2 Okunola Jeyifous,3 Rachael L. Neve,4 K. Ulrich Bayer,5 and Paul Vezina1,2 1 Committee on Neurobiology, The University of Chicago, Chicago, IL 60637 2 Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, IL 60637 3 Department of Neurobiology, The University of Chicago, Chicago, IL 60637 4 Massachusetts Institute of Technology, Cambridge, MA 02139 5 Department of Pharmacology, University of Colorado Denver, Aurora, CO 80045 Correspondence: Paul Vezina, Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, 5841 South Maryland Avenue, MC 3077, Chicago, IL 60637, TEL: (773) 702-2890, FAX: (773) 702-0857, Email: pvezina/at/yoda.bsd.uchicago.edu For information regarding CaMKII mutant biochemistry: K. Ulrich Bayer, ulli.bayer/at/ucdenver.edu Copyright notice and Disclaimer The publisher's final edited version of this article is available free at J Neurosci See other articles in PMC that cite the published article.

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4 The Journal of neuropsychiatry and clinical neurosciences Author Manuscript NIH Public Access

Elevated Neurobehavioral Symptoms are Associated with Everyday Functioning Problems in Chronic Methamphetamine Users
Jordan E. Cattie, Steven Paul Woods, [...], and The TMARC Group Additional article information

Abstract
Chronic methamphetamine (MA) use is commonly associated with neural injury and neurocognitive deficits. We examined the nature and correlates of self-reported neurobehavioral symptoms (i.e., apathy, disinihibition, and executive dysfunction) in 73 individuals with histories of MA dependence (MA+) and 85 comparison participants with comparable demographics and risk histories. MA+ individuals endorsed significantly more severe neurobehavioral symptoms on the Frontal Systems Behavioral Scale (FrSBe), especially disinhibition and executive dysfunction. Elevations in neurobehavioral symptoms were independent of common comorbidities, including hepatitis C infection, Attention-Deficit/Hyperactivity Disorder, mood disorders, and other substance use factors. Notably, the severity of neurobehavioral symptoms were uniquely associated with self-reported decrements in instrumental activities of daily living in the MA dependent sample. Findings indicate that chronic MA users may experience elevated neurobehavioral symptoms of disinhibition and executive dysfunction, potentially increasing their risk of functional declines.

Keywords: Methamphetamine, Substance abuse, Executive dysfunction, Behavioral disinhibition, Neuropsychological assessment, Activities of daily living

Methamphetamine (MA) is a potent, highly addictive and neurotoxic psychostimulant with well-documented adverse neural and neuropsychological effects {1}, as well as risk of functional declines {2}. Relative to other neurotoxic substances, MA may be particularly potent due to its high lipid solubility and rapid diffusion across the bloodbrain barrier {3}. As a result, MA-associated CNS effects can include a variety of metabolic, structural, and functional brain changes that may impact cognitive functioning. Although some evidence suggests that partial neural and cognitive recovery may occur with stable abstinence {4, 5}, alterations and impairments may nevertheless persist long after MA use is discontinued {6, 7}. Long-term effects of MA may be especially problematic in frontostriatal circuits, where potential consequences include neural injury in the striatum {4} and prefrontal cortex {8}. It has been hypothesized that these neural changes may affect the modulatory functions of the frontostriatal and limbic structures, as well as underlie the neurocognitive deficits observed in chronic MA users {9}. Approximately 40% of chronic MA users exhibit neurocognitive deficits {10}, with generally moderate impairments observed in the domains of episodic memory, motor skills, language, information processing speed, visuospatial functioning, and executive functions {1}. Within the domain of executive functions, MA has been associated with impulsivity, disinhibition, reduced ability to suppress irrelevant information, risky decision-making, and increased distractibility {7, 11,12}. Neurocognitive impairments, and particularly executive dysfunction, may increase the risk of everyday functioning problems and engagement in high-risk behaviors, which are common among MA users. Self-report measures indicate lower abilities and more disruptions in everyday activities including communication, work, and recreation {13}. These data are corroborated by significant impairments found on performance-based tests, including tests of medication and financial management, arranging travel, and communication skills {2}. MA use has also been associated with lack of health insurance, being on public assistance, and disproportionate representation in burn and trauma units {14}. MA use is negatively correlated with employment stability, and MA users are less likely to be employed fulltime {15}. Chronic MA users report elevated rates of psychosocial problems, including domestic conflict {16} and legal complications {17}. Of course, there are long-standing controversies regarding the construct validity of such self-reported versus more objective (e.g., performance-based or observational) assessments of everyday living problems such as these {18}. While self-report approaches are limited by potential bias and current mood, they may also be more sensitive to gross functional difficulties. In addition, selfreport measures may more flexibly identify declines specific to the demands of each individuals life {19}. As such, assessing self-reported neurobehavioral symptoms may nonetheless yield clinically meaningful and incrementally important information with limited investment of time and minimal examiner burden. To our knowledge, the prevalence and correlates of neurobehavioral disturbances in chronic MA users has not yet been fully established. Here we define neurobehavioral

disturbances as self-reported behavioral symptoms that have reliably been associated with brain injury and neuropsychiatric syndromes, particularly those involving dysregulation of frontostriatal systems {20}. Clinicians frequently note behavioral disturbances in MA, and broadly accept that this impulsivity, disinhibition, and predisposition toward stimulus-driven decision-making may reflect the observed neuropsychological deficits and frontal systems injury sustained by MA users. Importantly, studies have found these types of behaviors to be independently related to adverse psychosocial, psychological, substance-related and sexual risk factors. For example, higher levels of impulsivity in MA users have been associated with elevated rates of psychiatric diagnoses, higher rates of unemployment, high risk sexual encounters, and a greater tendency to use MA to cope with mood disturbances {21, 22}. Despite the suggestion that these neurobehavioral symptoms are uniquely associated with important outcomes, the nature and magnitude of neurobehavioral disturbances and their effects on everyday functioning have not been extensively studied in this population. Though some existing studies {23, 24, 25} have investigated neurobehavioral symptoms in substance-using populations, these designs have included heterogeneous groups of polysubstance abusers rather than examining substance-specific risks (e.g., MA dependence). Given the severity of the aforementioned neural, cognitive, and functional effects in MA relative to other substances, the primary aim of the current study is to examine the presence and severity of neurobehavioral symptoms (e.g., apathy, disinhibition, and executive dysfunction) in individuals with a history of MA dependence using the Frontal Systems Behavior Scale (FrSBe) {20}. The FrSBe has been used to quantify significant neurobehavioral sequelae in other conditions impacting similar brain regions and neural pathways (e.g., Parkinsons disease {26}). We also sought to explore the potential risks that may be associated with elevated neurobehavioral symptoms in MA, including neurocognitive and functional impairment. Neurobehavioral symptoms themselves may be an important indicator of an individuals functioning, and as in other populations (e.g., dementia) {27} could predict everyday functioning outcomes over and above any observed cognitive deficits. By clarifying the nature and severity of behavioral disturbances in MA users, clinicians may be able to better identify those at risk for functional impairments and better anticipate and account for difficulties complying with intervention programs.

Method
Participants
A total of 158 eligible participants were included in this study. Participants in the MA+ group met lifetime diagnostic criteria for MA dependence via semi-structured diagnostic interview (Composite International Diagnostic Interview; CIDI version 2.1) {28} and met criteria for MA abuse at least within the last 18 months (n = 73). Participants in the MA comparison group (n = 85) had never met criteria for MA dependence and reported no prior use of MA, but had been recruited to match the MA+ group on demographic and other substance-related risk factors (e.g., depression) wherever possible. A minimum of 10 days of abstinence from MA was required prior to testing, and a urine toxicology

screen confirmed that participants had abstained from use of all illicit substances, except marijuana. Marijuana is detectable up to 30 days after last use, and due to the high comorbidity of marijuana abuse and dependence in MA users, was not considered exclusionary for study participation in either group. Substance-related exclusion criteria included meeting Diagnostic and Statistical Manual-IV (DSM-IV) {29} criteria for current (i.e., within 30 days) abuse or dependence of non-MA substances. Individuals with histories of alcohol dependence within one year of evaluation, or other substance use dependence within five years of evaluation were also excluded. Potential participants were excluded if they reported a past head injury with a loss of consciousness greater than 30 minutes, HIV infection, a history of neurological condition (e.g., seizure disorder, stroke) or psychiatric illness (e.g., mental retardation or schizophrenia spectrum diagnoses) affecting cognitive functioning. All participants in the current study were HIV seronegative, as determined by enzyme-linked immunosorbent assay (ELISA). Given the prevalence of hepatitis C virus (HCV) in substance-abusing populations, HCV infected individuals were included in the analysis. HCV serostatus was determined using standard clinical antibody detection, and HCV RNA was measured in serum using real-time polymerase chain reaction (NGI SuperQuant; National Genetics Institute, Los Angeles, CA, USA; nominal detection limit of 100 IU/mL). The MA+ and MA groups were comparable on demographic factors (ps > 0.10; see Table 1). They did not significantly differ on HCV serostatus or lifetime rates of major depressive disorder. As might be expected, the MA group had higher lifetime rates of alcohol, cannabis, and cocaine dependence (all ps < .05), but did not significantly differ on histories of any other substances (p > .10). Though the MA+ group had a significantly higher proportion of individuals diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD; p < .05), differences between the proportions of individuals meeting criteria for Antisocial Personality Disorder (ASPD) approached significance (p > .07).

Table 1 Demographic and Psychiatric Characteristics of Study Participants

Materials and Procedure

Psychiatric and Substance Abuse Factors

Table 1 presents the psychiatric and substance use characteristics of the two study groups. MA use characteristics (e.g., duration and recency) were obtained via a semi-structured timeline follow-back interview {10}. Trained interviewers administered the CIDI {28}, which is a structured computer-assisted interview that provides lifetime and current

substance use and psychiatric (e.g., Major Depressive Disorder) diagnoses according to DSM-IV criteria. ASPD was diagnosed using the SCID {30}, and ADHD diagnoses were determined using the Diagnostic Interview Schedule.

Neurobehavioral Symptoms
As part of their evaluation, all participants completed the self-report version of the Frontal Systems Behavior Scale (FrSBe) {20}, a 46-item self- or other-report behavior rating scale that provides quantitative measurement of behavioral disturbances related to damaged frontal systems. The FrSBe yields a total score in addition to three subscale scores: apathy, disinhibition, and executive dysfunction. Behaviors for apathy (e.g., sit around doing nothing; show little emotion, am unconcerned and unresponsive), dysregulation (e.g., laugh or cry too easily; talk out of turn; interrupt others in conversation), and executive dysfunction (e.g., cannot do two things at once [for example, talk and prepare a meal]; show poor judgment, poor problem solver) are rated on a 6-point Likert-type scale between 1 (almost never) and 5 (almost always), where higher scores correspond to more abnormal behavior. Due to the inclusion of retrospective ratings as well as current ratings, the FrSBe also enables the comparison of pre- and post-injury responses. This feature is frequently utilized in patients with acute symptom onset (e.g., following head injury or a surgical intervention), but the current study included only current ratings due to the diffuse nature and insidious onset of MArelated pathology. This practice is consistent with a number of other investigations in which the FrSBe was used to assess behavioral symptoms of neurological conditions that present more gradually (e.g., HCV) {31}. Total and subscale raw scores were converted into demographically adjusted T-scores for analysis. As indicated by the measures authors, a T-score cut point of 65 and higher was used as an indicator of clinically elevated behavioral symptoms. FrSBe T-scores for the Total score and three subscales (i.e., Apathy, Disinhibition, Executive Dysfunction) were the primary dependent variables of interest.

Dependence on Activities of Daily Living

Participants also completed a modified version of the Lawton and Brody Activities of Daily Living Scale {32}. This instrument is designed to assess participants current functioning and identify improvements or declines relative to their best ever level of functioning in eight areas related to routine daily tasks (e.g., employment, financial management). Participants rated each item on a three (02) or four (03) point scale, and higher scores indicated poorer functioning. For the current study, a total score was generated to represent the total severity of declines reported in current versus past functioning on all tasks assessed by the measure (range: 0 to 11).

Neurocognitive and Neuromedical Assessments

All participants provided informed consent prior to completing comprehensive neurocognitive and neuromedical assessments. The neuropsychological assessment covered seven cognitive domains: verbal fluency, working memory, speed of information

processing, learning, recall, executive functions, and fine motor coordination. Iudicello et al. {5} provides a complete list of neuropsychological tasks included in each domain. Raw test scores were then converted into demographically (age and education) corrected T-scores before deficit scores were computed for each domain. Individual domain deficit scores were averaged to obtain a global deficit score (GDS) {33} for which higher scores reflect poorer neurocognitive performance.

Data Analysis
Due to the non-normality of the variables of interest (e.g., FrSBe T-scores; Shapiro-Wilk test ps < 0.01), all primary between-group analyses were conducted using nonparametric tests. First, a series of Wilcoxon Ranked Sum tests and Cohens d statistics {34} were used to compare behavioral symptoms (i.e., FrSBe Total and Apathy, Disinhibition, and Executive Dysfunction T-scores) in MA+ and MA groups. Chi-square tests and odds ratios were calculated to examine the effects of MA dependence on clinically elevated FrSBe scales (i.e., T-scores > 64) {20}. Next, a planned series of regressions were conducted to examine the unique effects of MA group on FrSBe variables, accounting for the effects of potentially confounding substance use factors on which the groups differed (i.e., lifetime diagnoses of cocaine, cannabis, and alcohol dependence). Due to the limited prevalence of HCV, ADHD, and ASPD in the MA group, associations between these conditions and the FrSBe ratings were conducted only within the MA+ group using Wilcoxon Ranked Sums tests. Nevertheless, it is important to note that the effect of MA+ group status on FrSBe T scores remained significant in a logistic regression in which these factors were included. Spearmans rho correlational analyses within the MA+ group were used to explore potential associations between FrSBe ratings and cognitive variables (GDS and domain deficit scores) and MA-use characteristics (i.e., last use, cumulative duration and quantity of use, age of first use, and age at onset and recency of MA-dependence diagnosis). Finally, a series of multiple regression analyses were used to examine each of the FrSBe variables as independent predictors of IADL dependence within the MA+ group while accounting for standard cognitive (i.e., GDS), medical (i.e., HCV status), psychiatric (i.e., current Major Depressive Disorder) and MA-use characteristics (i.e., last use of MA) known to be associated with IADL decline. The critical alpha was set to 0.05 for all analyses.

Results
Table 2 presents the means, standard deviations, and Cohens d effect sizes for the FrSBe variables. Relative to the non-MA using comparison participants, the MA-dependent group endorsed a significantly greater level of overall behavioral disturbance (i.e., FrSBe Total T-score; p < .002, d = .51), disinhibition (p < 0.001, d = 0.64) and executive dysfunction (p < 0.001, d = 0.61), but not apathy (p > .10). As shown in Table 3, MA group remained a significant predictor of the Total FrSBe T score as well as the Disinhibition and Executive Dysfunction subscales (ps < .01) even when accounting for potentially confounding factors on which the group differed. Although the proportion of individuals with comorbid ADHD diagnoses was significantly higher the MA+ group than the MA group, total and subscale T scores and proportions of clinically elevated

scores were comparable between MA+ individuals with and without comorbid ADHD (ps > .10). There were no significant effects of ASPD on any FrSBe scale within the MA+ group (all ps > .10). Finally, there were no significant differences between total and subscale T scores or proportion of clinically elevated individuals between MA+ individuals who were and were not infected with HCV (all ps > .10).

Table 2 FrSBe Subscales and Total T-scores in the MA+ and MA Groups with Effect Sizes

Table 3 Multiple Regressions Predicting Neurobehavioral Symptoms and IADL Declines

At the group level, the MA+ group had a significantly higher proportion of individuals with clinically elevated T-scores on FrSBe Total (45.2% relative to 23.5%), Disinhibition (36.1% relative to 15.3%), and Executive Dysfunction subscales (48.0% relative to 23.5%) relative to the non-MA users (all ps < .01; see Figure 1). Odds ratios revealed that a history of MA dependence was associated with an approximately threefold risk of clinical elevations on the FrSBe. Odds ratios were 2.68 for Total FrSBe (95% CI = 1.37, 5.37), 3.13 for Disinhibition (95% CI = 1.48, 6.87), and 2.99 (95% CI = 1.53, 5.99) for Executive Dysfunction.

Figure 1 Proportion of Individuals in the MA+ (n = 73) and MA (n = 85) Groups with Clinically Elevated T-Scores on the Frontal Systems Behavior Scale (FrSBe)

Within the MA+ group, no significant correlations were found between FrSBe T-scores and GDS or other domain deficit scores (all ps > .10). No significant correlations were observed between FrSBe T scores and MA-use parameters (e.g., age of first use,

cumulative quantity, cumulative days in which methamphetamine was used) in the MA+ group. Finally, MA-associated behavioral symptoms were predictive of functional decline even while accounting for standard cognitive, medical, psychiatric, and MA-use variables that have previously been associated with IADL decline. Specifically, within the MA+ group, identical linear regression models identified the FrSBe Total T score (B = .37, p < .002), Apathy subscale T score (B = .29, p < .005), Disinhibition subscale T score (B = .22, p < . 04), and Executive Dysfunction subscale T score (B = .36, p < .0003) as significant, independent predictors of IADL decline severity (see Table 3).

Discussion
Chronic MA use has been associated with neurocognitive and psychosocial complications and adverse neurobehavioral symptoms {7, 12}, potentially reflecting MA-associated neural damage to frontostriatal systems. Moreover, these behavioral symptoms have been linked to MA-specific risk behaviors {21} and adverse psychosocial outcomes {22}. This study extends the literature by demonstrating an increased prevalence and greater severity of self-reported behavioral symptoms in MA-dependent individuals relative to non-MA users. Specifically, we found medium-to-large differences between MA dependent individuals and their non-MA using comparison participants in terms of overall selfreported neurobehavioral symptoms, as well as elevated ratings of self-reported disinhibition and executive dysfunction. In fact, the MA-dependent individuals as a group had a significantly greater proportion of individuals reporting clinically elevated T-scores overall relative to the non-MA users; that is, MA users were approximately three times more likely than the comparison subjects to report a clinically elevated level of disinhibition and executive dyscontrol. This is consistent with evidence of the behavioral disturbances (e.g., impulsivity and discounting of monetary rewards) observed in other stimulant-using populations {35} and the higher levels of neurobehavioral symptoms reported on the FrSBe by polysubstance-using individuals {36}. To our knowledge, while research has identified neurobehavioral disturbances that are associated with substance dependence {23}, this was the first study to examine potential MA-specific neurobehavioral symptoms assessed using a well-validated, easily administered clinical questionnaire and examined as predictors of everyday functioning declines. Our results speak to the unique risk posed by MA, even in the context of other substances and comorbidities, including psychiatric disorders (e.g., ADHD, ASPD, and MDD) and infectious disease (e.g., HCV). Given the high rates of comorbid substance abuse and dependence in MA using populations, we did not exclude MA-users who also reported current and past use of other substances. To control for these effects, we utilized a comparison sample of individuals who were broadly comparable in terms of substance histories rather than healthy individuals. Moreover, the effects of MA group remained even when dependence on other substances of abuse was included in the statistical models. Thus, the robust effect sizes that we observed between MA+ and MA groups provide evidence for an independent effect of MA on neurobehavioral symptoms that may be separable from the effects of other illicit substance use.

No significant differences in apathy were observed between the MA+ and MA individuals. This finding was unexpected given clinically elevated means for apathy symptoms in clinical samples with high rates of stimulant use, including HIV {37} and HCV {38}. However, other investigations of polysubstance dependent individuals have also found trend-level effects for apathy symptoms similar to what we observed {23}. One possible reason for the lack of significant findings on the apathy subscale is the common utilization of amphetamines to treat apathy in a number of disorders (e.g., multiple sclerosis) {38}. Thus, apathy symptoms may not be as pronounced in MA users. Future work is nevertheless necessary to further investigate whether risk for apathy symptoms increases with prolonged abstinence from MA use. Also contrary to our expectations, we found no significant correlations between neurocognitive deficits and neurobehavioral symptoms in MA+ individuals. However, the observed relationship between neurobehavioral symptoms and everyday functioning in MA suggest that, as in other conditions (e.g., dementia) {27}, neurobehavioral symptoms may provide unique information about an individuals functioning beyond that which can be gleaned from their neuropsychological profiles. In fact, there is evidence from lesion studies to suggest that the expression of cognitive deficits and clinically observable neurobehavioral symptoms is dissociable at the neural level {39}. Further, correspondence between performance-based and self-report measures is poor in clinical populations {40}. Future studies may continue to explicate this apparent disconnect between neuropsychological performance and neurobehavioral symptoms. Of particular clinical relevance, MA-associated neurobehavioral symptoms were uniquely associated with declines in instrumental activities of daily living. Specifically, higher levels of overall neurobehavioral disturbance, as well as elevated ratings of disinhibition and executive dyscontrol, were each independently predictive of more severe IADL declines in the MA+ group. This is consistent with research demonstrating both behavioral disturbances {22} and compromised everyday functioning {13} in MAdependent individuals. These effects were noted independently of well-established predictors of everyday functioning, indicating the potential importance of neurobehavioral symptoms in predicting the IADL declines that may occur in MA+ individuals {2}. Results of this investigation suggest that behavioral disturbances in MA users, while often noted antecdotally in clinical settings, may serve as important indicators of IADL difficulties. These data speak to the potential adjunctive ecological value of self-reported behavioral disturbances when given alongside a standardized neuropsychological and psychiatric assessment of clinical symptoms. In particular, wellvalidated instruments such as the FrSBe may be useful in this regard. By measuring these neurobehavioral symptoms in MA+ individuals, clinicians and researchers may be able to identify those at risk for poorer functioning and diminished capacity to operate independently in important activities of daily living (e.g., managing finances, cooking, medication management). Future work may extend the current work by exploring whether other objective everyday functioning outcomes (e.g., credit card debt, employment) are associated with neurobehavioral symptoms in MA+ individuals. Further exploring the relationship between neurobehavioral symptoms and everyday functioning in chronic MA users may allow providers of rehabilitation services to better identify and

target behavioral problems that may subsequently impair aspects of social and occupational functioning. While the current study provides strong evidence for sizable neurobehavioral disturbances associated with MA dependence, important etiological questions remain and serve as potential targets for future work. For instance, it is not yet clear whether elevated neurobehavioral symptoms are directly indicative of MA-related frontal systems toxicity, though some functional neuroimaging studies demonstrate behavioral differences associated with prefrontal dysfunction in MA-dependent individuals {41}. It is known that these neurobehavioral symptoms are not specific to frontostriatal circuit involvement, as they have been observed in Multiple Sclerosis, and other disorders with vastly different effects on frontal systems {42}. For this reason, future investigations may incorporate functional and structural neuroimaging methodologies in order to link frontal systems compromise more directly to neurobehavioral symptom elevations in MA. A few limitations of the current study can also be addressed in future work. For instance, while the high proportion of HCV-infection in our sample is representative of community samples, HCV has been associated with elevated neurobehavioral symptoms in nonstimulant using samples {31}. Although we did not observe an HCV effect in our MA sample, prospective studies controlling for important cofactors (e.g., demographics) are needed to more carefully determine the potential additive or synergistic effects of MA and comorbid infectious disease, perhaps also including HIV infection {10}. Additionally, the current protocol did not collect the caregiver or clinician reports on the FrSBe. Other investigations might prioritize the collection of this data in order to compare self-reported neurobehavioral symptoms with those reported by others. However, as caregivers and clinicians tend to report higher levels of behavioral symptoms than do substance users {20}, we would expect any differences to occur in the conservative direction. In addition, the current study design did not include an analysis of participants self-reported neurobehavioral symptoms prior to MA use due to the early age at first use and insidious onset of MA-related changes. Given research to suggest that higher levels of trait impulsivity may serve as both a facilitator and a consequence of substance abuse {43}, future research is necessary in order to investigate whether individuals with premorbid neurobehavioral symptoms are more likely to have elevated symptoms during MA dependence and after long-term abstinence.

Acknowledgments
The Translational Methamphetamine AIDS Research Center (TMARC) is supported by Center award P50 DA026306 from the National Institute on Drug Abuse (NIDA) and is affiliated with the University of California, San Diego (UCSD) and the Burnham Institute for Medical Research. The TMARC is comprised of: Director: Igor Grant, M.D.; CoDirectors: Ronald J. Ellis, M.D., Ph.D., Cristian Achim, M.D., Ph.D., and Scott Letendre, M.D.; Center Manager: Steven Paul Woods, Psy.D.; Sara Ortiz (Assistant Center Manager); Clinical Assessment and Laboratory Core: Scott Letendre, M.D. (P.I.), Ronald J. Ellis, M.D., Ph.D., Rachel Schrier, Ph.D.; Neuropsychiatric Core: Robert K. Heaton, Ph.D. (P.I.), J. Hampton Atkinson, M.D., Mariana Cherner, Ph.D., Thomas Marcotte,

Ph.D.; Neuroimaging Core: Gregory Brown, Ph.D. (P.I.), Terry Jernigan, Ph.D., Anders Dale, Ph.D., Thomas Liu, Ph.D., Miriam Scadeng, Ph.D., Christine Fennema-Notestine, Ph.D., Sarah L. Archibald, M.A.; Neurosciences & Animal Models Core: Cristian Achim, M.D., Ph.D., Eliezer Masliah, M.D., Ian Everall, M.D., Ph.D., Stuart Lipton, M.D., Ph.D.; Participant Accrual and Retention Unit: J. Hampton Atkinson, M.D., Rodney von Jaeger, M.P.H. (PAR Manager); Data Management Unit: Anthony C. Gamst, Ph.D., Clint Cushman (Data Manager); Statistics Unit: Ian Abramson, Ph.D. (P.I.), Florin Vaida, Ph.D., Reena Deutsch, Ph.D., Anya Umlauf, M.S.; Project 1: Arpi Minassian, Ph.D. (P.I.), William Perry, Ph.D., Mark Geyer, Ph.D., Brook Henry, Ph.D.; Project 2: Amanda B. Grethe, Ph.D. (P.I.), Martin Paulus, M.D., Ronald J. Ellis, M.D., Ph.D.; Project 3: Sheldon Morris, M.D., M.P.H. (P.I.), David M. Smith, M.D., M.A.S., Igor Grant, M.D.; Project 4: Svetlana Semenova, Ph.D. (P.I.), Athina Markou, Ph.D.; Project 5: Marcus Kaul, Ph.D. (P.I.). This research was also supported by T32-DA31098 (S.P. Woods). The views expressed in this article are those of the authors and do not reflect the official policy or position of the United States Government.

Article information
J Neuropsychiatry Clin Neurosci. Author manuscript; available in PMC 2013 August 6. Published in final edited form as: J Neuropsychiatry Clin Neurosci. 2012 Summer; 24(3): 331339. doi: 10.1176/appi.neuropsych.11080192 PMCID: PMC3735421 NIHMSID: NIHMS496185 Jordan E. Cattie,1 Steven Paul Woods,2 Jennifer E. Iudicello,2 Carolina Posada,1 Igor Grant,2 and The TMARC Group 1 Joint Doctoral Program in Clinical Psychology, San Diego State University and University of California, San Diego, California 2 Department of Psychiatry, University of California, San Diego, School of Medicine, La Jolla, California Reprint requests to: Steven Paul Woods, UCSD HIV Neurobehavioral Research Program, 220 Dickinson Street, Suite B (mail code 8231), San Diego, CA 92103; Ph. (619) 543-5004. spwoods/at/ucsd.edu Copyright notice and Disclaimer The publisher's final edited version of this article is available at J Neuropsychiatry Clin Neurosci See other articles in PMC that cite the published article.

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5 Journal of Studies on Alcohol and Drugs

Rutgers University. Center of Alcohol Studies

Patient Reactance Moderates the Effect of Directive Telephone Counseling for Methamphetamine Users
Mitchell Karno, Ph.D., David Farabee, Ph.D., [...], and Richard Rawson, Ph.D. Additional article information

Abstract
Objective:
This study examined the impact of the interaction between patient reactance and treatment directiveness on the effectiveness of telephone aftercare for methamphetamine dependence.

Method:
Reactance was assessed at baseline, and participants were randomly assigned to directive or nondirective treatment conditions. Logistic regression tested for the significance of the interaction as a predictor of 3-month and 12-month use of methamphetamine and stimulants.

Results:
A significant interaction was observed at the 3-month follow-up, in which the directive condition was less effective for patients higher in reactance and was more effective for patients lower in reactance. Among patients at a high level of reactance, the nondirective condition increased the likelihood of abstinence.

Conclusions:
This study suggests that, in the context of telephone-based care, directive interventions offer short-term clinical benefit for methamphetamine users who readily accept influence from authority figures, whereas nondirective interventions offer benefit for patients who do not readily accept influence. The short-term nature of these effects indicates that there is a need for brief but ongoing telephone support to maintain treatment gains. In psychotherapy research, the construct of counselor directiveness has been characterized as leading the patient (Ashby et al., 1957), controlling the agenda during

psychotherapy sessions (Rogers, 1942), being authoritarian (Rudolph, 1989), and teaching and confronting (Patterson and Forgatch, 1985). More recently, Karno and Longabaugh (2005a) provided empirical support that controlling the agenda and authoritarian interventions to challenge thoughts or behaviors are each unique dimensions of directiveness. Directiveness thus can be broadly understood as a class of interventions that convey therapist control. Within this class, the specific interventions (e.g., challenging behaviors and agenda setting) may or may not co-occur in a given treatment context. Of relevance to directiveness in psychotherapy is the extent to which an individual readily accepts or rejects having his or her thoughts or behaviors influenced by others. This phenomenon has been termed psychological reactance (Brehm, 1966, 2000; Brehm and Brehm, 1981). A central tenet of the theory of reactance is that perceived threats to personal freedom can trigger a motivational state in which an individual directs energy toward opposing the source of the perceived threat. Concern about reactance among patients in psychotherapy has informed behavioral interventions such as motivational interviewing for substance use disorders, which seeks to minimize the likelihood of reactance by emphasizing personal freedom and proscribing the use of directive interventions such as confrontation (e.g., Miller, 2000; Miller and Rollnick, 1991). Yet, directive interventions in psychotherapy do not appear to be universally contraindicated. Rather, research has increasingly supported the idea that directive therapist interventions that challenge patients current thoughts or behaviors or advise them to engage in specific thoughts or behaviors have varying degrees of effectiveness depending on the extent to which patients are receptive to influence from others. In a study comparing psychosocial treatments for depression, Beutler et al. (1991) observed that a nondirective treatment modality that was supportive and self-directed was superior for patients high in reactance compared with either cognitivebehavioral or focusedexpressive therapies, which were deemed to have more counselor control and hence to be more directive. That study also found that patients low in reactance had the poorest outcome in the nondirective treatment, suggesting that a strategy of being less directive for reactant patients and more directive for patients low in reactance could yield optimal outcomes overall. In research on behavioral treatment for alcoholism, Karno et al. (2002) found that among high reactance patients, more therapist directiveness was associated with increased posttreatment alcohol use. Conversely, low reactance patients had a better drinking outcome following more directive interventions. In this study, directiveness was operationalized as a combination of challenging thoughts and behaviors as well as controlling the session agenda. These findings converged with the earlier research on depression treatment (Beutler et al., 1991) and suggested that tailoring the general level of directiveness to the level of patient reactance could play an important role in affecting outcomes of treatment for substance use disorders. Subsequent research attempted to replicate these findings on another alcohol-treatmentseeking sample and found that therapist directiveness negatively affected outcomes for

patients at medium and high levels of reactance but did not affect drinking patterns among patients low in reactance (Karno and Longabaugh, 2005a, 2005b). The most consistent finding across all of these studies was that directive counseling had a deleterious effect on treatment outcomes for patients who tended to resist being influenced by others. In two out of three of these studies, directive counseling had a beneficial effect for patients who scored low on their level of reactance. The present study examined if patient reactance moderates the effectiveness of directive treatment for a substance other than alcohol, namely methamphetamine. This question was addressed in the context of an aftercare intervention delivered by telephone. Aftercare interventions have received mixed support (McKay, 2009; McKay et al., 2011). The present research came from a parent study that was a randomized clinical trial to examine the effectiveness of telephone-based aftercare for stimulant users. The primary aim of the parent study was to test for main-effect differences between a no-call control group and active intervention groups that varied on two dimensions of counselor influence: counselor-initiated planning and advice on pro-recovery activities (termed directiveness) and the level of structure the counselor imposed on the session agenda (termed structure). The main outcomes from the parent study revealed that the active interventions were all modestly superior to the no-call control group in reducing drug use severity (Farabee et al., in press), yet the study found no significant main-effect differences between the active intervention conditions. A second aim of the parent study was to examine patient reactance as a moderator of response to the interventions. The current study presents this planned analysis that focuses on the relationship between patient reactance and the level of counselor-initiated planning and advice on pro-recovery activities. Consistent with prior research, the current study hypothesized that the directive condition would be more effective for patients with lower levels of reactance and that the nondirective condition (i.e., counselors do not help plan or give advice on recovery activities) would be more effective for patients at higher levels of reactance.

Method
Overview
The current study is based on a randomized clinical trial in which participants were randomly assigned to an active telephone aftercare condition that varied on the level of counselor activity to plan and provide advice on pro-recovery activities (directive vs. nondirective) and the extent to which the counselor provided an agenda for the call (structured vs. unstructured) (2 2 factorial design). The trial also included a no-call control condition. The standard aftercare plan for all participants consisted of weekly outpatient groups offered through their outpatient treatment program and self-help meetings. The recovery support calls were provided to study participants by trained University of California, Los Angeles, research counselors. Each counselor delivered all study conditions to minimize potential counselor effects. Interviews assessing background characteristics and drug use were conducted 1 week before completion of

primary treatment (baseline) and again at 3 and 12 months following study enrollment. Participants were randomized to a telephone aftercare condition after this baseline assessment and before they graduated from their intensive outpatient program. Follow-up rates for the 3- and 12-month assessments were 95.3% and 85.9%, respectively. The study had institutional review board approval from the University of California, Los Angeles. The current study focuses on the effects of the directive and nondirective counselor advice conditions among 66 participants who were randomized into the directive condition and 71 participants who were randomized into the nondirective condition. In the parent study, the structured and unstructured agenda conditions were crossed with the directive and nondirective conditions. For the current study, the structured and unstructured cells were collapsed together within each of the directive and nondirective conditions. The no-call control condition is not included in the current study.

Study participants
The sample for the present study comprised 137 substance users who reported primary use of either methamphetamine or both methamphetamine and cocaine/crack and completed a primary phase of intensive outpatient treatment. An additional 32 participants were excluded from the current study because baseline urine toxicology was unavailable (n = 10), they were lost to follow-up (n = 9), or urine toxicology at follow-up was unavailable (n = 13). Thus, the current sample represents 81% of study participants (n = 137 of 169) who were methamphetamine users and were randomized to an intervention condition in the parent study. Participants who were excluded had a larger proportion of women (41%) than did those who were included in the current sample (23% women), 2(1, N = 169) = 4.36, p < .05. Otherwise, no group differences were observed in age, referral source (court mandated or not), prevalence of stimulant use at baseline, Addiction Severity Index drug score (McLellan et al., 1985), or reactance score. Participants reported an average of 9.8 years (SD = 7.3 years) of methamphetamine use. Years of methamphetamine use ranged from less than 1 year to 37 years. Among participants who also had primary use of cocaine, they reported 7.5 years (SD = 7.0 years) of cocaine use. Years of cocaine use ranged from less than 1 year to 30 years. The demographic profile of the current sample (n = 137) was 77.4% male with a mean age of 35.6 years (SD = 9.3). Sixty-six percent of participants categorized themselves as White, 23% as non-White Hispanic, and 5% as African American. Levels of education were less than high school completion (21.2%), high school completion (49.6%), some posthigh school education (16.8%), and college completion or greater (12.4%). Participants reported that over the past 3 years they had maintained full-time employment (54.7%), part-time employment (19.7%), or were unemployed (17.5%). A few participants were students (1.5%), were retired (4.4%), or had been in a controlled environment (e.g., incarceration) (2.2%) over the past 3 years. Participants all received intensive outpatient treatment at one of five outpatient treatment sites located at either the Matrix Institute on Addictions (three sites, n = 112) or the Twin

Town Treatment Centers (two sites, n = 25) located in Los Angeles, San Bernardino, and Orange Counties in California. The Matrix Institute on Addictions provides cognitive behavioral group treatment, promotes patient involvement in a 12-step program, and provides a 4-month intensive outpatient program. The first month of the program entails 2.5 hours per day of group therapy and family education for 3 days per week plus 12-step participation. Months 24 entail 1.5 hours per day for 3 days per week and continued 12step participation. Participants from the Matrix Institute sites reported an average of 17.7 weeks (SD = 5.7) of outpatient treatment before the baseline assessment for the study. The Twin Town Treatment Centers emphasize 12-step participation and provide treatment on relapse prevention, family counseling, stress management, and problem solving skills. Twin Town has three phases of treatment over a period of 3 months. Phase 1 is intensive outpatient treatment (3 hours daily, 56 days per week) for 1 month and 12step attendance twice per week. Patients then step down to Phase 2 (1.5 hours daily) for 1 month plus regular 12-step attendance. Phase 3 is the lowest intensity phase for an additional month. Participants were recruited during Phase 2 because patients often ceased coming to formal treatment during Phase 3. Participants from the Twin Town sites reported an average of 5.2 weeks (SD = 2.5) of outpatient treatment before the baseline assessment for the study. A comparison of years of stimulant use across participants in the Matrix Institute and the Twin Town programs indicated that participants in Twin Town on average had more years of prior use (mean years [SD] = 12.4 [5.5]) relative to participants in the Matrix Institute (mean years [SD] = 9.5 [7.5]); however, this difference was not statistically significant, F(1, 135) = 3.32, p = .07.

Counseling conditions
Participants in the telephone-based counseling conditions were contacted on a fixed temporal schedule by a trained counselor. All of the telephone counseling conditions consisted of seven telephone calls conducted according to the same schedule: 1, 2, 4, 6, 8, 10, and 12 weeks following graduation from intensive outpatient treatment. The counseling conditions were as follows:

Nondirective.
Consistent with telephone counseling protocols implemented with alcohol treatment patients (Fitzgerald and Mulford, 1985), counselors in the nondirective condition provided subjects with general encouragement to participate in the outpatient continuedcare program. The counselors role was to heighten the participants awareness of the behaviors that are associated with sustained abstinence but leave it up to the participant to incorporate these activities in his or her own life. The counselors refrained from providing specific advice and instead focused on expressing genuine concern for the participants welfare.

Nondirective calls began with a check-in regarding how the participant was doing. The counselor then asked about what activities, if any, had been helpful in the past week for the participants recovery. In the structured version of the nondirective intervention, the counselor used a set list of pro-recovery activities to guide this discussion (e.g., How often in the past week did you attend 12-step meetings? How often in the past week did you avoid places where drugs were available?). In the unstructured version of the intervention, participants were asked to generate their own list of helpful activities. The counselor then thanked the participant for his or her time, scheduled the next call, and encouraged the participant to attend the continuing-care group therapy sessions offered by the outpatient treatment program he or she had attended. If participants asked the counselor for advice, counselors would offer such replies as, If this is something that you think is useful to you, I encourage you to do it or I would encourage you to talk about this with your continuing-care group leader.

Directive.
As with the nondirective condition, counselors in the directive condition began with a general check-in about how the participant was doing and then reviewed the participants recovery activities during the past week. In addition to encouraging participation in the outpatient continued-care program, counselors in the directive condition led a discussion about an action plan to promote engagement in recovery activities for the upcoming week. This action plan was the distinguishing characteristic of the directive intervention. For each activity that the participant identified as helpful for his or her recovery, the counselors worked toward creating a concrete plan. Examples of counselor questions included, What kinds of things can you plan to do in the next week to support your recovery? and What are some things you can do to build time into your schedule to do this activity in the next week? The counselors provided input about how to make the action plan more specific, and they encouraged participants to expand the amount of planned activities for the next week.

Intervention fidelity
On average, subjects participated in 5.6 (SD = 1.44) of the 7 possible calls. The mean duration of the calls was 4 minutes, 56 seconds (SD = 4.10). This amount of contact is consistent with that found in the Betty Ford Centers Telephone Enhancement of Longterm Engagement (TELE) demonstration study (Hubbard et al., 2007). Experience of the counselors ranged from a bachelors degree with a certification in counseling to a masters degree in social work. All counselors underwent didactic training and had to demonstrate proficiency by role playing each study condition before beginning work on the study. Counselors then received weekly supervision that involved listening to taped sessions and discussing any clinical issues that arose. All of the calls during the study were tape recorded and reviewed by the project director for fidelity. Fidelity was determined based on adherence to the script for each intervention and the absence of any proscribed counselor behaviors. Common elements for both the directive and nondirective interventions included a review of recovery activities from the previous

week; general encouragement to keep working on ones recovery; and counselor use of active listening, empathic responses, and a positive, encouraging attitude. The use of confrontation, arguing, or sarcasm was proscribed for both interventions. In addition to these common elements, the adherence rating for the directive condition centered on discussing a plan and giving advice to participate in recovery activities for the upcoming week. For the nondirective condition, it was proscribed for the counselor to initiate discussion about a plan for specific recovery activities in the upcoming week or to provide advice about such activities. The project director used a checklist of these prescribed and proscribed elements to evaluate the fidelity of each session. Fewer than 5% of the sessions were rated as not adhering to the intervention scripts. Almost all of these instances involved participants in the nondirective condition actively seeking specific advice from a counselor about recovery activities and the counselor yielding to these requests and giving some form of advice. When these instances were identified, the issue was raised in the weekly project meetings, and the counselors roleplayed how to respond in a manner consistent with the session script.

Assessments

Patient reactance.
The extent to which patients resisted influence from others was assessed via the Therapeutic Reactance Scale (Dowd et al., 1991), which was administered at baseline as a self-report questionnaire. Based on subsequent factor analysis of this scale (Buboltz et al., 2002), a subset of four items with high internal consistency (Cronbachs = .71 in current sample) was selected for analysis. These items target a specific component of reactance related to resistance of influence from authority figures. The content of these four items is as follows: I resent authority figures who try to tell me what to do, I find that I often have to question authority, If I am told what to do I often do the opposite, and It really bothers me when police officers tell people what to do. The average score across these four items was used for data analysis. Reactance scores were comparable between participants assigned to the directive and nondirective conditions.

Methamphetamine and cocaine use.

Timeline Follow-back interviews were conducted and urine specimens were collected at baseline and at the 3- and 12-month follow-ups. The 3-month and 12-month follow-ups each covered the previous 90 days. Given that this was an aftercare sample graduating from abstinence-based treatment programs, the target outcome was use of any methamphetamine or cocaine (i.e., use vs. no use) during the follow-up period. For the present study, methamphetamine or cocaine use at follow-up was determined if either self-report or urine toxicology indicated any use. Participants who self-reported no use but did not provide a urine specimen (n = 13 at the 3-month follow-up) were excluded from the current analysis based on decreased confidence in the validity of the self-report data.

Data analysis
Logistic regression was used to test the hypothesis that patient reactance interacted with treatment directiveness to predict use or no use of methamphetamine or cocaine during the follow-up periods. The analysis controlled for baseline stimulant use as per urine toxicology, the number of years of amphetamine or cocaine use (whichever was greater for each participant), and whether participants were court referred for treatment. Given the difference in amount of outpatient treatment received by participants between the Twin Town program and the Matrix Institute program, the analyses also included treatment program as a covariate. The product term between patient reactance and directiveness condition was included to provide a formal statistical test of the interaction hypothesis. The dependent variable was stimulant use based on urine toxicology and selfreport (as described above) over the 3-month follow-up and over the 12-month follow-up. Given the directional hypotheses for the interaction and the pattern of prior empirical support, a one-tailed test was conducted for the interaction term (i.e., the direction of significant differences in slopes needed to be in the hypothesized direction).

Results
Results from the logistic regression analysis predicting stimulant use at the 3-month follow-up supported a significant interaction between level of patient reactance as measured at baseline and assignment to either the directive or nondirective telephone aftercare condition (OR = 0.18, 95% CI [0.04, 0.77], p < .05). Detailed results from the analysis are presented in Table 1.

Table 1 Results of logistic regression analysis (n = 137) predicting any use of methamphetamine or cocaine at the 3-month follow-up from the interaction of patient reactance and directive versus nondirective intervention condition

The significant interaction effect indicated that the association between patient reactance and stimulant use at the 3-month follow-up differed across the directive and nondirective conditions. Among participants in the directive condition, increased levels of patient reactance were associated with greater odds of using methamphetamine or cocaine at the 3-month follow-up (OR = 5.39, 95% CI [1.64, 17.71], p < .01). However, no association between patient reactance and stimulant use was observed for participants in the nondirective condition (p > .50).

A simple slopes plot of the interaction is provided in Figure 1. Of interest, participants in the directive condition who rated lowest on reactance had the lowest likelihood of using cocaine or methamphetamine. Although overall the nondirective condition was marginally associated with a higher prevalence of use at the 3-month follow-up compared with the directive condition (i.e., irrespective of the level of reactance) (p < .10), participants higher in reactance who received the directive intervention appeared to fare worse than those higher in reactance who were in the nondirective condition.

Figure 1 Simple slopes plot of the Directiveness Patient Reactance interaction as a predictor of the conditional probability of any methamphetamine or cocaine use at the 3-month follow-up. High and low reactance levels are plotted at the mean 1 ...

These visual impressions were formally examined using the Johnson-Neyman technique (Johnson and Fey, 1950; Johnson and Neyman, 1936; Karpman, 1983) to identify reactance scores at which significant differences in outcome were observed across treatment conditions. The MODPROBE macro for SPSS (SPSS Inc., Chicago, IL) (Hayes and Matthes, 2009) was used for this purpose. One-tailed directional tests suggested that for participants with a reactance score of 1 (the lowest score on the 4-point scale), the directive intervention was more effective than the nondirective intervention in reducing the likelihood of any stimulant use over the 3-month follow-up period (b = 2.36, p < . 05). Among participants with a reactance score of 4 (the highest score on the 4-point scale), the results favored the nondirective intervention over the directive intervention (b = 2.77, p < .05). As can be seen in Figure 1, the probability of use during the 3-month follow-up period was low for the entire sample. Given that only 17% of participants in the sample reported use of methamphetamine or cocaine at the 3-month follow-up, such a finding is to be expected. Still, the results indicated that participants in the directive condition who were low in reactance had an especially low prevalence of methamphetamine or cocaine use relative to the rest of the sample. Results from the logistic regression analysis predicting stimulant use for the 12-month follow-up did not support an interaction between patient reactance and assignment to the directive or nondirective conditions (one tailed, p > .20). Among participants assigned to the directive condition, increased levels of reactance were associated with an increase in the likelihood of any stimulant use (OR = 4.69, 95% CI [1.46, 15.05], p < .01). This relationship was consistent with one part of the studys a priori hypothesis. Yet a similar relationship was also observed for participants assigned to the nondirective condition. Hence, rather than supporting an interaction effect, the results supported a main effect of reactance as a negative prognostic indicator over the longer term.

Discussion
The current study contributes to a growing body of empirical evidence that suggests there is a meaningful interplay between the level of interpersonal reactance by patients and the directiveness of psychosocial interventions for substance abuse and dependence. The findings indicate that this interplay is not reserved for face-to-face psychotherapy but rather also occurs in the context of brief telephone-based counseling for methamphetamine use. The results suggest that a brief assessment of reactance when a patient is being transitioned to aftercare can help inform the extent to which a counselor takes a proactive role in developing action plans for recovery. This finding was limited to proximal outcomes during the 3-month follow-up period. Thus, the active period of the effect appears to occur closer in time to when patients receive the telephone contact. In clinical practice, sustained effects may therefore require ongoing booster contacts. Of interest is that the pattern of results for this sample of methamphetamine users who received telephone aftercare was consistent with findings from previous research on faceto-face aftercare counseling for alcohol use disorders (Karno and Longabaugh, 2005b). Both studies demonstrated a significant interaction between directiveness and patient reactance in which there was a deleterious effect of directiveness for patients high in reactance. The current study also found a beneficial effect of directiveness for patients low in reactance. The findings support the studys a priori hypothesis and converge with other findings regarding patient reactance and therapy directiveness in the treatment of alcohol disorders (Karno et al., 2002) and depression (Beutler et al., 1991). The consistency in findings across these studies is notable despite there being methodological differences. Karno and Longabaugh (2005b) focused on individuals with an alcohol use disorder, whereas the current study focused on individuals with a methamphetamine use disorder. Second, the methods used to assess reactance and directiveness differ. Karno and Longabaugh (2005b) used observer-based ratings to assess reactance and directiveness, whereas the current study used patient self-report to assess reactance and randomly assigned participants to directive versus nondirective conditions. Finally, the mode of treatment delivery and intensity of treatment differ. The previous study (Karno and Longabaugh, 2005b) provided up to 12 hourly sessions of inperson treatment, whereas the current study provided up to seven 5-minute (on average) sessions by telephone. The convergence of findings across studies with different methods (e.g., observer ratings vs. self-report) provides good support that the hypothesized relationships between the constructs are valid. Where the current study and the study by Karno and Longabaugh (2005b) diverge is in the duration of the observed effect. The current study only observed the interaction effect over a proximal 3-month period, whereas the other study observed an effect over a 1-year follow-up. One factor to explain this difference is the relatively small dose of treatment delivered through the telephone intervention. Of the studies from independent samples that have examined the Reactance Directiveness interaction (Beutler et al., 1991; Karno et al., 2002; Karno and Longabaugh, 2005b), the current study has by far the lowest dose

for the intervention. This explanation suggests that brief and ongoing telephone support is important to promote abstinence over the longer term. This study improves on previous research by measuring patient reactance before the intervention begins, thereby having the measure of reactance be independent from any resistance that might be prompted by the counselorclient interaction. Additionally, the random assignment to treatment condition increases the internal validity of the observed effects compared with previous research that relied on post hoc ratings of counselor behaviors that were directive in nature. Further, the current study relied on correspondence between self-report and urine toxicology results for the dependent variable. Because the current study focused on aftercare, there was not a planned assessment of readiness to change. In hindsight, this omission opens up the possibility that readiness to change may be a potential confound. We cannot rule out that the worse outcomes for participants who were high in reactance and who were randomized to the directive condition were actually attributable to lower readiness to change for these individuals. Conversely, the better outcomes for participants who were high in reactance and were randomized to the nondirective condition may have been attributable to their being higher in readiness to change. Although the analysis did include court referral as a covariate, that variable is not an ideal proxy for readiness to change. Also, random assignment may not have equally distributed participants across conditions in terms of readiness to change. Another limitation of the study is that reactance was treated as a traitlike construct. Presumably, reactance also has a state-dependent quality that the current study does not address. Thus, the current study cannot speak to fluctuations in reactance over time or the effect of prior or current substance use disorder treatment on an individuals level of reactance. The current findings are therefore limited to the reactance level for patients at a point in time when they have completed an initial phase of intensive outpatient treatment and are transitioning into a continuing care phase of treatment. Going forward, it will be important to examine potential mediators of this interaction effect. Specific questions to address are whether directive and nondirective telephone aftercare interventions differentially promote increased use of other aftercare treatment services and pro-recovery activities for patients at different levels of reactance.

Footnotes
This study was supported by National Institute on Drug Abuse Grant DA 018208 (to David Farabee, principal investigator).

Article information
J Stud Alcohol Drugs. 2012 September; 73(5): 844850. PMCID: PMC3410952

Mitchell Karno, Ph.D.,a,* David Farabee, Ph.D.,a Mary-Lynn Brecht, Ph.D.,a and Richard Rawson, Ph.D.a a Integrated Substance Abuse Programs, Department of Psychiatry & Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, California * Correspondence may be sent to Mitchell Karno at the Integrated Substance Abuse Programs, Department of Psychiatry & Biobehavioral Sciences, University of California, Los Angeles, 11075 Santa Monica Boulevard, Suite 200, Los Angeles, CA 90025, or via email at: karno/at/ucla.edu. Received December 20, 2011; Accepted April 6, 2012. Copyright 2012 by Alcohol Research Documentation, Inc. Articles from Journal of Studies on Alcohol and Drugs are provided here courtesy of Rutgers University. Center of Alcohol Studies

References

Ashby JD, Ford DH, Guerkey BG, Jr, Guerkey LF, Snyder WU. Effect on clients of a reflective and a leading type of psychotherapy. Psychological Monographs: General and Applied. 1957;71(24):132. Beutler LE, Engle D, Mohr D, Daldrup RJ, Bergan J, Meredith K, Merry W. Predictors of differential response to cognitive, experiential, and selfdirected psychotherapeutic procedures. Journal of Consulting and Clinical Psychology. 1991;59:333340. [PubMed] Brehm JW. A theory of psychological reactance. Oxford, England: Academic Press; 1966. Brehm JW. Reactance. In: Kazdin AE, editor. Encyclopedia of psychology. Vol. 7. Washington, DC: American Psychological Association; 2000. pp. 1012. Brehm SS, Brehm JW. Psychological reactance: A theory of freedom and control. Oxford, England: Academic Press; 1981. Buboltz WC, Jr, Thomas A, Donnell AJ. Examining the factor structure and internal consistency reliability of the Therapeutic Reactance Scale. Journal of Counseling & Development. 2002;80:120125. Dowd ET, Milne CR, Wise SL. The Therapeutic Reactance Scale: A measure of psychological reactance. Journal of Counseling & Development. 1991;69:541545. Farabee D, Cousins S, Brecht M, Pearce V, Bellows A, Brummer J, et al. in press. A comparison of four telephone-based coaching styles for recovering stimulant users. Psychology of Addictive Behaviors [PMC free article] [PubMed] Fitzgerald JL, Mulford HA. An experimental test of telephone aftercare contacts with alcoholics. Journal of Studies on Alcohol. 1985;46:418 424. [PubMed] Hayes AF, Matthes J. Computational procedures for probing interactions in OLS and logistic regression: SPSS and SAS implementations. Behavior Research Methods. 2009;41:924936. [PubMed] Hubbard RL, Leimberger JD, Haynes L, Patkar AA, Holter J, Liepman MR, Hasson A. Telephone enhancement of long-term engagement (TELE) in

continuing care for substance abuse treatment: A NIDA Clinical Trials Network (CTN) study. American Journal on Addictions. 2007;16:495 502. [PubMed] Johnson PO, Fay LC. The Johnson-Neyman technique, its theory and application. Psychometrika. 1950;15:349367. [PubMed] Johnson PO, Neyman J. Tests of certain linear hypotheses and their application to some educational problems. Statistical Research Memoirs. 1936;1:5793. Karno MP, Beutler LE, Harwood TM. Interactions between psychotherapy procedures and patient attributes that predict alcohol treatment effectiveness: A preliminary report. Addictive Behaviors. 2002;27:779797. [PubMed] Karno MP, Longabaugh R. An examination of how therapist directiveness interacts with patient anger and reactance to predict alcohol use. Journal of Studies on Alcohol. 2005a;66:825832. [PubMed] Karno MP, Longabaugh R. Less directiveness by therapists improves drinking outcomes of reactant clients in alcoholism treatment. Journal of Consulting and Clinical Psychology. 2005b;73:262267. [PubMed] Karpman MB. The Johnson-Neyman technique using SPSS or BMDP. Educational and Psychological Measurement. 1983;43:137147. McKay JR. Continuing care research: What we have learned and where we are going. Journal of Substance Abuse Treatment. 2009;36:131 145. [PMC free article] [PubMed] McKay JR, Van Horn D, Oslin DW, Ivey M, Drapkin ML, Coviello DM, Lynch KG. Extended telephone-based continuing care for alcohol dependence: 24-month outcomes and subgroup analyses. Addiction. 2011;106:17601769. [PMC free article] [PubMed] McLellan AT, Luborsky L, Woody GE, OBrien CP. Guide to Addiction Severity Index. Washington, DC: U. S. Government Printing Office; 1985. Miller WR. Motivational Enhancement Therapy: Description of counseling approach. In: Boren JJ, Onken LS, Carroll KM, editors. Approaches to drug abuse counseling. Washington, DC: National Institute on Drug Abuse; 2000. Miller WR, Rollnick S. Motivational interviewing: Preparing people to change addictive behavior. New York, NY: Guilford Press; 1991. Patterson GR, Forgatch MS. Therapist behavior as a determinant for client noncompliance: A paradox for the behavior modifier. Journal of Consulting and Clinical Psychology. 1985;53:846851. [PubMed] Rogers CR. Counseling and psychotherapy: Newer concepts in practice. Boston, MA: Houghton Mifflin; 1942. Rudolph J. Effects of an affirmative gay psychotherapy workshop on counselors authoritarianism. Psychological Reports. 1989;65:945946. [PubMed]

AIDS Patient Care and STDs Mary Ann Liebert, Inc.

A Novel Combination HIV Prevention Strategy: Post-Exposure Prophylaxis with Contingency Management for Substance Abuse Treatment Among Methamphetamine-Using Men Who Have Sex with Men
Raphael J. Landovitz, M.D. M.Sc., Jesse B. Fletcher, Ph.D., [...], and Cathy J. Reback, Ph.D. Additional article information

Abstract
Methamphetamine use has been associated with HIV transmission among men who have sex with men (MSM). However, providers have been hesitant to utilize post-exposure prophylaxis (PEP) in populations of stimulant users. This single-arm, open label pilot study sought to demonstrate the safety, feasibility, and acceptability of PEP combined with the drug abstinence intervention of contingency management (CM) in methamphetamine-using MSM. HIV-uninfected MSM reporting recent methamphetamine use were recruited to a CM intervention. Those who reported a recent high-risk sexual or injection drug exposure to an HIV-infected or serostatus unknown source were initiated on tenofovir/emtricitabine (Truvada)-based PEP. Participants were followed over 3 months for infectious/biologic, behavioral, and drug use outcomes. Fiftythree participants enrolled in the study; 35 participants (66%) initiated PEP after a highrisk exposure. The median time from exposure to medication administration was 37.8 h (range 12.568.0 h). Twenty-five (71.4%) PEP initiators successfully completed the treatment course. Median medication adherence was 96% (IQR 57100%), and medication was generally well tolerated. Methamphetamine abstinence during CM treatment increased PEP adherence (2% [95% CI +1+3%]) per clean urine toxicology sample provided), and increased the odds of PEP course completion (OR 1.17, 95% CI 1.041.31). One incident of HIV seroconversion was observed in a participant who did not complete PEP treatment, and reported multiple subsequent exposures. Findings demonstrate that PEP, when combined with CM, is safe, feasible, and acceptable as an HIV prevention strategy in methamphetamine-using MSM.

Introduction
In the United States, men who have sex with men (MSM) are at disproportionate risk for HIV infection. In 2008, MSM accounted for 68% of newly diagnosed infections, with an overall HIV prevalence rate of 19%.1,2 In Los Angeles County (LAC), MSM represent 84% of all prevalent AIDS cases. Research suggests that high rates of HIV infection among MSM are associated with substance use, in particular methamphetamine use.3,4 Thirteen percent of MSM in LAC reported methamphetamine use in the past year, when assessed as part of behavioral surveillance (T.A. Bingham, unpublished observation). Among urban MSM, methamphetamine use is strongly associated with HIV infection,3 presumably mediated through increases in risky sexual behavior, such as an increased number of sexual partners;5 decreased condom use;5,6 sex with casual, anonymous,7 and multiple partners;8 and unprotected receptive and insertive anal sex with casual partners;6 all of which increase the likelihood of HIV and sexually transmitted infection (STI) acquisition.3,5,813 There is an ecological association between intensity of methamphetamine use and HIV infection among MSM; as drug use increases, the greater the likelihood of prevalent HIV infection, with prevalence rates increasing from 23% among MSM reporting occasional use of the drug (approximating domestic and LAC prevalence rates among MSM of 19%2,14), 42% among MSM reporting regular monthly use, 61% among those seeking outpatient treatment for methamphetamine use, and 86% among those seeking residential treatment for methamphetamine dependence.4 Therefore, there is a pressing need for novel and effective interventions to prevent HIV acquisition by methamphetamine-using MSM.15 There is increasing interest in biomedical approaches to HIV prevention particularly using HIV antiretroviral therapy (ART) in a preventive capacity among HIV-uninfected high-risk populations. PEP, the strategy of taking 28 days of ART, initiated rapidly after an exposure to HIV, has been estimated to reduce the odds of HIV acquisition by 81% after occupational needle-stick injuries,16 and is recommended for the prevention of HIV transmission in high-risk cases of sexual exposure and needle-sharing, despite a lack of efficacy data for this indication.17 The available data suggest that important parameters for PEP efficacy are (1) the time from exposure to initiation of medication,18,19 (2) medication adherence,20 and (3) medication course completion.21 These parameters may be adversely influenced by active substance use,2225 explaining some the reluctance of providers to use PEP in actively substance-using populations.26 Additional concerns include the potential for risk compensation,27 a reactionary increase in high-risk behavior induced by a perception of protection against HIV afforded by prophylactic therapy. In mathematical models, such behavior changes have the potential to mitigate or abrogate the efficacy of ART-based prevention strategies,28 although the available data suggest that PEP is not associated with risk compensation when accompanied by directed riskreduction counseling.2931 Long-standing reluctance to endorse PEP use among substance-using populations is reinforced by observations of poor medical compliance among methamphetamine-using

HIV-infected persons.24,25 This concern was supported in a Los Angeles-based pilot program of PEP administration, in which findings demonstrated that the odds for PEP treatment course completion were 4.6-fold lower for participants reporting substance use at the time of their high-risk exposure episode than among the non-substance users.32 This project sought to assess whether incorporating a contingency management (CM) intervention to reduce methamphetamine use could facilitate PEP initiation, adherence, and completion for HIV prevention among methamphetamine-using MSM. CM is a behavioral intervention that utilizes positive reinforcement in the form of vouchers, gift certificates, goods and services to shape targeted operant behaviors. CM has been successfully implemented in research, community, and public health settings, and has targeted a variety of behaviors such as medication adherence, weight loss, and smoking cessation.3336 Randomized controlled trials have shown CM to be an effective intervention for reducing stimulant use with effects sustained to at least 1 year, as well as reducing HIV-transmission risk behaviors.3741 Voucher-based CM for substance users involves providing participants with vouchers in exchange for verified urine samples that are negative for metabolites of the targeted drug. Vouchers are then exchanged for gift certificates, goods and services, or other items that promote pro-social and healthy behaviors.4244 Local success with CM, particularly in groups of methamphetamine-using MSM, and the observation that the HIV epidemic in Los Angeles is notable for high rates of methamphetamine use among MSM, suggested a potential synergy of combination prevention interventions in this population. We hypothesized that the application of a CM intervention for out-of-treatment methamphetamine-using MSM would optimize the use of PEP with regard to initiation, adherence, and completion. This single-arm, open-label pilot study evaluated the safety and feasibility of the combination prevention approach of coupling CM with PEP as a method for helping HIV-uninfected methamphetamine-using MSM to remain HIV-negative. Results are contextualized with other reports from cohorts of PEP recipients that were not specifically targeted as substance-using MSM.

Methods
The Institutional Review Boards for the University of California, Los Angeles and Friends Research Institute provided oversight for all study activities, and approved all study-related documents, materials, and procedures.

Participants
Participants were recruited through targeted advertisements posted in local gay magazines; the distribution of flyers and club cards in the settings where methamphetamine-using MSM congregate such as cruising areas of parks, bars, dance clubs, bathhouses, bookstores, video stores, sex clubs, and at gay-specific events; and at in-services at local agencies. Potential participants were eligible if they self-identified as MSM, were at least 18 years of age, were HIV uninfected on rapid HIV ELISA testing,

self-reported methamphetamine use within the previous 30 days, and reported unprotected anal intercourse (UAI) with an HIV-positive or HIV-serostatus-unknown partner in the previous 90 days. The protocol was amended early in the study to remove an inclusion criterion obligating a positive urine toxicology screen for methamphetamine metabolites at study entry. This was done after observed frequent non-correlation of urine test results with self-report of recent methamphetamine use.

Study procedures
All study procedures were conducted at a community research site in Los Angeles, California. At the baseline visit, all eligible participants underwent informed consent; completed baseline assessments (discussed subsequently); received rapid HIV testing (OraQuick Advance, OraSure technologies, Bethlehem, PA); provided specimens for syphilis, gonorrhea and chlamydia testing; and received a medical examination. Participants also received an orientation to the CM intervention. Those who reported a high-risk sexual or drug exposure episode with an HIV-positive or serostatus-unknown source within the preceding 72 h immediately initiated tenofovir disoproxil fumarate+emtricitabine (Truvada, Gilead Sciences), one tablet daily, for 28 days (Immediate Initiators). All other participants received a 4-day starter pack of Truvada to be initiated only in the case of a future high-risk exposure to HIV. Not all participants initiated PEP during the study period (Non-Initiators). Participants who reported a postentry high-risk exposure during the study period initiated PEP via the provided starter pack (Delayed Initiators).

Behavioral intervention (CM)

All participants began the voucher-based CM intervention upon study entry. For the initial 8 weeks of study conduct, participants presented to the study site three times weekly for a urine drug screen for methamphetamine metabolites. Participants who provided urine samples that were negative for methamphetamine metabolites earned vouchers, which escalated in value for successive negative urine samples. A participant with a missing sample or a sample positive for methamphetamine metabolites did not earn vouchers. The participant's initial urine sample that was negative for methamphetamine metabolites earned $2.50. Vouchers increased in value by $1.25 for each consecutive methamphetamine-free sample to a maximum additive value of $20. Participants earned a $10 bonus voucher for every three consecutive methamphetaminefree samples. If a participant provided methamphetamine-free urine samples for the entire 8 week intervention, maximum earnings of $430 in vouchers were possible. Accrued vouchers were never forfeited and could be redeemed at any time during the study for gift certificates or goods or services that promote healthy, pro-social behaviors; vouchers could not be redeemed for cash.

Assessments
Baseline assessments included demographics, diagnosis of methamphetamine abuse or dependence (Diagnostic and Statistical Manual of Mental Disorders, 4th ed.[DSM-IV]),

sexual risk behaviors (Behavioral Questionnaire-Amphetamine [BQA - II]), depression (Beck Depression Inventory [BDI]), HIV serostatus, and STIs, urine sample, and selfperformed rectal swab for nucleic acid amplification [NAAT] for Neisseria gonorrhoeae and Chlamydia trachomatis, pharyngeal swab for N. gonorrheae, and syphilis testing via serum rapid plasma reagin [RPR] assay). A urine test strip for methamphetamine metabolites was used for drug screening. Sample validity was confirmed by urine temperature, creatinine content, and pH. BDI was administered weekly and the BQA-II was additionally performed at the 3-month followup visit. HIV and STI testing was performed at the 3-month follow-up; HIV RNA testing was performed only in the event of clinical suspicion of acute HIV seroconversion. For all PEP initiators (immediate or delayed), additional HIV re-testing was performed at 46 weeks post-exposure and at 3 months post-exposure. Delayed initiators were also retested at the time of PEP initiation. Serum electrolytes, creatinine, liver function tests (alanine transaminase [ALT], aspartate transaminase [AST], alkaline phosphatase, and total bilirubin), complete blood count (CBC) with differential, and hepatitis B surface antigen (HBsAg) were collected at baseline and upon PEP initiation (for delayed initiators), and directed laboratory evaluations were performed to evaluate potential medication toxicity. PEP initiators found to be HBsAg positive at baseline were followed with serial liver function test monitoring on a monthly basis for 6 months after PEP completion, or until evaluation by a hepatologist. Medication adherence was assessed by 4-day medication recall, self-report, and pill counts at day 14 and 28 of PEP treatment; if CM and PEP were concurrent, self-report and pill counts were additionally assessed at all CM visits. Adverse events were assessed at all visits and graded according to the 2004 DAIDS Toxicity Tables (2009 update). All participants initiating PEP were followed for 3 months post-exposure, regardless of the time interval from study enrollment.

Statistical analysis
T-tests were used to test for differences between outcome variables that were measured at both baseline and follow-up. Multivariate ordinary least squares (OLS) regression was used for analyses of PEP adherence and hours to PEP initiation, and multivariate logistic regression was used for analysis of course completion. Because of the small sample size, and the potentially collinear effects of the two included covariates (i.e., years of heavy methamphetamine use and CM-induced abstinence), significance is reported for any coefficient with a p<0.1. All analyses were performed using Stata version 10SE (StataCorp, College Station, TX).

Missing data

Missing data were not imputed. A small number of participants refused to answer questions about methamphetamine usage at baseline (n=3), about their number of sexual partners at follow-up (n=7), or had missing or indeterminate STI testing at baseline (n=2). Two participants who initiated PEP withdrew consent shortly after beginning treatment, and all data after withdrawal of consent were considered missing. Analysis of missing urine drug screen samples revealed no significant differences between participants who did or did not initiate PEP (50% vs. 41.2%, p=0.536), implying that the data are missing at random and appropriate for statistical analysis.

Results
Study recruitment and retention
Between March 2009 and August 2010, 358 individuals inquired about the study on the basis of recruitment efforts, 64 presented for screening, and 53 participants enrolled in the study (Fig. 1).

FIG. 1. Study progression and retention. Participant baseline characteristics are presented in Table 1, and are consistent with the demographics of participants seen for methamphetamine treatment services collocated at the study facility.45

Table 1. Participant Sociodemographic Characteristics (n=53)

Methamphetamine use, dependency, and high-risk sexual behaviors

At baseline, participants self-reported a mean of 10.1 years (SD=8.2) of methamphetamine use and 2.7 years (SD=4.4) of self-reported heavy use. Most study

participants (83%) met criteria for methamphetamine dependence on the DSM-IV diagnostic assessment. Additionally, participants reported high rates of lifetime use of recreational drugs and alcohol (Table 2).

Table 2. Methamphetamine Usage and Sexual Behaviors Methamphetamine use decreased significantly from baseline to 3-month follow-up, by multiple parameters. Mean number of days (of the past 30) of methamphetamine use decreased from 4.8 to 1.6 (p<0.001), with mean number of uses per day decreased from 5.3 to 1.1 (p<0.001). Similarly, at baseline, participants reported spending a mean of $172.40 (SD=$431.10) on methamphetamine in the previous 30 days, which decreased to $29.20 (SD=$63.80; p<0.05) by 3-month follow-up. The percentage of participants who provided urine specimens free of methamphetamine metabolites (suggestive of methamphetamine abstinence for the 72 h prior to specimen provision) increased significantly over the course of the 3-month study period, from 71.7% at baseline to 89.47% at 3-month follow-up (p<0.05). The mean number of self-reported sexual partners in the previous 30 days from baseline to 3-month follow-up decreased from 5.1 to 3.1 (p<0.05); additionally, participants reported significantly fewer mean episodes of UAI in the previous 30 days, 6.5 at baseline and 0.44 at 3-month follow-up (p=0.05).

STI
Prevalence and 3-month incidence rates of syphilis (11.8% and 6.8%, respectively), rectal gonorrhea (5.7% and 6.8%), pharyngeal gonorrhea (5.8% and 11.4%), and rectal chlamydia (5.7% and 4.5%) were high (Table 2), in contrast with reported decreases in sexual risk behavior.

PEP initiation, adherence, and adverse events

Thirty-five participants (66%) initiated PEP during the course of the study, with a median time from exposure to initiation of 37.8 h (range, 12.568.0 h; Table 3). Thirty (85.7%) participants were immediate initiators, and five were delayed initiators. There were no significant differences between immediate and delayed initiators in rates of medication adherence, medication possession, or course completion. Twenty-five (71.4%) participants completed the 28 dose course of PEP medication, with overall median medication adherence of 96% (IQR, 57100%). Commonly reported adverse events are

listed in Table 3. Most (78.1%) adverse events were graded as mild (grade 1 or 2), with one grade 3 adverse event (syncope) and one grade 4 adverse event (depression with suicidality); however, neither grade 3 or grade 4 adverse event was considered to be related to PEP medication. Of the four adverse events of any grade considered possibly related to the PEP medication (two cases of abdominal pain, one case of diarrhea, one case of flatulence), all resolved without the need for medication discontinuation.

Table 3. Multivariate Associations of Critical PEP Parameters with Years of Heavy Methamphetamine Use and CM Drug Abstinence Induction (n=32)

PEP adherence
Exploratory multivariate analyses were performed to determine if lifetime or ongoing methamphetamine use (assessed by self-report and urine metabolite assay, respectively) influenced PEP adherence, course completion, and/or hours to PEP initiation (Table 3). The number of clean urine samples provided by a participant significantly increased PEP adherence, with each additional clean urine sample increasing adherence by 2% (95% CI, +1+3%; p=0.002). Self-reported years of heavy methamphetamine usage demonstrated a trend toward decreased PEP adherence; every 1 additional year of heavy usage decreased PEP adherence by 3% (95% CI, 7+1%; p=0.095).

PEP course completion

The number of clean urine samples significantly increased the odds of course completion (OR, 1.17, 95% CI, 1.041.31; p=0.011). The number of cumulative years of heavy methamphetamine usage demonstrated a trend to decrease the odds of course completion (OR, 0.75, 95% CI, 0.531.05; p=0.099).

Exposure-to-dosing time
Cumulative number of years of heavy methamphetamine usage demonstrated a nonstatistically significant increase in the number of hours to PEP initiation, with each additional year of heavy methamphetamine usage increasing the number of hours to PEP initiation by 1.4 (95% CI, 0.643.44; p=0.17).

Incident seroconversion

One incident seroconversion was observed during study conduct in a participant who discontinued PEP medication after 16 days of treatment for logistic reasons. The participant reported multiple repeat exposures subsequent to PEP treatment and had laboratory evidence of incident STIs at the time of serconversion.

Discussion
PEP has potential to be a powerful HIV prevention strategy, although historically, providers have been reluctant to initiate PEP with substance users out of concern for poor adherence, ability to present within the narrow window of post-exposure therapeutic efficacy, and the propensity for repeat exposures. Compelling data that substance-using MSM have high HIV prevalence and incidence rates underscore the urgency of finding effective HIV prevention interventions for this population. This pilot study explored an intervention that addressed these concerns by pairing CM with PEP to facilitate medication initiation, adherence, and completion, as well as to promote behavioral risk reduction; with the hope of creating combination prophylactic synergy. During the course of the study, 35 (66%) of study participants reported a high-risk sexual exposure that met eligibility criteria for initiation of PEP. This finding corroborates the observation that methamphetamine-using MSM are an extremely high-risk population, and a population in whom biomedical HIV prevention strategies might be particularly beneficial with regard to reducing incident HIV infections, if the use of such strategies can be optimized. One of the most critical parameters of PEP efficacy is exposure-to-dose time interval, with animal and human data suggesting diminished efficacy with incrementally delayed medication administration post-exposure.22,46 Previous PEP studies in non-occupational settings, which did not specifically target substance-using or substance-dependent MSM, have reported median exposure-to-dose times of 33 h.47 Although cross-study comparisons must be made with caution, our CM-facilitated PEP protocol found a median time from exposure to PEP initiation of 37.8 (range 12.568.0) h. Similarly, a PEP medication adherence rate of 76.3% and course completion rate of 71.4% compares favorably with other cohorts.30,47,48 Reductions in methamphetamine use and sexual risk behaviors including days of methamphetamine use, numbers of sexual partners, episodes of UAI, and drug use during sex (all with a 30-day horizon), as well as increases in rates of methamphetamine-free urine specimens, suggest that the CM intervention was successful and had potent methamphetamine-use and sexual risk behavior benefit. The absence of any additional behavioral intervention other than the CM suggests that the reduction in sexual risk behavior was largely mediated by reduced methamphetamine use, as has been seen in other studies.39 The durability of these benefits was not assessed past 3 months, but prior studies have demonstrated durability to 1-year follow-up evaluation.39,49 The high rate of incident STIs at the 3 month point tempers enthusiasm for the self-reported decrease in sexual risk behaviors, as it suggests underreporting of risk behavior and a high risk population in which even limited exposures are likely to result in STI acquisition. This

situation suggests that these men transact parts of their sexual lives near the core of many epidemics, which reinforces the rationale of providing combination prevention to these MSM that includes efficacious interventions for both sex (PEP) and drug use (CM). CM was considered the ideal behavioral intervention for this trial, given that the target population was out-of-treatment methamphetamine users. CM has been demonstrated to be the most efficacious intervention for promoting abstinence from stimulants during treatment,37,39 and, given that this was a non-treatment-seeking population it was unlikely that the participants would attend to a counselor-facilitated intervention. By providing a powerful reward for urine samples that were negative for methamphetamine metabolites, CM offered an external motivation to users who were not yet in the earliest stages of the change process.50 There was a concern that the early removal of a baseline positive urine-toxicology result could bias the sample to a less severely methamphetamide-affected study population; however, that concern was unfounded, as a full 83% met criteria for methamphetamine dependence on the baseline DSM-IV, rather than the lesser diagnostic classification of abuse. Increased abstinence from methamphetamine use during the intervention predicted increases in PEP adherence and the odds of course completion. Given that these findings persisted in multivariate analyses, future studies of combination HIV prevention strategies should focus on, or at minimum include, high-risk populations (including methamphetamine-using MSM), and include low-threshold substance use interventions, such as CM, to optimize the capacity of substance users to access the full benefits of the prevention package. The findings are consistent with previous observations that methamphetamine use reduces the ability to adhere to medical protocols, underscoring the need for behavioral interventions to be used in conjunction with PEP (or similar medical treatments) in methamphetamine-using populations, and suggesting that therapies that successfully reduce drug use may have significant independent HIV prevention potential. We observed one incident of seroconversion in a participant who terminated PEP medication after 16 days and reported numerous high-risk exposures subsequent to PEP treatment, corroborated by concomitant incident STIs. He seroconverted with a multidrug-resistant (MDR) strain of HIV; however, the genotypic resistance profile and the absence of baseline and week 46 viremia exonerate incomplete PEP treatment as the etiology of the resistance. He most likely acquired an MDR strain primarily. Rather than a failure of the PEP strategy, this seroconversion underscores the high risk of HIV seroconversion in the face of repeat exposures.20 It is notable that despite high rates of both prevalent and incident STIs among the participants (Table 2), the overall screen failure rate for prevalent HIV positivity (Fig. 1), and incident HIV infections were limited. A plausible explanation is that HIV and other STIs may largely circulate in different social and/or sexual networks in this population.51,52 Although we demonstrated a decrease in sexual risk behavior among study participants, the overall high rates of STIs in this sample suggest a persistently high

level of ongoing sexual risk behavior. These findings highlight the need for both regular STI testing and the importance of finding preventive synergies among interventions. The current study had several limitations. The single-arm design and absence of a control group prevented the attribution of salutary rates of PEP-related parameters to CM (contrast structured study participation). A small sample size and a 66% rate of PEP initiation limited the power to detect associations between intensity of methamphetamine use and PEP-related outcomes. The relatively brief follow-up period (3 months) additionally limited the ability to assess durability of the intervention on drug and sexual risk behaviors, as well as potentially underestimated the number of HIV seroconversions. Additionally, allowing participants to initiate PEP at study entry or at a delayed exposure time point during study conduct (including subsequent to the 8 week CM intervention) compromises the ability to directly implicate concomitant CM as the reason for salutary PEP use parameters; however, studies of CM for methamphetamine abstinence have noted sustained effects out to 1-year post CM-induction, therefore covering the period of even delayed PEP initiators. These pilot data demonstrate the feasibility, safety, and acceptability of HIV chemoprophylaxis in a sample of out-of-treatment, methamphetamine-using MSM, as demonstrated by exposure-to-dose times, adherence rates, and course completion rates comparable to non-methamphetamine-specific populations. With alarmingly high HIV prevalence and incidence rates among MSM methamphetamine users, the coupling of PEP with CM holds promise as a combination HIV prevention strategy. A randomized controlled trial of CM and a control behavioral condition for the facilitation of PEP use in stimulant users is currently enrolling participants.

Acknowledgments
This work was supported by the County of Los Angeles Department of Public Health, Office of AIDS Programs and Policy (contract number H-2702632 to Cathy J. Reback) and the National Institute of Drug Abuse at the National Institutes of Health (grant K23 DA 026308 to Raphael J. Landovitz).

Author Disclosure Statement

Raphael J. Landovitz reports being the site principal investigator for a Gilead Sciencessponsored research protocol. No significant conflicts of interest exist for the other authors.

Article information
AIDS Patient Care STDS. 2012 June; 26(6): 320328. doi: 10.1089/apc.2011.0432 PMCID: PMC3366332

Raphael J. Landovitz, M.D. M.Sc., 1 Jesse B. Fletcher, Ph.D.,2 Galina Inzhakova, M.P.H.,2 Jordan E. Lake, M.D.,1 Steven Shoptaw, Ph.D.,3 and Cathy J. Reback, Ph.D.2,,4 1 UCLA Center for Clinical AIDS Research & Education, David Geffen School of Medicine, University of California, Los Angeles, California. 2 Friends Research Institute, Inc., Los Angeles, California. 3 Department of Family Medicine, University of California, Los Angeles, California. 4 UCLA Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, California. Corresponding author. Address correspondence to: Raphael J. Landovitz, M.D., M.Sc., UCLA Center for Clinical AIDS Research & Education, 9911 W Pico Boulevard, Suite 980, Los Angeles, CA 90035. E-mail:Email: rlandovitz/at/mednet.ucla.edu These data have been presented in part at the National STD Prevention Conference, Atlanta, Georgia [March 2010; Abstract P156] and AIDS 2010, Vienna, Austria [July 2010; Abstract CDC0614]. Copyright 2012, Mary Ann Liebert, Inc. Articles from AIDS Patient Care and STDs are provided here courtesy of Mary Ann Liebert, Inc.

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The Psychiatric clinics of North America Author Manuscript NIH Public Access

Psychostimulant Treatment of Cocaine Dependence

John J. Mariani, M.D. and Frances R. Levin, M.D. Additional article information

Synopsis
Cocaine dependence continues to be a significant public health problem and no clearly effective pharmacotherapy has yet been identified. Substitution pharmacotherapy is an effective approach for treating opioid and nicotine dependence, and accumulating evidence indicates that stimulant pharmacotherapy for cocaine dependence is a promising strategy. Broadly, stimulant medications that produce behavioral arousal, and medications across several therapeutic classes can be considered psychostimulants. To date, the available evidence is strongest for amphetamine analogs or dopaminergic agents combined with contingency management behavioral interventions as potential psychostimulant treatments for cocaine dependence. Most psychostimulants are controlled substances with inherent risks of misuse and diversion, and their use in patients with active substance use disorders is complex. As stimulant substitution treatment models for cocaine dependence are developed, particular attention to patient risk stratification is needed. Keywords: Cocaine dependence, Psychostimulant, Substance abuse

Introduction
Cocaine dependence continues to be a substantial public health problem in the US, yet no clearly effective pharmacotherapy has been identified. There are approximately 1.6 million current users of cocaine in the US,[1] and the past-year prevalence of cocaine dependence is estimated to be 1.1%[2]. Controlled trials of behavioral treatments for cocaine dependence yield abstinence rates of up to 30%,[3] with the majority of patients continuing to use cocaine. Scores of double-blind, placebo-controlled pharmacotherapy clinical trials for cocaine dependence have been conducted, [46] testing agents drawn from a wide variety of medication classes. Stimulants have shown promise as a treatment for cocaine dependence despite resistance in the field to using controlled substances as therapeutic agents for addictive disorders.

Psychoactive drugs that cause addiction generally do so by increasing dopamine release within the nucleus accumbens.[7] Cocaine binds to the dopamine transporter and inhibits catecholamine reuptake,[8] directly increasing synaptic dopamine levels in the mesocortico-limbic system. The increased levels of dopamine in the synaptic cleft result in increased activation of type 1 and type 2 dopamine receptors. Although the behavioral effects of cocaine are attributed primarily to the blockade of dopamine reuptake, cocaine also blocks the reuptake of the other major monoamines neurotransmitters, norepinephrine and serotonin. Stimulant medications can be defined broadly as agents that produce behavioral arousal, typically acting, either directly or indirectly, through a sympathomimetic mechanism of action, stimulating alpha- and beta-adrenergic receptors or increasing dopamine and norepinephrine in the synaptic cleft. Stimulant medications available in the US for psychiatric treatment include amphetamine analogs, methamphetamine, methylphenidate, modafinil, and armodafinil. Other sympathomimetics that are available for short-term appetite suppression include benzphetamine, phentermine, diethylpropion, phenmetrazine, phendimetrazine, and mazindol. However, there are other medications, not usually classified as stimulants, that affect catecholamine reuptake and have some stimulant-like properties. Certain antidepressant medications, such as bupropion, which blocks the reuptake of dopamine and norepinephrine, have weak stimulant properties. Drugs such as levodopa increase dopamine release into the synaptic space in a manner similar to stimulant medications, but do not cause behavioral activation and for the purposes of this review will be discussed as dopamine agonists. As a class of medications, classical psychostimulants, including the amphetamines and methylphenidate, have a rapid onset of action, immediate behavioral effects, and the propensity to induce tolerance, all of which present a risk of misuse and dependence in vulnerable individuals, and have been classified as controlled drugs and their distribution and use are regulated by state and federal agencies. Substitution pharmacotherapy, which has been proven effective for opioid [9] and nicotine [10] dependence, is a plausible strategy for treating cocaine dependence. Conceptually, the goal of substitution pharmacotherapy is to replace a drug of abuse with rapid onset and a brief half-life with an agent that has a more gradual onset of action and long half-life, resulting in less intoxication and withdrawal, reducing the cycle of compulsive use. Successful examples of this approach include the use of methadone or buprenorphine for the treatment of opioid dependence and the use of transdermal nicotine or varenicline for nicotine dependence. Long-acting replacement medications reduce craving and potentially blunt the effects of the primary substance by either receptor blockade (buprenorphine or varenicline) or inducing high levels of physiological tolerance (methadone). Since cocaine is a short-acting psychostimulant with a rapid onset of action, a potential treatment strategy for cocaine dependence would be to substitute a longer-acting psychostimulant medication with a slower onset of action.

Neurobiology of stimulant treatment of cocaine dependence

The concept of reinforcement is central to understanding the mechanism of addiction. A reinforcer can be defined operationally as any event that increases the probability of a response. When a drug is said to have reinforcing effects, exposure to the drug makes it likely that the animal or human will work to be re-exposed to the drug. For most substances that have addictive potential, the mechanism of reinforcement is thought to be via dopamine release in the nucleus accumbens. The acute dosing of amphetamine has been associated with priming effects for rats previously trained to self-administer cocaine. Acute administration of dextroamphetamine into the basolateral amygdala, in combination with conditioned cue presentation, to rats trained to self-administer cocaine has been shown to potentiate reinstatement of cocaine-seeking behavior.[11] Amphetamine infusion in the absence of conditioned cues failed to reinstate the extinguished response. The facilitation of conditioned-cue reinstatement produced by amphetamine was apparent only during the initial half hour of the test session. These results suggest that while acute administration of amphetamine may potentiate cocaine reinforcement, more chronic exposure to amphetamine does not. Animal laboratory studies have demonstrated that sustained dextroamphetamine administration can attenuate the reinforcing effects of cocaine. Dextroamphetamine has been shown to produce dose-dependent reductions in cocaine self-administration in rats. [12] In monkeys, oral dextroamphetamine pretreatment decreased responding for a sweetened cocaine fluid.[13] Dextroamphetamine administered by slow intravenous infusion has been shown to decrease cocaine self-administration in rhesus monkeys in a dose-dependent manner, possibly by attenuating the reinforcing effects of cocaine.[14, 15] Further work with monkeys has suggested that continued treatment with dextroamphetamine may be necessary to produce a sustained reduction in the reinforcing effects of cocaine.[16] These preclinical data suggest that amphetamine administration must be of a sufficient dose and duration to affect cocaine reinforcement. Human laboratory experiments have evaluated the effects of stimulant administration on models of cocaine self-administration. Initial studies investigated the possibility that stimulant treatment of cocaine-dependent patients would worsen cocaine craving and use. In a combination clinical trial and human lab study, Grabowski et al.[17] found that methylphenidate did not prime patients to use cocaine. Methylphenidate has been shown to be safe and not associated with increased cocaine craving or stimulantrelated euphoria in the human lab.[18] Dextroamphetamine has been shown to be safe and well tolerated when co-administered with cocaine, and attenuates some of the subjective effects of cocaine.[19] Dextroamphetamine has also been shown to alter cocaine selfadministration, most likely by altering the reinforcing effects of cocaine.[20] These human laboratory experiments support to potential utility of stimulant treatment of cocaine dependence. In current medical practice, the most common clinical use of psychostimulant medication is to treat attention-deficit/hyperactivity disorder (ADHD). In patients with ADHD, stimulants have been shown to be preferred to placebo using a laboratory choice

procedure, although this preference is thought to be due to symptom relief rather than abuse potential.[21] In the human lab, methylphenidate administration has been shown to reduce cocaine self-administration in individuals with and without attention deficit/hyperactivity disorder (ADHD).[22] These results suggest that stimulant pharmacotherapy is a potential approach for treating co-occurring ADHD and cocaine dependence. Brain imaging studies of cocaine-dependent individuals have been used to examine the potential mechanism for psychostimulant pharmacotherapy of cocaine dependence. Functional MRI imaging has shown methylphenidate to be associated with robustly decreased stop signal reaction time, an index of improved control, in cocaine-dependent patients, a population in which inhibitory control is impaired.[23] Methylphenidate has also been shown using functional MRI imaging to increase responses to a salient cognitive task, and these improvements were correlated with attenuation of anterior cingulate cortex hypoactivation.[24] Using PET and 2-fluoro-D-glucose (FDG) to measure brain glucose metabolism as a marker of brain function, methylphenidate has been shown to attenuate brain reactivity to cocaine-cues.[25] Brain imaging using the PET raclopride displacement procedure has shown that deficient dopamine transmission is associated with failure to respond to behavioral treatment. [26]. Brain imaging of cocaine-dependent individuals receiving psychostimulants is at an early stage of development, but the initial results are quite promising in terms of both understanding the brain physiological deficits associated with cocaine dependence, as well as the potential therapeutic mechanisms of stimulant pharmacotherapy. If deficient dopamine transmission predicts poor response to behavioral interventions, then stimulant medication treatment could potentially reverse this deficit. The association of deficient dopamine signaling with poor response to behavioral treatment[26] in particular highlights the proposed mechanism by which stimulant medications may be effective for treating cocaine dependence. Intact dopamine signaling is required for response to naturally-occurring (e.g., social or work relationships) or therapeutically manipulated (e.g., vouchers) contingencies. In a dopamine deficient state, non-cocaine rewards are not as salient as the rewarding effects of cocaine. Stimulant medication may correct the deficits in dopaminergic signaling in cocaine-dependent individuals, and thereby enhancing dopamine release in response to environmental contingencies, thereby improving the salience of competing reinforcers to cocaine.

Stimulant pharmacotherapy for cocaine dependence

Double-blind placebo-controlled trials of stimulant medications for cocaine dependence are listed in table 1. The studies, arranged by therapeutic drug class, are discussed below.

Table 1 Psychostimulant and Dopaminergic Treatment of Cocaine Dependence: Double-Blind Placebo-Controlled Clinical Trials

Amphetamines
Amphetamines cause release of monoamines, in particular dopamine, and also blocks monoamine reuptake.[27] These actions are similar to cocaine (dopamine reuptake blockade), although the half-life of amphetamines, in particular long-acting formulations, [28] are much longer than cocaine. Dextroamphetamine has been evaluated in outpatient clinical trials for cocaine dependence. Grabowski et al.[29] evaluated dextroamphetamine in two escalating dosing schedules (15 to 30 mg daily and 30 to 60 mg daily) to placebo for the treatment of cocaine dependence in 128 outpatients. Retention was best for the 15 to 30 mg group and the proportion of positive urine toxicology samples was lowest for the 30 to 60 mg group, followed by the 15 to 30 mg group, and then the placebo group. Grabowski et al.[30] also compared dextroamphetamine in two different escalating dose regimens to placebo for the treatment of cocaine- and opioid-dependent patients (n=120) receiving methadone maintenance treatment. The higher dose group of dextroamphetamine (30 to 60 mg per day) was superior to both the lower dose group (15 to 30 mg per day) and placebo. Shearer et al.[31] evaluated dextroamphetamine for the treatment of cocaine dependence in a sample of 30 patients. No between group differences were detected, although the small sample size suggests lack of statistical power to do so. Participants in the active medication group experienced reductions in the proportion of cocaine positive urines, craving scores, and other measures of cocaine dependence severity, while those in the placebo group did not improve on these measures. Methamphetamine, an amphetamine analogue, with a similar mechanism of action to cocaine, has been studied for the treatment of cocaine dependence. Mooney et al. [32] reported that in 82 cocaine-dependent outpatients the sustained release preparation of methamphetamine was found to be associated with lower rates of cocaine-positive urine samples and greater reduction in craving than placebo, while the immediate-release formulation of methamphetamine was not superior to placebo for cocaine use outcomes. Despite these promising results, no other randomized placebo-controlled clinical trials have tested the use of methamphetamine for cocaine dependence. Mazindol, a sympathomimetic amine similar to amphetamine, is a catecholamine reuptake blocker, and was among the first stimulant medications studied for the treatment

of cocaine dependence. Margolin et al.[33] conducted a small double-blind placebocontrolled trial of mazindol in 37 opioid-dependent methadone maintenance patients with cocaine abuse and found no statistically significant difference between treatment groups. In a double-blind placebo-controlled trial, Stine et al.[34] also evaluated mazindol in 43 cocaine-dependent outpatients and found no difference between treatment groups. These trials for testing mazindol did not yield significant results. However, given the relatively small sample sizes, these results are not likely to be definitive. The results for dextroamphetamine and methamphetamine as potential treatments for cocaine dependence are promising, but there have been no large-scale, multi-site trials confirming the results. A possible explanation for the lack of confirmatory studies despite promising initial results is that the field is resistant to investigating a controlled substance as a treatment for cocaine dependence. Other agents, with less or no abuse potential, including modafinil (discussed below)[35, 36] and vigabatrin,[37] proceeded relatively quickly to multi-site trials based on the results of positive findings in single-site studies.

Dopamine Agonists
Medications that directly stimulate dopamine receptors or increase the levels of synaptic dopamine have a mechanism of action similar to stimulants, although they do not necessarily have the same activating effects on behavior. Mooney et al. [38] reported on two trials testing the combination of levodopa and carbidopa in 189 cocaine-dependent outpatients. Levodopa-carbidopa was well tolerated by cocaine-dependent patients, but did not improve cocaine use outcomes compared to placebo. These results contrast the use of levodopa when combined with contingency management (discussed below).

Methylphenidate
Methylphenidate is structurally related to the amphetamines, but differs in mechanism of action. The stimulant properties of methylphenidate are presumed to be mainly due to inhibition of dopamine reuptake by binding to the dopamine transporter, while the primary action of amphetamine is to cause dopamine release into the synaptic cleft, and secondarily block catecholamine reuptake.[39] Reuptake inhibition of norepinephrine by blockade for the norepinephrine transporter is presumed to be an important secondary mechanism of action of methylphenidate. The main clinical use of methylphenidate is, like for amphetamine, for the treatment of ADHD. Methylphenidate has been investigated as a treatment for cocaine dependence. In a human lab study, methylphenidate has been shown to be safe and well tolerated in doses up to 90 mg daily when co-administered with cocaine.[40] Grabowski et al.[17] compared methylphenidate to placebo for the treatment of cocaine dependence in 24 outpatients. Retention was equivalent between groups, with no significant differences in cocaine use outcomes, although statistical power was limited due to the small sample size. No significant adverse effects were reported. Larger, adequately powered studies examining the effect of methylphenidate on cocaine dependence have not been conducted.

Methylphenidate has also been studied as a treatment for cocaine dependence cooccurring with ADHD. Schubiner et al.[41] studied methylphenidate in comparison to placebo for the treatment of 48 cocaine-dependent attention-deficit/hyperactivity adults (ADHD) and found significantly greater ADHD symptom relief in the methylphenidate group, but no group differences in cocaine use outcomes. Levin et al.[42] evaluated methylphenidate in comparison to placebo for the treatment of co-occurring ADHD and cocaine dependence in 106 outpatients. There were no significant between group differences in ADHD symptom response or retention. While the primary cocaine use outcome measure was negative, a secondary analysis using logistic regression found that methylphenidate was associated with a lower probability of cocaine positive urine samples. Secondary analyses demonstrated that in the methylphenidate group, ADHD treatment responders, were more likely to have a reduction in cocaine use as compared to non-ADHD responders. These results suggest that methylphenidate has therapeutic effects on ADHD symptoms even in active cocaine users, and that ADHD symptom response may be important for improving cocaine use outcomes in patients with cooccurring ADHD and cocaine dependence.

Modafinil and Armodafinil

Modafinil is a psychostimulant medication unrelated to the structure of amphetamine, and has a differing profile of pharmacologic and behavioral effects.[43] Modafinil binds moderately to dopamine and norepinephrine transporters, increasing synaptic catecholamine levels. Elevations in other neurotransmitters appear to be secondary to changesin elevations in catecholamines. Modafinil has been studied for the treatment of cocaine dependence and has been found to be safe and well tolerated when co-administered with cocaine.[44] Dackis et al.[35] conducted a pilot study of 62 cocaine-dependent participants and found that modafinil was superior to placebo in achieving abstinence and was associated with significantly more cocaine-negative urine samples. However, the follow-up multi-site trial of 210 participants randomized to placebo, modafinil 200 mg/daily, or modafinil 400 mg daily, showed no advantage of modafinil on the primary outcome measure.[36] Secondary outcomes, including reduction of craving and the maximum number of consecutive nonuse days for cocaine, favored modafinil treatment, and a post hoc analysis showed a significant effect of modafinil on the weekly percentage of non-use days in the subgroup of cocaine-dependent patients who did not have a history of alcohol dependence. Based on these data, modafinil does not appear to be effective for treating cocaine-dependent patients with a history of alcohol dependence, but may be effective for cocaine-dependent patients without alcohol dependence. Future studies should exclude participants with alcohol dependence.

Stimulant Antidepressants
Bupropion is a novel antidepressant medication with a chemical structure dissimilar to existing antidepressant medications, but slightly similar to the endogenous monoamine neurotransmitters dopamine and norepinephrine. The presumed mechanism of action of

bupropion has evolved over time, and is now thought to be due to reuptake inhibition of dopamine and norepinephrine by blocking the respective transporters.[45] The clinical profile of bupropion is that of mild stimulating effects. Bupropion has been studied for the treatment of cocaine dependence. Margolin et al.[46] studied the bupropion for cocaine dependence in a multisite trial with 149 participants. No differences were observed between placebo and bupropion in cocaine use, depression, or psychosocial function. However, a secondary analysis showed that among the subset of participants (n=36) with baseline depression there was a significant decrease in the proportion of urine toxicology samples positive for cocaine in the bupropion group. Shoptaw et al.[47] compared bupropion to placebo in a double-blind trail of 70 cocainedependent outpatients and found no differences between treatment groups. Secondary analyses found no significant differences by treatment group when controlling for baseline depression scores. The results of these two large clinical trials suggest that bupropion is not an effective treatment for cocaine dependence. Selegiline is an irreversible selective inhibitor of monoamine oxidase type B (MAO-B). The inhibition of MAO-B increases the concentration of dopamine and other neurotransmitters, and is partially metabolized to l-methamphetamine and lamphetamine. However, selegiline does not have consistent behavioral activation properties and should not be classified as a stimulant. Elkashef et al.[48] studied the use of a transdermal patch delivery system of selegiline for the treatment of 300 cocainedependent outpatients in a multi-site double-blind placebo-controlled trial. No differences between selegiline and placebo were detected, suggesting that selegiline is not likely to have a role for treating cocaine dependence.

Dopaminergic augmentation of contingency management

Dopaminergic medications have been tested in combination with contingency management behavioral interventions (see table 2). The theoretical framework for this approach is that cocaine dependent individuals have difficulty responding to non-cocaine rewards, and that dopaminergic medications may normalize dopamine signaling and thereby increase the saliency of rewards offered as part of a behavioral treatment. In a clinical trial comparing levodopa-carbidopa to placebo combined with clinical management, cognitive behavioral therapy or voucher-based reinforcement therapy, levodopa combined with vouchers was associated with higher rates of abstinence and higher proportions of cocaine-free urines.[49] Levodopa-carbidopa was also evaluated in combination with three different contingency management (CM) targets (urine, medication, or attendance) and the combination of levodopa with CM-urine was associated with superior cocaine use outcomes, an effect moderated by medication compliance.[50] In a population of cocaine- and opioid-dependent methadone maintenance patients, bupropion was compared to placebo in combination with either CM or a voucher control condition, and the combination of CM with bupropion was associated with improved cocaine use outcomes as compared to bupropion alone.[51]

Table 2 Dopaminergic Augmentation of Contingency Management Treatment of Cocaine Dependence: Double-Blind Placebo-Controlled Trials However, studies of antidepressant medications that block reuptake of monoamines other than dopamine have also yielded positive results as augmenters of contingency management for cocaine dependence, including citalopram[52] and desipramine.[53] These results suggest that blocking the reuptake of monoamines in general may be responsible for the mechanism of augmentation of contingency management, and not limited to dopaminergic effects per se. Further research is needed to elucidate the mechanism of the observed monoamine augmentation of contingency management treatment of cocaine dependence. The strategy of augmenting contingency management interventions with drugs that enhance dopaminergic transmission is consistent with the hypothesis that cocainedependent individuals have deficient dopaminergic tone and that competing rewards to cocaine are less salient. A logical step in the development of this research would be to study more potent dopaminergic medications, such as amphetamines and methylphenidate, as augmenters of behavioral treatment.

Co-occurring ADHD and Cocaine Dependence

ADHD and cocaine dependence commonly occur. In clinical populations, the prevalence of ADHD in substance use disorder treatment settings ranges up to 24%.[54, 55] In the general population, the prevalence of adult ADHD is 4.4%, while in individuals with a substance use disorder, ADHD co-occurs at a rate of 10.8%.[56] These data indicate that co-occurring ADHD and cocaine dependence will be routinely encountered in clinical settings. Amphetamines[57] and methylphenidate[58] are effective treatments for treating adult ADHD. Since ADHD treatment is the main current clinical use of psychostimulant medications, concerns have been raised about the potential interaction between cocaine and psychostimulants. Stimulant therapy of ADHD in childhood is associated with a reduction in the risk for subsequent drug and alcohol use disorders.[59] However, psychostimulants increase extracellular dopamine in the brain, which is associated with both therapeutic and reinforcing effects. Volkow and Swanson,[60] identified four variables that affected the therapeutic and reinforcing effects of methylphenidate, which included:

1. 2. 3. 4.

dose pharmacokinetics individual differences in sensitivity to methylphenidate context

Large doses that penetrate the blood brain barrier rapidly are associated with greater reinforcing effects, leading to the recommendation that the lowest possible dose that relieves symptoms be used, and that sustained-release preparations are preferred for individuals with a predisposition to addiction.

Addictive Potential of Psychostimulants

Stimulant medications have the potential for misuse, diversion, and addiction.[6163] Methylphenidate and dextroamphetamine have been shown to have reinforcing effects in individuals without histories of substance use disorders[64] and individuals with stimulant abuse histories.[65] The rate of onset of a drugs effect is an important determinant of its abuse potential. In a controlled laboratory evaluation, Kollins et al.,[66] found that the sustained-release formulation of methylphenidate was associated with less ratings of good effects as compared to the immediate-release formulation. These findings suggest that the abuse potential of the immediate release preparation may be greater than the sustained release preparation.

Precautions in Prescribing Stimulant Medications

Misuse, diversion, and addiction are inherent risks of prescribing controlled substances, and a substantial minority of patients prescribed stimulants will divert their medications to others or misuse their own prescription.[61] An assessment of risk in a specific patient has to be determined at a specific point in time. All patients prescribed controlled substances should be assessed at each visit for signs of misuse, abuse, or addiction. Evaluations should be conducted using matter-of-fact and non-threatening questioning. Red Flags for Diversion or Misue Symptoms of intoxication or withdrawal Demands for a particular, usually fast acting, medication (amphetamine IR) Extended-release doesnt work for me Repeated lost prescriptions Discordant pill count Excessive preoccupation with securing medication supply Multiple prescribers New development of cardiac symptoms

New onset psychosis

There are a number of strategies that can be employed to minimize the risks presented when prescribing controlled substances psychostimulant treatment to patients with

cocaine dependence. All patients with substance use disorders who are prescribed controlled substances should be advised of the risk of combining prescription medication with other substances. Patients should be warned about diversion and abuse liability of prescription stimulant medications. Delayed release preparations are in general preferred over immediate release preparations for behavioral safety. Prescription of small quantities of medication at a time, with pill count reconciled at each visit. Urine toxicology and breath alcohol testing can be useful in assessing patients overall clinical status. State prescribing databases can be consulted to check for multiple prescribers. Frequent patient visits may help detect problems or a change in clinical status sooner. In general, it should be emphasized to patients to take medications regularly, not on an as needed basis, creating a structure of consistency and predictability around stimulant medication taking. Discussions with patients regarding safe storage and not advertising/sharing medications with others should occur regularly.

Conclusions
The use of stimulant medications for the treatment of cocaine dependence is an evolving scientific literature. To date, the most promising results are with the higher potency medications, the amphetamine analogues, or a combination of a dopaminergic medication with a contingency management behavioral intervention. The development of effective pharmacotherapies for opioid and nicotine dependence using an agonist replacement approach suggests that these promising findings need to continue to be vigorously investigated. In clinical trial reports there are very few instances of cardiovascular adverse events, which suggest that for well-selected patients with cocaine dependence, stimulant replacement therapy can be safe. However, clinical trial eligibility criteria excludes most high-risk patients from participating, and introducing stimulant substitution to the wider treatment community would likely expose more vulnerable patients to the medical risks associated with stimulant treatment while using cocaine. As treatment development research moves forward, attention must be paid to helping clinicians select patients who are most likely to benefit from stimulant substitution treatment, and how to identify those at risk. An additional concern with the use of stimulant medication treatment of cocaine dependence is prescribing controlled substances for patients with active substance use disorders. Again, within a clinical trial, medication supplies are carefully monitored and distributed in small quantities. In a community setting, misuse or diversion will be risks associated with prescribing controlled substances to patients with addictive disorders, but therapeutic strategies for monitoring and limiting that risk can be implemented. In summary, psychostimulant pharmacotherapy is a promising line of research for the treatment of cocaine dependence, a condition for which no effective pharmacotherapy has been identified. Further research is required to confirm positive results from single-site trials, in particular the study of amphetamines as a treatment for cocaine dependence. As this literature evolves, strategies to manage the risk of prescribing controlled substances

to patients with addictive disorders need to be tested and refined. Biases against using controlled substances as a treatment for cocaine dependence should be challenged, much in the way the use of agonist treatment transformed the treatment of opioid dependence despite initial resistance from the field.

Key Points
A reinforcer, in terms of mechanisms of addiction, can be defined operationally as any event that increases the probability of a response; psychostimulants increase extracellular dopamine in the brain, which is associated with both therapeutic and reinforcing effects In current medical practice, the most common clinical use of psychostimulant medication is to treat attention-deficit/hyperactivity disorder (ADHD). ADHD co-occurs in individuals with a substance use disorder at a rate of 10.8% Misuse, diversion, and addiction are inherent risks of prescribing controlled substances; all patients prescribed controlled substances should be assessed at each visit for signs of misuse, abuse, or addiction.

Footnotes
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Article information
Psychiatr Clin North Am. Author manuscript; available in PMC 2013 June 1. Published in final edited form as: Psychiatr Clin North Am. 2012 June; 35(2): 425439. Published online 2012 April 26. doi: 10.1016/j.psc.2012.03.012 PMCID: PMC3417072 NIHMSID: NIHMS364281 John J. Mariani, M.D.1,2 and Frances R. Levin, M.D.1,2 1 New York State Psychiatric Institute, Division of Substance Abuse, 1051 Riverside Drive, New York, NY 10032, USA 2 Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 630 West 168th Street, New York, NY 10032, USA

Address correspondence to: John J. Mariani, M.D., 1051 Riverside Drive, Unit 66, New York, New York 10032, U.S.A., Telephone: (212) 543-5987 FAX: (212) 543-6018, Email: jm2330/at/columbia.edu Copyright notice and Disclaimer Publisher's Disclaimer The publisher's final edited version of this article is available at Psychiatr Clin North Am

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Drug and alcohol dependence Author Manuscript NIH Public Access

A Retrospective Analysis of Two Randomized Trials of Bupropion for Methamphetamine Dependence: Suggested Guidelines for Treatment Discontinuation/Augmentation
Matthew Brensilver, Keith G. Heinzerling, [...], and Steven J. Shoptaw Additional article information

Abstract
Background
Two clinical trials have shown efficacy for bupropion in treating methamphetamine (MA) dependence among those with moderate baseline MA use. However, treatment response is highly variable and it is unclear what duration of treatment is necessary to determine if maintaining the treatment course is indicated or if discontinuation or augmentation is appropriate. The present study assessed the relationship among early

bupropion treatment response for moderate MA users and end-of-treatment (EOT) abstinence. These data provide estimates of the duration of treatment and the degree of responsiveness required to persist in bupropion treatment.

Methods
Participants with moderate baseline MA use in the bupropion condition of two randomized double-blind placebo controlled trials were included. The relationship between early treatment response and EOT outcomes was assessed with Receiver Operating Characteristic (ROC) curves.

Results
With thrice weekly urine drug testing, excellent predictive power was established in the first two weeks of treatment. The inability to achieve at least three MA negative samples in the first two weeks is associated with greater than 90% likelihood of treatment failure. More closely approximating clinical settings, once-weekly testing featured reliable predictive power within three weeks, suggesting that the failure to produce at least two clean samples in the first three weekly visits confers high risk of treatment failure.

Discussion
The findings provide preliminary evidence to guide clinical decisions for moderate MA users receiving bupropion. The results are consistent with data from the smoking cessation literature and may highlight the importance of early response in addiction treatment. Keywords: methamphetamine dependence, abstinence, early response, bupropion, treatment switching

1. Introduction
Clinical response to pharmacotherapy for methamphetamine (MA) dependence is highly variable and no single medication has evidenced clear efficacy. Although not broadly efficacious for increasing the proportion of MA dependent participants achieving abstinence, bupropion has outperformed placebo among subgroups of MA users. Bupropion is approved as a treatment for depression, seasonal affective disorder and smoking cessation. It has several effects on the dopaminergic system that are relevant to the pathophysiology of addiction (Dwoskin et al., 2006; Rau et al., 2005). Two randomized placebo-controlled clinical trials have found that bupropion (300 mg/day), in conjunction with behavioral treatment, outperforms placebo in terms of MA-abstinence among those with more modest use during the weeks preceding treatment initiation (Elkashef et al., 2008; Shoptaw et al., 2008). A re-analysis of the Elkashef et al. (2008) trial using a nonbinary assessment of abstinence found beneficial effects for bupropion across the entire sample (McCann and Li, 2012). Despite preliminary evidence of

efficacy at least in the subgroup of moderate users, treatment response is variable with the majority failing to achieve end-of-trial (EOT) abstinence. A critical question for a clinician treating individuals with MA dependence is the duration of treatment necessary to determine if maintaining the treatment course is indicated or if discontinuation, adding an adjunctive treatment modality or recommending inpatient treatment is appropriate (Murphy et al., 2007). Quickly identifying likely treatment failures is valuable in improving clinical outcomes. Additionally, discontinuation of an ineffective medication may militate against disenchantment with treatment in general while conserving resources and minimizing needless medication exposure. Data for methamphetamine treatment is lacking but a substantial body of relevant research exists. Findings in clinical trials for smoking cessation and cocaine dependence are instructive. In her seminal paper, Kenford et al. (1994) found that pre-treatment variables generally failed to predict EOT and 6-month post-treatment smoking abstinence. However, abstinence in the second week of nicotine replacement therapy was strongly predictive of outcomes at 6 months, with two studies finding odds ratios between 4 and 24. Interestingly, few pretreatment variables were associated with early treatment abstinence and were only weakly predictive, suggesting that some unique information is captured by early treatment response. Plebani et al. (2009) assessed the predictive value of early abstinence for 407 cocaine dependent patients who received either putative medications or placebo. No medication effects were observed and analyses collapsed the medication and placebo groups. Abstinence during the first two weeks of treatment was related to EOT abstinence and to the proportion of cocaine-negative samples. The reader is directed to their paper for a fuller explanation of the relation between early and later abstinence in treatment for stimulant dependence. While clinical experience suggests that early response is critical for methamphetamine treatment success, research has not addressed this question. The present study assesses the relationship among early bupropion treatment response among moderate users and EOT abstinence. This group was selected as there is preliminary evidence for the efficacy of bupropion with this subgroup and clinicians may rely on this medication in treatment settings. We examine the hypothesis that the first two weeks of treatment will provide adequate basis to predict likely treatment failures. While it is expected that some establishing early abstinence will relapse, we hypothesize that early response is critical for EOT abstinence.

2. Methods
2.1 Design
The data analyzed here are from two randomized, double-blind, placebo-controlled trials of bupropion. Participants received 150 mg of bupropion sustained release for the first three days and 300 mg (150 mg twice daily) thereafter. Methodological details are provided in the original reports (Elkashef et al., 2008; Shoptaw et al., 2008). Participants had current MA dependence verified by the Structured Clinical Interview for DSM-IV and featured no current dependence on other drugs of abuse. Individuals with serious

medical or psychiatric disorders were excluded. A two-week non-treatment screening period was followed by 12 weeks of active treatment. All participants received cognitive behavioral therapy (CBT). Urine samples were collected thrice weekly and analyzed using radioimmunoassay. Some methodological differences existed between the trials. Shoptaw et al. (2008) provided weekly CBT and abstinence-based contingency management with a maximum earning potential of $537. Elkashef et al. (2008) provided thrice weekly CBT and attendance-based contingency management with a maximum earning potential of $530. Elkashef et al. (2008) verified positive radioimmunoassay results with gas chromatography/mass spectrometry and considered a sample negative if the assay was less than 300ng/ml and Shoptaw et al. (2008) relied on the qualitative radioimmunoassay results. All research activities were approved by the respective Institutional Review Boards. The current report selected moderate users as defined in the original reports (fewer than 19 self-reported days of MA use in the month before study initiation) who were receiving bupropion (N=55). The 55 participants included in the present analyses represent 48% of the combined sample who received bupropion.

2.2 Data Analysis

EOT abstinence was defined as no positive MA samples in the final two weeks of treatment with only one missing sample permitted per week. Participants with a single MA positive sample or missing more than one sample per week were considered persistent users. ROC analysis determined the extent of drug use in the first two weeks of treatment that optimally predicted persistent drug use at EOT. In determining early treatment response, missing samples were considered positive. Thus, the number of MA positive urine drug samples served as the classification variable with the failure to achieve EOT abstinence as the reference variable. Two additional ROC analyses assessed the predictive accuracy of one week and three weeks of MA testing for EOT outcomes. The area under the curve (AUC) between the three ROC curves was compared to determine the extent to which predictive power increases with each additional week of data (DeLong et al., 1988). Hosmer and Lemeshow (2000) have offered the following guidelines for interpreting AUC: .70.80 is acceptable discrimination, .80.90 is excellent and AUCs in excess of .90 are outstanding. As clinical care often utilizes weekly assessments rather than the thrice-weekly assessments featured in these clinical trials, the predictive power of a single screening in each of the first three weeks was also assessed. Summary statistics including AUC, sensitivity, specificity and positive and negative predictive values characterized different dimensions of predictive validity. Analyses were conducted with Stata (StataCorp LP, College Station, TX).

3. Results
3.1 Baseline Demographics and Drug Use
Participants (N=55) had a mean age of 36.5 (SD=10.6), 25% were female, averaged 12.8 years of education and were predominantly Caucasian (62%), Hispanic (18%) and Asian (11%). The mean number of days of MA use in the month preceding study screening was 8 (SD=6). Twenty-eight participants (51%) submitted at least one sample in the final

week of treatment. Fourteen patients (26%) achieved abstinence in the final two weeks of treatment. All 55 participants are included in the analyses.

3.2 ROC Analyses with Thrice Weekly Urine Drug Samples

We identified empirically-derived standards for predicting EOT outcomes by estimating the number of positive MA samples that would optimally predict persistent EOT MA use. A ROC analysis using the number of MA positive samples in the first two weeks of treatment estimated the predictive power of early treatment response on EOT status. Table 1 displays the predictive accuracy of early response for EOT outcomes. Using the Youden (1950) index, three MA positive samples within the first two weeks of treatment optimally predicted persistent EOT MA use. As there were six samples during this period, this result suggests that the inability to achieve at least three MA negative samples is associated with greater than 90% likelihood of treatment failure.

Table 1 Predictive power of thrice weekly urine drug screens during first two weeks of treatment for persistent MA use at EOT* As we were interested in determining the optimal timing for decisions regarding switching treatment modality or intensity, ROC analyses assessed the comparative predictive power of one, two and three weeks of urine drug testing. If an additional week of testing data does not add substantially to the prediction of EOT outcomes, treatment switching decisions could be made earlier, thereby improving retention and clinical outcomes. The AUC reflects the probability that a randomly selected MA user at EOT will have more MA positive samples during the test period than a randomly selected participant who obtained EOT abstinence. For week 1 (three samples), week 2 (six samples) and week 3 (nine samples), the AUCs were .723 (95% CI=.569.867), .801 (95% CI=.675.926), and .808 (95% CI=.689.928), respectively, all of which are significantly better than a non-informative variable which has an AUC of 0.5. In pairwise comparisons of these three AUCs, data from the first two weeks outperformed data from only the first week of testing. However, the third week of testing did not add significantly to the predictive power of week 2 data for predicting EOT outcomes. Of note, by week 2, the AUC had reached the threshold traditionally considered excellent. Results using a parametric model were consistent with results from the traditional empirical approach. In order to assess if study moderated the outcome, we fit a ROC model with study as a covariate. Results suggested this was not the case, and a pairwise test of the AUCs from the two studies revealed no difference (Elkashef AUC=.850; Shoptaw AUC=.823). Additionally, the ROC curve for the placebo group was compared with the ROC curve

for the bupropion group. Results indicated very similar characteristics for the two groups, highlighting the general importance of early responsiveness for EOT outcomes.

3.3 ROC Analyses with Once Weekly Urine Drug Samples

Next, the predictive power of only the first sample of each week was examined a standard more closely approximating many clinical settings. For week 1, week 2 and week 3, the AUCs were .673 (95% CI=.537.809), .696 (95% CI=.533.859), and .775 (95% CI=.655.896), respectively. Three weeks of testing data outperformed one week (p<.05), and was marginally more precise in predicting EOT outcomes than two weeks of testing data (p=.06). Analyses suggested that the failure to produce two clean samples in the first three weekly visits confers high risk of treatment failure (positive predictive value=88%). The ability to predict treatment successes was substantially less precise. Having all negative samples in the first three weeks was associated with a negative predictive value of 51 percent. Analyses with the first two weekly visits suggested that failure to produce at least one clean urine also represented high risk of treatment failure (positive predictive value=85%). Six weeks of weekly samples did not improve the prediction of EOT outcomes beyond three weeks of samples.

4. Discussion
This research provides preliminary guidance for treatment discontinuation or augmentation for moderate users of methamphetamine treated with bupropion. Early treatment responsiveness appears important for EOT outcomes among a subgroup of MA dependent individuals in whom the medication has demonstrated preliminary efficacy. This finding is consistent with findings from cigarette smoking (Kenford et al., 1994) and represents a novel finding within the MA literature. These data suggest that clinicians prescribing bupropion can confidently predict treatment failures within two weeks when doing thrice weekly drug testing. Weekly testing yields acceptable predictive power within three weeks. Notably, the ability to predict treatment failure was substantially more precise than the prediction of treatment successes, a fact partially reflecting the overall treatment failure rate. The absence of an early response better predicts treatment failure than the presence of an early response predicts treatment success. Clinically, the prediction of treatment failures is relevant and signals the need for a change in modality or intensity. Unfortunately, treatment options are limited but more intensive behavioral intervention, pharmacologic treatment of comorbid psychiatric symptoms or inpatient treatment might be indicated. The present study found that early responsiveness in the placebo treated participants was equally important as early response in bupropion treated participants. Early treatment responsiveness appears to be an important variable in cocaine treatment as well (Plebani et al., 2009). These results may signal the general importance of early response in addiction treatment. These findings should be interpreted in light of the study limitations. Analyses combined data from two trials which used a very similar but not identical study design. Sample size was limited to 55. In the Shoptaw et al. (2008) study, bupropion outperformed placebo among those with moderate use during the screening period rather than those with

moderate self-reported use in the past 30 days. The definition of EOT abstinence is a measure of both retention and MA abstinence as attriters are considered non-abstinent. Consequently, the association between achieving early MA abstinence and EOT success are likely influenced in part by retention effects. Despite the aforementioned limitations, the study provides preliminary guidance for determining treatment discontinuation or augmentation with one of the very few medications to show signs of efficacy in methamphetamine dependence.

Table 2 Predictive Power of Three Weeks of Once Weekly Screening Data for persistent MA use at EOT*

Acknowledgements
The authors gratefully acknowledge NIDA's permission to use data from the Elkashef et al. (2008) clinical trial and thank the investigators who conducted the trial. Role of funding source Funding for this study was provided by NIDA Grants P50 DA18185, T32 DA026400, N01-DA8804 and N01-DA8824; NIDA had no further role in study design, in the collection, analysis and interpretation of data, in the writing of the report or in the decision to submit the paper for publication.

Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Conflicts of Interest All authors declare no conflicts of interest. Contributors Dr. Brensilver conceptualized the analysis, wrote the first draft of the manuscript and performed statistical analyses. Drs. Heinzerling and Swanson supervised all clinical and research activities of the Shoptaw (2008) trial. Drs. Shoptaw, Heinzerling and Swanson designed the Shoptaw (2008) trial. Drs. Heinzerling and Shoptaw edited the manuscript. All authors approved the final manuscript.

Article information
Drug Alcohol Depend. Author manuscript; available in PMC 2013 September 1. Published in final edited form as: Drug Alcohol Depend. 2012 September 1; 125(1-2): 169172. Published online 2012 April 23. doi: 10.1016/j.drugalcdep.2012.03.027 PMCID: PMC3418457 NIHMSID: NIHMS372524 Matthew Brensilver, Keith G. Heinzerling, Aimee-Noelle Swanson, and Steven J. Shoptaw Department of Family Medicine, David Geffen School of Medicine at UCLA, CA, 90095 Corresponding author: Matthew Brensilver, 10880 Wilshire Blvd, Suite 1800, Los Angeles, CA, USA. Phone: (310) 794-0619; Email: mbrensilver/at/mednet.ucla.edu; Fax: (310) 794 2808 Copyright notice and Disclaimer Publisher's Disclaimer The publisher's final edited version of this article is available at Drug Alcohol Depend See other articles in PMC that cite the published article.

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Addiction (Abingdon, England) Author Manuscript NIH Public Access This article has been corrected. See the correction in volume 107 on page 1718.

Topiramate for the treatment of methamphetamine addiction: a multicenter placebo-controlled trial

Ahmed Elkashef, M.D., Roberta Kahn, M.D., [...], and Bankole A. Johnson, D.Sc., M.D., Ph.D. Additional article information

Abstract
Aims
Topiramate has shown efficacy at facilitating abstinence from alcohol and cocaine abuse. This double-blind, placebo-controlled outpatient trial tested topiramate for treating methamphetamine addiction.

Design
Participants (N=140) were randomized to receive topiramate or placebo (13 weeks) in escalating doses from 50 mg/day to the target maintenance of 200 mg/day in weeks 612 (tapered in week 13). Medication was combined with weekly brief behavioral compliance enhancement treatment.

Setting
The trial was conducted at eight medical centers in the United States.

Participants
One hundred forty methamphetamine-dependent adults took part in the trial.

Measurements
The primary outcome was abstinence from methamphetamine during weeks 6 12. Secondary outcomes included use reduction versus baseline, as well as psychosocial variables.

Findings
In the intent-to-treat analysis, topiramate did not increase abstinence from methamphetamine during weeks 612. For secondary outcomes, topiramate reduced weekly median urine methamphetamine levels and observer-rated severity of dependence scores significantly. Subjects with negative urine before randomization (N=26) had significantly greater abstinence on topiramate versus placebo during study weeks 612. Topiramate was safe and well tolerated.

Conclusions
Topiramate does not appear to promote abstinence in methamphetamine users but can reduce the amount taken and reduce relapse rates in those who are already abstinent. Keywords: topiramate, methamphetamine abuse, abstinence facilitation, treatment

Introduction
After a positive finding in a proof-of-concept study of topiramate in alcoholics [1] and a successful multi-site, placebo-controlled, randomized trial of topiramate for alcohol dependence [2], topiramate was considered an appropriate candidate for treating stimulant abuse. In a placebo-controlled pilot study, topiramate was effective at reducing cocaine use after the full dose of topiramate was achieved in week 8 [3]. Two potential mechanisms of action are relevant to the treatment of stimulant abuse. Topiramate facilitates GABAergic function through a non-benzodiazepine site on the gamma-aminobutyric acid-A (GABAA) receptor, depressing cortico-mesolimbic dopaminergic activity. Pharmacologically increasing GABA concentration has been shown to block cocaine self-administration in an animal model [4]. Topiramate also antagonizes glutaminergic activity through an effect at kainate/alpha-amino-3-hydroxy-5methylisoxazole-4-propionic acid receptors [5]. Experimentally, blocking glutamate

through the kainate receptor reduced reinstatement of drug-seeking behavior [6]. Anticonvulsants with GABAergic properties have been shown to treat craving for alcohol [1], nicotine [7], and cocaine [3], and eating disorders [8]. The potential of topiramate for facilitating abstinence from methamphetamine is less clear. A study in rats of conditioned place preference for methamphetamine demonstrated no topiramate effect [9], but other models of drug-seeking behavior have not been tested. In a clinical case, however, topiramate treatment aided successfully the abstinence of a 3,4-methylenedioxymethamphetamine abuser and blocked his euphoria [10]. The need to expand upon previous clinical trials and findings on topiramates mechanisms of action led us to conduct a multi-site clinical trial investigating topiramates potential to facilitate abstinence from methamphetamine.

Methods
This study was a placebo-controlled randomized trial of daily oral topiramate in methamphetamine-dependent adults. Under an inter-agency agreement between the National Institute on Drug Abuse and the Veterans Affairs (VA) Cooperative Studies Program, eight medical centers participated: University of Virginia (Charlottesville), UCLA (Los Angeles), START Research and Treatment (Kansas City), University of Hawaii (Honolulu), South Bay Treatment Center (San Diego), Iowa Lutheran Hospital (Des Moines), Matrix Institute (West Los Angeles), and Salt Lake City Health Care System, Department of Veterans Affairs (Salt Lake City). The sites Institutional Review Boards and the VA Human Rights Committee approved the protocol and conduct of the study. The principal investigator was Prof. Bankole Johnson.

Study Design
One hundred forty Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) [11]diagnosed methamphetamine-dependent individuals 18 years of age were randomized into two treatment groups: topiramate (N=69) and placebo (N=71). After providing written informed consent, they were screened for up to 14 days, and if meeting the eligibility criteria, they began 14 days of baseline assessment. Exclusion criteria included serious medical illness, psychiatric conditions requiring ongoing medication, pregnancy or lactation, nephrolithiasis or renal impairment, and court-mandated drug abuse treatment. Screening and baseline assessments were completed during the 28 days before randomization. Subjects had to provide 1 methamphetamine-positive urine specimen (>500 ng/ml) during screening and 4 urine specimens during completion of other baseline assessments. All candidates had a Structured Clinical Interview for Axis I disorders according to DSM-IV criteria [12], Montgomery-Asberg Depression Rating Scale assessment [13], physical examination, 12-lead electrocardiogram, electrolytes and liver enzymes, complete blood count, urinalysis, urine pregnancy test of female subjects, and tuberculin (purified protein derivative) skin test or chest X-ray completed during screening.

Study medication was randomized in a 1:1 ratio of daily oral topiramate or matched placebo. Adaptive randomization was balanced on investigational site and positive or negative methamphetamine use within 7 days before randomization, according to selfreport and/or urine sample. Once during screening and once per week during the treatment phase, all subjects received brief behavioral compliance enhancement treatment (BBCET), a manual-driven, low-intensity supportive program to promote compliance with the study medication and continuation in the study. BBCETs use was based on compliance with treatment in alcoholics, where historical comparison to more cognitive-intensive behavioral therapy suggested comparable efficacy [14]. Treatment was conducted over 13 weeks. Commercially available topiramate (Topamax; Ortho-McNeil Neurologics, Titusville, NJ) and matched placebo were film-coated and distributed from a central pharmacy (VA Cooperative Studies Program, Albuquerque, NM). At randomization, oral topiramate or placebo was initiated at 25 mg/day and escalated over the first 35 days of the study until 200 mg/day or the subjects maximum tolerated dose was achieved. Over weeks 612, this dose was maintained. However, if a subject was intolerant of side effects, the investigator could reduce the daily dose once during maintenance, to the highest previously tolerated dose. The subject had to take 50 mg/day to remain in the study. Over the last week of treatment (week 13), the dose was tapered to 100 mg/day for 3 days, 50 mg/day for 2 days, and then 25 mg/day for 2 days. Medication compliance was measured by pill count. A final follow-up assessment was conducted approximately 28 days after treatment completion. Prior and concomitant medication use, self-report of substances used, and a urine drug screen for substances of abuse were assessed during screening, baseline, and treatment. Urine samples were screened for methamphetamine and amphetamines in a central laboratory by radioimmunoassay with a minimal sensitivity of 300 ng/ml. Positive samples were assayed by gas chromatography/mass spectrometry with a methamphetamine quantification of 78 ng/ml.

Data Analysis
The primary outcome assessment was negative methamphetamine use weeks during study weeks 612. Urine samples were collected from subjects three times per week. Methamphetamine use was based on the qualitative urine screen performed at a central laboratory for methamphetamine and amphetamines. Use week was defined as each 7day period starting with the first day of topiramate administration. A positive use week was any week in which 1 qualitative urine drug screen for methamphetamine was positive. A negative use week was any week in which all qualitative urine drug screens for methamphetamine were negative, even if only 1 or 2 urine samples were collected and tested. If and only if no drug screening results were available, the data for that week were considered missing.

A generalized estimating equations (GEE) model was used to analyze the primary outcome for study weeks 612. The GEE model included methamphetamine use week as the dependent variable (1=use week, 0=non-use week), treatment group, study week as the time variable, and the first-order interaction term between treatment and study week. Per the protocol, secondary analyses of use reduction were conducted on the intent-totreat population, including measures of weekly methamphetamine use by urine assays or self-report, abstinence for 21 days anytime during the treatment period, relapse rate for subjects with negative urine at randomization, overall methamphetamine use reduction during treatment compared with each individuals historical self-report during screening, and quantitative reductions in amount of methamphetamine measured in weekly urine samples. GEE models, Fishers exact tests, and Cox proportional hazards models were used, where appropriate, for the secondary analyses. For each variable, the GEE model was the same as that applied for the primary outcome variable. Psychological effects of treatment were assessed using the Clinical Global Impression Scale-Observer and -Self (CGI-O and CGI-S), Brief Substance Craving Scale (BSCS), and Addiction Severity Index-Lite (ASI-Lite). Study retention from randomization to last study visit was compared between groups by log-rank test. Exploratory analyses were conducted to examine the influence of alcohol dependence, severity of methamphetamine use at entry, and dose of medication achieved.

Results
Subjects
Of 338 subjects screened, 193 were ineligible. Major reasons for exclusion included inability to comply with study requirements, failure to provide one positive urine sample during the screening period, failure to provide four urine samples for testing during the baseline period, dependence on other psychoactive substances besides methamphetamine, nicotine, or marijuana, significant psychiatric history or other medical problems, and failure to return to complete screening assessments. Five of the 145 eligible subjects declined to participate, leaving 140 who were randomized equally between treatment groups (Figure 1).

Figure 1 Trial flow diagram. The two groups were well matched demographically (Table 1). The topiramate group had a slightly higher number of women, but the difference from the placebo group was not

statistically significant. No statistically significant difference existed between treatment groups in mean number of days of methamphetamine use during the 30 days before informed consent21.28.98 (meanSD) days and 21.47.84 days for topiramate and placebo, respectively.

Table 1 Demographics of randomized subjects.

Study Retention
Seventy-seven of 140 randomized subjects completed 12 weeks and had 1 visit in week 13 (Figure 2). Of these, 39 were topiramate recipients and 38 received placebo. Attrition among placebo recipients was greater until around week 4, after which dropout among topiramate recipients was greater, causing retention in both groups to be similar by the end of the study. At week 6, retention was 70%; this decreased weekly to 55% by week 12. The most common reason for dropout was failure to return to the clinic (19 topiramate, 18 placebo). Two subjects in each group dropped out because of reported side effects or toxicity related to study medication. Differences between groups in total dropout rate were not statistically significant (log-rank p-value=0.72).

Figure 2 Study retention for the topiramate and placebo groups.

Compliance
Medication compliance rate was the total dose (mg) dispensed minus total dose returned divided by recommended dose, multiplied by 100. Mean compliance rate was 69.8% 40.8 for topiramate and 67.4%43.2 for placebo, with no significant difference between groups.

Outcomes
Figure 3 represents the primary outcome variable, percentage of subjects with a negative methamphetamine use week during study weeks 612 by treatment group. The GEE model used to analyze the primary outcome for study weeks 612 included

methamphetamine use week as the dependent variable, treatment group, study week as the time variable, and the first-order interaction term between treatment and study week. No significant difference existed between treatment groups over weeks 612 (p=0.13). A secondary analysis of the primary outcome variable was adjusted for additional covariates. Abstinence or use at baseline (p=0.001), age (p=0.032), and race (p=0.008) were significant and remained in the model; however, despite adjustment for these covariates, the difference remained non-significant between groups. When the outcome was expanded to include study weeks 112, the percentage of topiramate recipients with a negative use week rose from 20% at week 1 to 40% at week 12, but this change remained non-significant compared with placebo.

Figure 3 Percentage of subjects with a negative methamphetamine use week during weeks 612 for topiramate (N=69) and placebo (N=71). Generalized estimating equations (GEE) result for treatment over weeks 612 (p=0.13). Some secondary measures of use reduction in the whole population supported a topiramate treatment effect. When use reduction was measured by weekly median quantitative methamphetamine urine level, significantly more topiramate versus placebo recipients (64.2% vs. 42.3%; Fishers exact test, p=0.03) reduced their use by 25% of the baseline rate during weeks 612. For weeks 112, a trend in favor of topiramate versus placebo (53.6% vs. 36.6%; p=0.06) was seen for a reduction by 25% of urine baseline concentrations and was significant for a reduction to 50% of baseline (42.0% vs. 25.4%; p=0.05). A 50% reduction of use by self-report also favored a significant topiramate treatment effect versus placebo for both the entire treatment period (37.9% vs. 14.3%; p=0.003) and weeks 612 (49.1% vs. 26.9%; p=0.027). The evaluable population comprised randomized subjects who contributed 6 usable onstudy urine samples and took 50 mg/day of topiramate (or equivalent placebo) for 21 days. Of the 140 randomized subjects, 111 (79.3%) were evaluable (58 topiramate, 53 placebo). The placebo group was 71% male, versus 57% of topiramate recipients. No other demographic differences existed between groups. Results in the evaluable population were similar to those in the intent-to-treat analysis for weeks 612 and 112; no difference existed between placebo and topiramate in percentage of subjects with a negative use week.

Psychometrics
Topiramate recipients experienced an improvement in observer-rated global severity of dependence, measured by CGI-O (p=0.03). For self-rated global severity of dependence (CGI-S), a difference was observed at baseline but not over time between treatment

groups. Topiramate showed a trend toward decreasing craving over time, measured by BSCS (p=0.09). There were no significant changes in any categories of ASI-Lite between treatment groups and no treatment effect on Montgomery-Asberg Depression Rating Scale scores or HIV Risk-Taking Behavior Scale scores.

Exploratory Analysis
Several post hoc exploratory analyses of the data were conducted. We investigated the possible influences of underlying factors such as alcohol dependence, severity of methamphetamine use at entry, and dose of medication achieved. History of alcohol dependence at baseline had no effect on primary outcome. Treatment group differences were analyzed based on self-reported frequency of use during the 30 days before informed consent, and on whether the last urine obtained before randomization was positive or negative, which is a good proxy for severity of dependence [15]. When primary outcome was examined based on whether the last urine obtained before randomization was positive or negative, subjects in both groups were more successful during weeks 612 if their last urine before randomization was negative (Figure 4). Additionally, while subjects in both groups who were negative at randomization were not different at 6 weeks, a sustained treatment effect for topiramate was seen in weeks 612 (p=0.02).

Figure 4 Treatment group and last urine result prior to randomization for the percentage of subjects with a negative methamphetamine use week in study weeks 612. At week 6, the total sample size of subjects with a negative baseline urine test for methamphetamine ... Because this protocol allowed adjustment of the total medication dose, we quantified whether subjects reached and maintained the target dose (200 mg/day). The majority reached a mean maintenance dose of 150 mg/day during weeks 612. Only six subjects achieved and maintained the target dose of topiramate or placebo equivalent during all 49 days of treatment in weeks 612.

Safety
Sixty-three topiramate recipients (91%) and 64 placebo recipients (90%) experienced adverse events during the trial. The most frequently reported complaint was headache, in 48% of topiramate subjects and 42% of placebo subjects. Other common complaints were: fatigue, reported in 29% of topiramate subjects and 20% of placebo subjects; paresthesia, in 26% and 6%, respectively; cough, in 23% and 15%; attention disturbance, in 17% and 15%; nausea, in 16% and 13%; diarrhea, in 16% and 11%; dizziness, in 13%

and 7%, and dysgeusia, in 16% and 4%, respectively. Of all adverse events, only the differences between groups for paresthesia and dysgeusia were statistically significant. Eye-related complaints and visual disturbances were infrequent in both groups, with eye and vision disorders experienced by 25% of topiramate and 15% of placebo recipients (difference not statistically significant). Thirteen serious adverse events occurred and were resolved by the conclusion of the trial. Only one serious adverse event was categorized as possibly and one as probably related to the study medication; both were in placebo recipients.

Discussion
Topiramate was not different from placebo in achieving the primary efficacy goal of abstinence from methamphetamine use in those who remained in the study during weeks 612. Positive findings on secondary variables showed that topiramate versus placebo reduced methamphetamine use over time. Topiramate showed efficacy at reducing methamphetamine use in those who were abstinent at the trials outset. In this secondary analysis, 26 subjects (evenly divided between the placebo and topiramate groups) were abstinent at the trials outset. With the caveat that these findings were observed in a subset of the total cohort, it is reasonable to propose that topiramate should be considered for relapse prevention rather than simply being targeted to decrease methamphetamine use in current users. In clinical practice, this has the strong rationale of asking patients to be abstinent briefly before commencing medication treatment. Another advantage is that subjects who can manage this short period of abstinence before starting treatment might also be more likely to comply with the medication regimen and maintain higher doses. Topiramate recipients also were significantly more likely to achieve a 50% or 25% reduction in baseline level of methamphetamine use, suggesting that even when topiramate treatment did not lead to abstinence, it was associated with a significant decrease in risk of harm from methamphetamine use. This was underscored by the observer-rated clinical impression of a global reduction in the severity of methamphetamine dependence in topiramate recipients. Our study had four important limitations. First, similar to previous pharmacotherapy studies with methamphetamine, attrition after the first 6 weeks of treatment was relatively high, thereby limiting our potential to identify differences between active treatment and placebo. We view this as characteristic of the target population, who are often migratory or whose disease state perhaps is associated with greater dissociation from society than those who abuse other psychostimulants or alcohol. Nevertheless, the compliance enhancement treatment ensured that attrition was no different for topiramate versus placebo despite the higher level of adverse events with topiramate. Second, unexpectedly, few subjects achieved the maximum target dose of 200 mg/day. Indeed, the majority of subjects took 150 mg daily, which might have reduced our ability to demonstrate stronger therapeutic effects. Probably, this occurred because the

study protocol allowed liberal downward dose titration of topiramate, thereby inadvertently encouraging the use of the lower topiramate doses. Since alcoholics have tolerated and responded to topiramate at 300 mg/day, the question arises as to whether the final dose that we chose was sufficient. The target dose of 200 mg/day was the same dose that Kampman et al. used in their pilot study of cocaine abstinence [3]; Johnson et al. later studied it as the maximum dose for safety with methamphetamine [16]. An additional consideration is the unintended heterogeneity of doses that the subjects received a common problem in medication studies. Although the medication compliance rate of 70% is higher than that achieved in previous pharmacotherapy studies with methamphetamine [17-19], the use of pill count to monitor compliance is fraught with inaccuracy. Medication studies must incorporate specific markers of medication compliance, including blood level monitoring and riboflavin (for both active and placebo medication), to avoid inconclusive results. The third limitation concerns the effect of topiramate, a mild carbonic anhydrase inhibitor, on the metabolism and excretion of methamphetamine. Urinary filtration of methamphetamine is enhanced by acidification of urine and impeded by alkalinization. This pharmacokinetic mechanism has been demonstrated experimentally by intravenous administration of either an alkalinizing or acidifying agent [20]. However, carbonic anhydrase inhibition simultaneously acidifies blood and alkalinizes urine. A rise of urine pH should reduce methamphetamine elimination, causing higher blood levels of methamphetamine to be sustained, but the downward pH shift in the plasma should also accelerate methamphetamines metabolism. Johnson et al.s interaction study [16] suggests that methamphetamine plasma concentrations increase slightly in topiramates presence, possibly a net effect of reduced urinary excretion. Due to topiramates mild effect on carbonic anhydrase, its net effect on methamphetamines metabolism and elimination kinetics may not be significant; on the other hand, the net effect of a pH shift on methamphetamines concentration gradient across the bloodbrain barrier is unknown. Whether topiramate exerts an unusual pharmacokinetic effect on methamphetamine has an important implication for chronic therapy because although users are consuming less methamphetamine, urine sampling might underestimate the extent of this reduction. Fourth, from the small therapeutic effect evidenced by this study, a double-blind controlled trial of ampler sample size, testing higher doses, is needed for more definitive conclusions. In conclusion, topiramate at doses up to 200 mg/day was safely tolerated by currently using methamphetamine-dependent individuals in this study, but its efficacy in helping them achieve abstinence was not supported. Nonetheless, some use reduction variables were indicative of an effect by topiramate. As seen in some other medication studies, a subgroup of light users are more responsive to topiramate, possibly because they are more likely to adhere to study requirements, or perhaps because we administered a barely therapeutic dose. Topiramates utility in preventing relapse in those who have ceased methamphetamine use should be explored further.

Acknowledgments

We are grateful to the National Institute on Drug Abuse for its generous support through the Department of Veterans Affairs Cooperative Studies Program (Interagency Agreement No. Y1-DA4006). We also thank Robert H. Cormier, Jr., B.A., for his assistance with manuscript preparation.

Footnotes
Declaration of interest: E. Yu serves as a member of the scientific advisory board for US WorldMeds, LLC. C. Gorodetzky serves as a consultant to Catalyst Pharmaceutical Partners, Inc., Helicon Therapeutics, Inc., and US WorldMeds, LLC. M. D. Li serves as a scientific advisor to ADial Pharmaceuticals LLC. B. A. Johnson has served as a consultant to Johnson & Johnson (Ortho-McNeil Janssen Scientific Affairs, LLC), Transcept Pharmaceuticals, Inc., D&A Pharma, Organon, ADial Pharmaceuticals LLC, Psychological Education Publishing Company (PEPCo LLC), and Eli Lilly and Company. A. Elkashef, R. Kahn, E. Iturriaga, S.-H. Li, A. Anderson, N. Chiang, N. AitDaoud, D. Weiss, F. McSherry, T. Serpi, R. Rawson, M. Hrymoc, D. Weis, M. McCann, T. Pham, C. Stock, R. Dickinson, J. Campbell, W. Haning, B. Carlton, and J. Mawhinney report no competing interests.

Article information
Addiction. Author manuscript; available in PMC 2013 July 1. Published in final edited form as: Addiction. 2012 July; 107(7): 12971306. Published online 2012 February 28. doi: 10.1111/j.1360-0443.2011.03771.x PMCID: PMC3331916 NIHMSID: NIHMS344283 Ahmed Elkashef, M.D.,1 Roberta Kahn, M.D.,1 Elmer Yu, M.D.,2 Erin Iturriaga, R.N.,1 Shou-Hua Li, Ph.D.,1 Ann Anderson, M.D.,1 Nora Chiang, Ph.D.,1 Nassima Ait-Daoud, M.D.,3 David Weiss, Ph.D.,4 Frances McSherry, M.A.,4 Tracey Serpi, Ph.D.,4 Richard Rawson, Ph.D.,5 Mark Hrymoc, M.D.,5 Dennis Weis, M.D.,6 Michael McCann, M.A.,7 Tony Pham, M.D.,7 Christopher Stock, Pharm.D.,8 Ruth Dickinson, M.D.,8 Jan Campbell, M.D.,9 Charles Gorodetzky, M.D., Ph.D.,9 William Haning, M.D.,10 Barry Carlton, M.D.,10 Joseph Mawhinney, M.D.,11 Ming D. Li, Ph.D.,3 and Bankole A. Johnson, D.Sc., M.D., Ph.D.3,* 1 National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland 2 Veterans Administration Medical Center, Philadelphia, Pennsylvania 3 Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, Virginia 4 Department of Veterans Affairs Cooperative Studies Program Coordinating Center, Perry Point, Maryland 5 UCLA Integrated Substance Abuse Programs, Los Angeles, California 6 Lutheran Hospital Office of Research, Des Moines, Iowa 7 Matrix Institute on Addictions, Costa Mesa, California

Department of Veterans Affairs, Salt Lake City Health Care System, Salt Lake City, Utah 9 Department of Psychiatry, University of Missouri, Kansas City, Missouri 10 Pacific Addiction Research Center, Honolulu, Hawaii 11 South Bay Treatment Center, San Diego, California * Correspondence: Bankole A. Johnson, D.Sc., M.D., Ph.D., Alumni Professor and Chairman, Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, P.O. Box 800623, Charlottesville, VA 22908-0623. Phone: 434-924-5457. Fax: 434-244-7565. Email: bankolejohnson/at/virginia.edu Copyright notice and Disclaimer The publisher's final edited version of this article is available at Addiction This article has been corrected. See the correction in volume 107 on page 1718.

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12. First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSM-IV Axis I Disorders Patient Edition (SCID-I/P, Version 2.0) New York: New York State Psychiatric Institute, Biometrics Research Department; 1994. 13. Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry. 1979;134:382389. [PubMed] 14. Johnson BA, DiClemente CC, Ait-Daoud N, Stoks SM. Brief Behavioral Compliance Enhancement Treatment (BBCET) manual. In: Johnson BA, Ruiz P, Galanter M, editors. Handbook of Clinical Alcoholism Treatment. Baltimore, MD: Lippincott Williams & Wilkins; 2003. pp. 282301. 15. Kampman KM, Volpicelli JR, Mulvaney F, Rukstalis M, Alterman AI, Pettinati H, et al. Cocaine withdrawal severity and urine toxicology results from treatment entry predict outcome in medication trials for cocaine dependence. Addict Behav. 2002;27:251260. [PubMed] 16. Johnson BA, Wells LT, Roache JD, Wallace CL, Ait-Daoud N, Dawes MA, et al. Kinetic and cardiovascular effects of acute topiramate dosing among non-treatmentseeking, methamphetamine-dependent individuals. Prog Neuropsychopharmacol Biol Psychiatry. 2007;31:455461. [PMC free article] [PubMed] 17. Johnson BA, Ait-Daoud N, Elkashef AM, Smith EV, Kahn R, Vocci F, et al. A preliminary randomized, double-blind, placebo-controlled study of the safety and efficacy of ondansetron in the treatment of methamphetamine dependence. Int J Neuropsychopharmacol. 2008;11:114. [PubMed] 18. Shearer J, Darke S, Rodgers C, Slade T, van Beek I, Lewis J, et al. A double-blind, placebo-controlled trial of modafinil (200 mg/day) for methamphetamine dependence. Addiction. 2009;104:224233. [PubMed] 19. Elkashef AM, Rawson RA, Anderson AL, Li SH, Holmes T, Smith EV, et al. Bupropion for the treatment of methamphetamine dependence. Neuropsychopharmacology. 2008;33:11621170. [PubMed] 20. Davis JM, Kopin IJ, Lemberger L, Axelrod J. Effects of urinary pH on amphetamine metabolism. Ann N Y Acad Sci. 1971;179:493501. [PubMed]

10 The international journal of neuropsychopharmacology / official scientific journal of the Collegium Internationale Neuropsychopharmacologicum (CINP) Author Manuscript NIH Public Access

Acute modafinil exposure reduces daytime sleepiness in abstinent methamphetamine-dependent volunteers

James J. Mahoney, III, Brian J. Jackson, [...], and Thomas F. Newton Additional article information

Abstract
The purpose of this study was to evaluate the effects of acute, oral modafinil (200 mg) exposure on daytime sleepiness in methamphetamine (Meth)-dependent individuals. Eighteen Meth-dependent subjects were enrolled in a 7-d inpatient study and were administered placebo or modafinil on day 6 and the counter-condition on day 7 (randomized) of the protocol. Subjects completed several subjective daily assessments (such as the Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Beck Depression Inventory and visual analogue scale) throughout the protocol as well as objective assessments on days 57, when the Multiple Sleep Latency Test was performed. The results of the current study suggest that short-term abstinence from Meth is associated with increased daytime sleepiness and that a single dose of 200 mg modafinil reduces daytime somnolence in this population. In addition, a positive correlation was found between subjective reporting of the likelihood of taking a nap and craving and desire for Meth, as well as the likelihood of using Meth and whether Meth would make the participant feel better. The results of this study should be considered when investigating candidate medications for Meth-dependence, especially in those individuals who attribute their Meth use to overcoming deficits resulting from sleep abnormalities.
Keywords: Methamphetamine, modafinil, sleep

Introduction
Methamphetamine (Meth) users self-report poor sleep quality, sleep disturbances and significant daytime sleepiness (Mahoney et al. unpublished observations; McGregor et al. 2005). Specifically, Mahoney et al. reported that, in a sample of 71 Meth-dependent individuals, the average score on the Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) were 8.55.0 and 9.85.5 respectively, whereas the average scores in typical, healthy individuals are 2.71.7 for the PSQI (Buysse et al. 1989) and 5.92.2 for the ESS (Johns, 1991). These elevated scores raise the concern that sleep deficiencies can precipitate Meth use as a way to reduce daytime sleepiness and to increase alertness and attention. In fact, related studies reported that Meth administration is associated with reduced self-reported fatigue and daytime sleepiness (Shappell et al. 1996) and improved performance on measures of information-processing speed (Hart et al. 2003). Poor sleep quality has also been reported in other stimulant users, such as cocainedependent individuals (Gawin & Kleber, 1986; Morgan & Malison, 2007; Weddington et al. 1990). For example, Mahoney et al. (unpublished observations) reported that, in a sample of 51 cocaine-dependent individuals, the average scores on the PSQI and ESS were 7.84.4 and 9.75.1, respectively. Thus, cocaine-dependent individuals also

endorsed more sleep deficiencies when compared to healthy individuals and those sleep difficulties were comparable to those reported by Meth-dependent individuals. Moreover, this suggests that Meth-associated daytime sleepiness should be a target of treatment. One possibility is that medications can be used to ameliorate these sleep difficulties and the wake-promoting agent, modafinil, is one such candidate. It has been reported that modafanil exposure is associated with increased daytime sleep latency and decreased daytime sleepiness in abstinent cocaine-dependent individuals (Morgan et al. 2010). Other characteristics of modafanil increase the viability of this compound as a treatment for Meth-associated sleep disturbances. For example, modafinil does not accentuate the stimulant effects produced by the administration of Meth in a laboratory setting (De La Garza et al. 2010). Furthermore, modafinil reduces daytime sleepiness in individuals with hypersomnolence due to narcolepsy and sleep apnea (Arnulf et al. 1997; Besset et al. 1993). Additionally, treatment with modafinil reduces fatigue, agitation and irritability in individuals experiencing Meth withdrawal (McGregor et al. 2008). Similarly, it has been reported that modafinil reduced sensory aspects of fatigue in Meth-dependent subjects (Ghahremani et al. 2011). Importantly, none of these studies reported serious adverse events as a result of modafinil exposure. Each of the aforementioned factors supports the use of modafinil as a treatment for Methassociated sleep disorders. To address this, we conducted a double-blind, placebocontrolled study to investigate the impact of modafinil administration on sleep characteristics among Meth-dependent individuals. Similar to the reported outcomes by Morgan et al. (2010) in abstinent cocaine users, we hypothesized that modafinil would increase daytime sleep latency and decrease daytime sleepiness in acutely abstinent Meth users.

Method
Subjects
Eighteen Meth-dependent subjects were enrolled in a 7-d inpatient study. The Institutional Review Board of the University of California, Los Angeles approved this study and all subjects gave informed consent after being made aware of the possible risks of participation. All individuals were compensated for their participation in this study. Individuals were recruited via newspaper and radio advertisements. All Meth-dependent subjects were non-treatment seeking and met DSM-IV-TR criteria for Meth-dependence, as assessed by the Mini International Neuropsychiatric Interview (Sheehan et al. 1997). Other inclusion criteria included being aged between 18 and 45 yr, at least twice-weekly use of Meth (smoked or i.v.), positive urine toxicology for Meth prior to admission, and normal vital signs and electrocardiogram. Exclusion criteria included diagnosis of any other Axis I psychiatric disorder, dependence on any other drugs aside from nicotine, a history of seizure disorder, prior head trauma, or concomitant use of any psychotropic medication. Additionally, a previous diagnosis with any primary sleep disorder

(narcolepsy, insomnia, rapid eye movement sleep behaviour disorder) or any sleep disordered breathing, such as apnea, was exclusionary. Upon intake to the UCLA General Clinical Research Center (GCRC), Meth-dependent individuals completed a comprehensive drug use history form, the PSQI (Buysse et al. 1989), to assess the quality and patterns of sleep, the ESS (Johns, 1991) to assess selfperceived sleep quality and excessive daytime sleepiness over the past month, the Beck Depression Inventory (BDI-II; Beck et al. 1996) to assess presence of depressive symptoms, sleep quality and craving visual analogue scales (VAS), and the American National Adult Reading Test to assess for verbal IQ. Subjects spent days 14 acclimatizing to GCRC and washing out from any recent Meth use and no major procedures were performed on those days; however, the aforementioned daily written assessments (e.g. PSQI, ESS and VAS) were conducted. Subjects were required to be in bed with lights out at 23:00 hours and were awoken at 07:00 hours every morning for daily assessments. Other than these times (23:0007:00 hours), subjects were not allowed to nap or lie down unless they participated in the Multiple Sleep Latency Test (MSLT) sessions.

Drugs
On day 1, Meth-dependent subjects were randomized to receive one dose (200 mg) of modafinil (Provigil; Cephalon, USA) on either the sixth or seventh day of the study, with the counter-condition presented the following day (i.e. if the subject received modafinil on day 6, he/she received placebo on day 7 and vice versa). Modafinil was encapsulated to match placebo in appearance and subjects were administered the drug at 08:00 hours.

Daytime sleep assessment

On days 57, at 09:00, 11:00, 13:00 and 15:00 hours, the MSLT, a procedure used to assess sleep onset latency and measure physiological sleep tendency in the absence of alerting stimuli (Carskadon & Dement, 1982), was performed. Standard electroencephalography electrodes were attached to the scalp and face according to the international 1020 system. Five minutes prior to each test, subjects were asked to get into bed and were led through a standardized diagnostic series of movements (eyes left, eyes right, eyes up, eyes down, blink) to ensure electrode connectivity. Afterward, subjects completed the Stanford Sleepiness Scale (SSS) to assess self-perceived somnolence. Immediately following completion of the SSS, lights in the room were turned off, shades and curtains were drawn and the subjects were asked to try to fall asleep (these sessions are referred to as naps throughout the remainder of this paper). As per clinical research standards for the MSLT, subjects were given 20 min to fall asleep. If they did not fall asleep after 20 min, the test was concluded and the lights were turned back on. Individuals were permitted to sleep if it occurred during the MSLT, meaning that the absolute maximum of sleep during the day would have been 80 min (four naps 20 min each); however, they were not permitted to lie down at times other than the MSLT sessions. Between test sessions, subjects were instructed to remain out of

bed and no napping was permitted on those days. To prevent confounds due to the arousing effects of nicotine, exercise and caffeine, each was restricted during the inpatient stay (Prosise et al. 1994).

A note on full study design

Participants in the current study also completed neurocognitive assessments following modafinil administration and these null findings will be published separately. Also, a subset of these individuals (n=9) were also exposed to temazepam during the evenings of days 5 and 6 and the null findings from that study will also be reported separately.

Statistical analysis
Sleep onset during the MSLT was defined as the first 30-s epoch of any stage of sleep and sleep stages were scored using a standardized set of criteria (Rechtschaffen & Kales, 1968). For baseline (day 5 when no medication was administered) and on days in which placebo or modafinil were administered, only three naps were utilized to calculate mean daytime sleep latency (the first nap was excluded from the analysis). The rationale for this approach was as follows: modafinil was administered at 08:00 hours on the scheduled days and peak plasma levels are not achieved for approximately 2 h following dosing (Cephalon, 2004; Wong et al. 1999). Thus, the 09:00 hours nap on that day would not be an accurate representation of modafinils effects. As such, only the naps at 11:00, 13:00 and 15:00 hours were used to calculate mean sleep latency at baseline and on placebo days for consistency purposes. Paired t tests were used to determine the relationship between subjective reporting of sleep quality, mood and variables associated with Meth use (e.g. craving, desire, etc.). The variables night-time sleep, bedtime, how well did you sleep last night, how likely would you be to take a nap, how much better would meth make you feel and how likely would you be to use meth were included as part of the sleep quality VAS, which was administered on days 27 of the protocol. The other variables (ESS, BDI, craving and desire) were all obtained on day 1 during admission and were completed daily to day 7. We decided to compare days 1 or 2 to day 5 because it provided a valuable and important comparison between baseline (when they first arrived at the GCRC) and after becoming acclimatized to the GCRC, but prior to any modafinil administration (day 5). In addition, correlations between sleep and Meth variables were determined using Pearson product-moment correlations. Statistical significance was set at p<0.05. All analyses were performed using PASW 18.0 (SPSS, USA).

Results
Characteristics of Meth users

Demographic and sleep characteristics

Demographic and drug use information for subjects is provided in Table 1. Subjects were primarily male (89%) and either Caucasian (44%) or Hispanic (44%). The average age was ~35 yr, average years of education were ~12 and the average verbal IQ was ~110. On average, subjects reported using Meth for ~12 yr, used ~18 d out of the past 30 and ~10 g per week. In addition, the majority (83%) of the subjects reported smoking cigarettes.

Table 1 Demographic and drug use characteristics a

With regard to sleep characteristics, upon enrolment subjects reported an average score of 6.44.3 on the PSQI and 8.94.8 on the ESS. On day 2 and day 5, when subjects were asked to report the previous nights sleep, subjects reported sleeping significantly less on night 4 (7.62.1 h) in comparison to night 1 (9.32.1 h; t15=3.6, p<0.005, 2=0.5). Moreover, subjects bedtime was significantly later on night 4 relative to night 1 (t15=4.3, p<0.001, 2=0.6). There were no significant correlations between days abstinent prior to admission and total hours of sleep on night 1 (r=0.1, p=0.9) or bedtime on night 1 (r=0.3, p=0.3). In addition, BDI-II scores decreased significantly between day 1 and day 5 (Table 2). Likelihood of taking a nap on day 5 was not different from day 2 (t16=1.0, p=0.3) nor was there a difference between quality of sleep between night 1 and night 4 when asked how well did you sleep last night? (t16=1.5, p=0.2).

Table 2 Baseline subjective mood and sleep characteristics for methamphetamine users

Drug use characteristics

As mentioned previously, subjects in the current study were asked to provide a self-report of their craving for Meth once daily, at 11:45 hours. Data from four items of interest on

the sleep quality and craving VAS forms were analysed to examine changes across 4 d abstinence from Meth (Table 2). When asked, If you had access to methamphetamine right now, how likely would you be to use it, subjects ratings decreased significantly from 83.1 on day 2 to 65.0 on day 5 (t15=2.4, p<0.03, 2=0.3). Subjects rating of How much better would methamphetamine make you feel right now, did not differ across days 2 and 5 t16=1.2, p=0.2). On the craving VAS form, there were no significant differences between day 1 and day 5 for either craving (t15=0.5, p=0.7, 2=0.0) or desire for Meth (t15=0.5, p=0.6, 2=0.0). Responses to the craving variables of interest (I crave methamphetamine right now) was positively correlated with the question How likely are you to take a nap today (r=0.6, r2=0.3, p<0.02; Fig. 1a). Similarly, I desire methamphetamine right now was also positively correlated with the question How likely are you to take a nap today (r=0.5, r2=0.3, p0.03; Fig. 1b). Other drug use questions such as If you had access to methamphetamine, how likely would you be to use it (r=0.5, r2=0.2, p<0.01) and How much better would methamphetamine make you feel right now (r=0.7, r2=0.5, p<0.05) were also strongly correlated with the question How likely are you to take a nap today.

Fig. 1 (a) Correlation between likelihood of taking a nap and craving for methamphetamine (Meth); (b) correlation between likelihood of taking a nap and desire for Meth.

Efficacy of modafinil
On average, sleep latency (min) was 12.13.5 at baseline and 16.04.6 following modafinil administration (t14=4.0, p<0.001, 2=0.9). Follow-up analyses revealed that the sleep latencies differed significantly between baseline and the second (11.15.6 vs. 14.66.1; t13=2.4, p<0.03, 2=0.9) and third (13.14.2 vs. 16.25.3; t13=2.5, p<0.03, 2=1.0) naps and a trend towards significance during baseline and the fourth nap (12.95.9 vs. 16.25.3; t14=1.8, p=0.1, 2=0.9) (Table 3). There were no significant differences between baseline and post-placebo administration with regard to MSLT on any of the three naps (as well as the MSLT average). When comparing days where modafinil was administered vs. placebo, there were no significant differences with regard to sleep latency.

Table 3 Baseline sleep latency vs. sleep latency post-modafinil administration

Discussion
The results of the current study suggest that short-term abstinence from Meth is associated with increased daytime sleepiness and that a single dose of 200 mg modafinil reduced daytime somnolence in this population. In addition, a positive correlation was found between subjective reporting of the likelihood of taking a nap and craving and desire for Meth, as well as the likelihood of using Meth and whether Meth would make the participant feel better. Since depressive symptoms have been linked to sleep abnormalities (Rothschild, 1988), it is important to rule these out as a potential confound. BDI-II scores were not associated with any sleep variables, indicating that self-reported levels of depression did not modulate sleep. A frequently reported symptom of acute abstinence/withdrawal from Meth is hyper-somnolence (for review, see Meredith et al. 2005). This symptom was observed in the subjects in the current study. Subjects initially slept just over 9 h the first night following abstinence initiation. By the fourth night of study participation, participant sleep levels declined to<8 h, which is consistent with the average weeknight sleep duration reported by healthy adults of a similar age (NSF, 2009). In addition to the difference in time spent asleep, subjects went to bed, on average, earlier on their first night of enrolment than their fourth night. Despite normalization of night-time sleep, subjects still reported daytime somnolence, as the mean ESS score was unchanged between day 1 and day 5. In addition to the unchanged ESS score, subjects did not report reductions in likelihood of taking naps between admission (day 1) and day 5. Mean sleep latency for the four naps on day 5 was ~12 min. Importantly, mean sleep latencies for comparably aged control individuals are in the range of 15.5 min (Johnson et al. 1990), suggesting mild daytime sleepiness in this cohort of Meth-dependent individuals. It is also important to evaluate modafinil, Meth and their impact on sleep from a neurochemical perspective. The precise mechanism of action for modafinil is currently unknown; however, rodent and primate models of modafinil exposure are associated with the modulation of several neurotransmitter systems, including dopamine (Madras et al. 2006; Volkow et al. 2009), norepinephrine (Madras et al. 2006) and orexin/hypocretin (Tobin, 2007). Notably, dopamine, serotonin and norepinephrine systems are affected as a consequence of Meth-dependence (Sofuoglu & Sewell, 2009).

Another possible explanation for excessive daytime sleepiness in this population involves the recently emerging literature concerning the relationship between Meth use and compromised immune system functioning. Immune function plays a critical role in the regulation and maintenance of sleep, so it would not be unexpected to see alterations in levels of immune system makers and function in a population with disturbed sleep. Perhaps the most interesting and relevant data concerning immune function, sleep and Meth deal with pro-inflammatory cytokines, such as interleukin-6 (IL-6), interleukin-1 (IL-1) and tumour necrosis factor-. Daytime IL-6 plasma concentrations are negatively correlated with quality of night-time sleep (Vgontzas et al. 1997) and sleep deprivation results in increased IL-6 levels (Shearer et al. 2001; Vgontzas et al. 1999). We did not collect serum as part of this protocol and future studies might obtain these data to determine the degree to which levels of proinflammatory cytokines co-vary with sleep in Methdependent individuals. As the current results show, abstinence from Meth is associated with sleepiness ratings of about 10 (on a scale of 024), which generally remain stable over 10 d from last use. ESS scores of 10 reflect normal levels of sleepiness (Johns, 1991). The mean length of abstinence for subjects in the current study was approximately 6 d. Given that the halflife of Meth is 1012 h (Cho et al. 2001) and that baseline MSLT observations did not occur until the fifth day of the study, not only would Meth no longer be in the subjects body, any initial withdrawal symptoms that occur during acute abstinence would have resolved (Newton et al. 2004). However, the longer in duration the symptoms last, the more appropriate it is to refer to the phenomenon as an abstinence syndrome. Resolution of the abstinence syndrome is further illustrated by scores on the BDI-II and the selfreported estimates of length of night-time sleep. Specifically, both measures were significantly lower on day 5 than on day 1 of the study and were in the subclinical range (<10), suggesting that daytime sleep latency on day 5 was not due to the crash and rebound hypersomnia often associated with withdrawal from Meth (Gawin et al. 1994). The results of the current study show that a single dose of 200 mg modafinil significantly lengthens daytime sleep latency. The implications of lengthening sleep latency include improving alertness, which may affect Meth usage patterns. In other words, if an individual is more alert, he/she may be able to avoid triggers associated with continued Meth use. It was not known whether modafinil would increase wakefulness in Meth users, who have been shown to have reduced dopamine transporter (DAT) availability as compared to healthy controls (McCann et al. 1998, 2007; Sekine et al. 2001, 2003; Volkow et al. 2001). A number of studies have shown reduced DAT availability in the prefrontal cortex of Meth users and this may play a role in the lack of an effect seen in this study. Another interesting finding is that subjective ratings for Meth craving and desire did not significantly increase after subjects had been abstinent for several days, which may have been expected among nontreatment- seeking individuals; yet, this is consistent with previously published research (Galloway et al. 2010). In addition, when subjects were asked to rate the likelihood that they would use if they had access to Meth, there was a significant decrease between day 2 and day 5. We expected that the likelihood of use

would be higher after a period of prolonged abstinence from Meth, but the opposite effect was observed. One potential explanation for this would be that, as subjects remained abstinent over several days, their interest in using if given access would decrease since withdrawal effects would expectedly subside over time. In other words, the subjects would become acclimatized to not using Meth and would then be less likely to report using Meth if they had access to the drug. It is important to concede some limitations with this study. First, a higher dose of modafinil and longer duration of treatment may increase daytime sleep latency and further reduce daytime sleepiness. Specifically, since it takes approximately 72 h for modafinil to reach steady-state peak levels (Robertson & Hellriegel, 2003), the efficacy of a single dose of modafinil is unlikely to reveal the full effectiveness of the compound. A second limitation, night-time sleepiness, was not assessed using polysomnographic sleep measurement, which would have provided a quantifiable measure of night-time sleep. In lieu of this, the current study relied on self-report for assessing night-time sleep characteristics. Since several other symptoms of stimulant withdrawal seem to be improving, and total sleep seems to be declining, it would be of great interest to know whether sleep latency during daytime naps is increasing or declining. Unfortunately, we did not measure sleep latency prior to day 5 to make this comparison. In addition, while the subset of subjects (n=9) receiving temazapam did not differ on any of the subjective or objective measurements when compared to those receiving placebo, we still concede the lack of uniformity in procedures as a potential confound. Also, it would have been very informative to assess craving levels (as well as the other subjective variables) more than once daily to determine whether these subjective reports changed throughout the day. Finally, we did not administer modafinil to a control group to investigate differences in sleep characteristics between Meth-dependent individuals and healthy controls. In addition to the ability of modafinil to reduce objective symptoms of excessive daytime sleepiness, modafinil also reduced subjective ratings, specifically self-perceived likelihood of taking a nap. As likelihood of taking a nap correlated positively to a number of the craving questions (access and better) both prior to and after treatment with modafinil, we report indirect evidence that self-perceived symptoms of excessive daytime sleepiness may be a trigger for drug use and that treating these symptoms may improve treatment outcomes and reduce relapse.

Acknowledgments
The authors acknowledge grants from the National Institutes of Health DA 18185, DA 014593, DA 017754 and RR-00865. In addition, the authors acknowledge the UCLA General Clinical Research Center nursing staff for their support.

Footnotes
Statement of Interest

None.

Article information
Int J Neuropsychopharmacol. Author manuscript; available in PMC 2012 October 1. Published in final edited form as: Int J Neuropsychopharmacol. 2012 October; 15(9): 12411249. Published online 2012 January 4. doi: 10.1017/S1461145711001805 PMCID: PMC3411896 NIHMSID: NIHMS372899 James J. Mahoney, III, Brian J. Jackson, Ari D. Kalechstein, Richard De La Garza, II, Lee C. Chang, and Thomas F. Newton Baylor College of Medicine, Menninger Department of Psychiatry and Behavioral Sciences, Houston, TX, USA. Michael E. DeBakey VA Medical Center, Houston, TX, USA Address for correspondence: Mr J. J. Mahoney, 1977 E. Butler, Houston, TX 77030, USA. Tel.: (713) 791 1414 Fax: (713) 794 7833, Email: james.mahoney/at/bcm.edu Copyright notice and Disclaimer The publisher's final edited version of this article is available at Int J Neuropsychopharmacol

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