Heroin "overdose" death: contribution of drug-associated environmental cues

CNS–immune system interactions: Conditioning phenomena

Converging data from different disciplines indicate that central nervous system processes are capable of influencing immune responses. This paper concentrates on recent studies documenting behaviorally conditioned suppression and enhancement of immunity. Exposing rats or mice to a conditioned stimulus previously paired with an immunomodulating agent results in alterations in humoral and cell-mediated immune responses to antigenic stimuli, and unreinforced reexposures to the conditioned stimuli result in extinction of the conditioned response. Although the magnitude of such conditioning effects has not been large, the phenomenon has been independently verified under a variety of experimental conditions. The biological impact of conditioned alterations in immune function is illustrated by studies in which conditioning operations were applied in the pharmacotherapy of autoimmune disease in New Zealand mice. In conditioned animals, substituting conditioned stimuli for active drugs delays the onset of autoimmune disease relative to nonconditioned animals using a dose of immunosuppressive drug that, by itself, is ineffective in modifying the progression of disease. The hypothesis that such conditioning effects are mediated by elevations in adrenocortical steroid levels receives no support from available data. Despite its capacity for self-regulation, it appears that the immune system is integrated with other psychophysiological processes and subject to modulation by the brain.

Drug effects: agonistic and antagonistic processes

The research presented here has shown that tolerance to drugs can be accelerated by conditioning processes. Placebo effects may be considered the opposite of tolerance, and we have shown that placebo effects may be objectively recorded by physiological measures (electromyography, skin conductance responses, and event-related potentials), as well as by behavioral and subjective methods. The placebo response, or more precisely, the expectation of drug effects, can add to the effect of the drug. Drug antagonistic expectations can also reverse the effect of the drug. There is some evidence that placebo effects are strongest when expectations are reinforced by administration of an active drug. Expectations have graded effects and may affect symptoms to a smaller or larger degree. Although drug effects can be considered stimuli, the investigation of the role of classical conditioning in drug use and drug effects involves special issues that must be carefully considered.

Extinction of drug- and withdrawal-paired cues in animal models: relevance to the treatment of addiction

Conditioned drug craving and withdrawal elicited by cues paired with drug use or acute withdrawal are among the many factors contributing to compulsive drug taking. Understanding how to stop these cues from having these effects is a major goal of addiction research. Extinction is a form of learning in which associations between cues and the events they predict are weakened by exposure to the cues in the absence of those events. Evidence from animal models suggests that conditioned responses to drug cues can be extinguished, although the degree to which this occurs in humans is controversial. Investigations into the neurobiological substrates of extinction of conditioned drug craving and withdrawal may facilitate the successful use of drug cue extinction within clinical contexts. While this work is still in the early stages, there are indications that extinction of drug- and withdrawal-paired cues shares neural mechanisms with extinction of conditioned fear. Using the fear extinction literature as a template, it is possible to organize the observations on drug cue extinction into a cohesive framework.

Yoked delivery of cocaine is aversive and protects against the motivation for drug in rats

In Experiment 1, water-deprived rats had 5-min access to saccharin followed by active or yoked intravenous delivery of saline or cocaine (0.33 mg/infusion). Both cocaine groups avoided intake of the saccharin cue following saccharin-cocaine pairings; however, the rats in the yoked condition exhibited greater avoidance of the taste cue than did the actively administering rats. Experiment 2 evaluated subsequent self-administration behavior on fixed- and progressive-ratio schedules of reinforcement. The results showed that prior yoked exposure to cocaine reduced subsequent drug-taking behavior on a progressive-ratio but not on a fixed-ratio schedule. Finally, Experiment 3 used a choice test to determine the impact of yoked drug delivery on the relative preference for cocaine versus water. The results showed that rats with a history of self-administering cocaine preferred to perform operant behaviors on the side of the chamber previously paired with cocaine, whereas the rats with a history of yoked delivery of cocaine avoided this side. These data show that, in most rats, the unpredictable, uncontrollable delivery of cocaine protects against the subsequent motivation for cocaine through an aversive mechanism.

Classical Conditioning: Still Going Strong

This paper summarizes developments in the field of classical conditioning. Attention is paid to four common misconceptions of what is classical conditioning. First, classical conditioning does not ensue as a simple result of temporal pairing of conditioned and unconditioned stimuli. Rather, conditioned reacting occurs if and to the degree that the subject is able to predict the occurrence of one stimulus from the presence of another one. Second, what is learned during classical conditioning is not necessarily a response to a cue, but rather a probabilistic relationship between various stimuli. Third, classical conditioning is not only manifested in responses mediated by the autonomic nervous system, but also in immunological parameters, in motoric behaviour and in evaluative judgments. Fourth, the nature of the conditioned and the unconditioned stimulus is (often) not a matter of indifference: particular combinations of CS and US produce more powerful conditioning effects than do other combinations. In the second part of the paper, the potential relevance of these developments is illustrated. Discussions are included about anxiety, addictions and food aversions/conditioned nausea.

The Pavlovian power of palatable food: lessons for weight-loss adherence from a new rodent model of cue-induced overeating

OBJECTIVE

Relapsing to overeating is a stubborn problem in obesity treatment. We tested the hypothesis that context cues surrounding palatable food (PF) intake have the power to disrupt caloric regulation even of less PF. Context cues are non-food cues that are in the environment where PF is habitually eaten.

DESIGN

Rats were conditioned to associate intake of Oreo cookies as the PF to cages with distinct context cues that differed from cues in cages where they were only given chow. PF naturally stimulated greater caloric intake. The rats were then tested in the PF cage with only chow available to determine whether the PF-paired cues, alone, could elicit overeating of plain chow.

SUBJECTS

Non-food-deprived female Sprague-Dawley rats.

MEASUREMENTS

Intake of plain chow under PF-paired cues vs chow-paired cues was compared. This was also measured in tests that included a morsel of PF as a priming stimulus. We also controlled for any effect of binge-prone vs binge-resistant status to predict cued-overeating.

RESULTS

Rats consumed significantly more chow when exposed to context cues paired earlier with PF than with chow (P<0.01). This effect occurred using various cues (for example, different types of bedding or wallpaper). The effect was strengthened by priming with a morsel of PF (P<0.001) and was unaffected by baseline differences in propensity to binge on PF.

CONCLUSION

Context-cues associated with PF intake can drive overeating even of a less PF and abolish the ability of rats to compensate for the calories of a PF primer. Just as drug-associated context cues can reinstate drug-addiction relapse, PF-paired cues may trigger overeating relapses linked to weight regain and obesity. This model should help identify the reflex-like biology that sabotages attempts to adhere to healthy reduced calorie regimens and call greater attention to the cue-factor in the treatment of binge eating and obesity.

Aspects of the relationship between drug dose and drug effect

It is generally assumed that there exists a well-defined relationship between drug dose and drug effect and that this can be expressed by a dose-response curve. This paper argues that there is no such clear relation and that the dose-response curve provides only limited information about the drug effect. It is demonstrated that tolerance development during the measurement of the dose-response curve may cause major distortion of the curve and it is argued that the curve may only be used to indicate the response to the first administration of a drug, before tolerance has developed. The precise effect of a drug on an individual depends on the dynamic relation between several variables, particularly the level of tolerance, the dose anticipated by the organism and the actual drug dose. Simulations with a previously published mathematical model of drug tolerance demonstrate that the effect of a dose smaller than the dose the organism has developed tolerance to is difficult to predict and may be opposite to the action of the usual dose.

Identifying the neural circuitry of alcohol craving and relapse vulnerability

With no further intervention, relapse rates in detoxified alcoholics are high and usually exceed 80% of all detoxified patients. It has been suggested that stress and exposure to priming doses of alcohol and to alcohol-associated stimuli (cues) contribute to the relapse risk after detoxification. This article focuses on neuronal correlates of cue responses in detoxified alcoholics. Current brain imaging studies indicate that dysfunction of dopaminergic, glutamatergic and opioidergic neurotransmission in the brain reward system (ventral striatum including the nucleus accumbens) can be associated with alcohol craving and functional brain activation in neuronal systems that process attentional relevant stimuli, reward expectancy and experience. Increased functional brain activation elicited by such alcohol-associated cues predicted an increased relapse risk, whereas high brain activity elicited by affectively positive stimuli may represent a protective factor and was correlated with a decreased prospective relapse risk. These findings are discussed with respect to psychotherapeutic and pharmacological treatment options.

Pharmakologische Rückfallprävention bei Alkohol- und Tabakabhängigkeit

A better understanding of the neurobiological substrates of alcohol and tobacco dependence has been accompanied by the increasing role of pharmacological relapse prevention. In alcohol dependence, substances which are able to block or ameliorate alcohol craving improve the maintenance of abstinence in combination with psychosocial treatment. In particular, the N-methyl-D-aspartate receptor antagonist acamprosate and the opiate receptor antagonist naltrexone have been shown to be effective in numerous trials. Administration starts immediately after detoxification and should last for 12 months. This treatment, however, is not a replacement for the psychosocial treatment of the alcohol dependence. Compared with placebo treatment, approximately twice as many patients remain abstinent under acamprosate 1 year after the end of treatment. The most widely studied and used pharmacotherapy for the treatment of tobacco dependence is nicotine containing medications. Nicotine replacement therapies (patch, gum, tablet, inhaler) have been shown to reduce tobacco craving and enhance abstinence. The only non-nicotine medication that has been approved in Germany is the antidepressant bupropion. Current studies identify particularly suitable subgroups of patients responding to more individualized pharmacological relapse prevention. A specific application of these substances will optimise the outcome for alcohol and tobacco dependent patients.

Effects of expectation on amygdala‐kindled convulsions and interictal behaviour in rats: confirmation of a Pavlovian mechanism

We found evidence that the effects of exposure to the stimulation environment on the convulsions and interictal behaviour of basolateral amygdala (BA)-kindled rats are the result of Pavlovian conditioning. In Experiment 1, the rats first received 45 BA stimuli in one environment (CS+) and 45 sham stimuli in another environment (CS-). During this first phase of the experiment, the CS+ and CS- began to exert differential effects on interictal behaviour and convulsions. Then, during the second phase, rats received 45 stimuli and 45 sham stimuli, either as before in their original CS+ and CS- (nonreversal rats) or with their original CS+ and CS- interchanged (reversal rats). During the second phase, the CS+ and CS- continued to exert the same pattern of differential effects on the interictal behaviour and convulsions of the nonreversal rats, whereas the reversal rats began to display the reverse pattern. In Experiment 2, rats received 60 sham stimuli in one environment (CS1). Then, half of the rats received 30 stimuli in a second environment (CS2) and 30 sham stimuli in CS1 (no-pre-exposure rats), whereas the other half (pre-exposure rats) received 30 stimuli and 30 sham stimuli in CS1. Pre-exposure to the stimulation environment attenuated the kindled convulsions. These findings confirm that the conditioned effects of kindling are mediated by a Pavlovian mechanism.

Toxicological analysis in rats subjected to heroin and morphine overdose

In heroin overdose deaths the blood morphine concentration varies substantially. To explore possible pharmacokinetic explanations for variable sensitivity to opiate toxicity we studied mortality and drug concentrations in male Sprague-Dawley rats. Groups of rats were injected intravenously (i.v.) with heroin, 21.5 mg/kg, or morphine, 223 mg/kg, causing a 60-80% mortality among drug-naïve rats. Additional groups of rats were pre-treated with morphine for 14 days, with or without 1 week of subsequent abstinence. Brain, lung and blood samples were analyzed for 6-acetylmorphine, morphine, morphine-3-glucuronide and morphine-6-glucuronide. i.v. morphine administration to drug-naïve rats resulted in both rapid and delayed deaths. The brain morphine concentration conformed to an exponential elimination curve in all samples, ruling out accumulation of morphine as an explanation for delayed deaths. This study found no support for formation of toxic concentration of morphine-6-glucuronide. Spontaneous death among both heroin and morphine rats occurred at fairly uniform brain morphine concentrations. Morphine pre-treatment significantly reduced mortality upon i.v. morphine injection, but the protective effect was less evident upon i.v. heroin challenge. The morphine pre-treatment still afforded some protection after 1 week of abstinence among rats receiving i.v. morphine, whereas rats given i.v. heroin showed similar death rate as drug-naïve rats.

Discrete cues paired with naloxone-precipitated withdrawal from acute morphine dependence elicit conditioned withdrawal responses

Acute bolus doses of morphine induce a state of acute opioid dependence as measured by naloxone-precipitated withdrawal. Repeated morphine and precipitated withdrawal experience further enhances naloxone-induced withdrawal severity, partly because of direct neuroadaptation to repeated morphine, and partly because of conditioned associations of context and withdrawal experience. To determine whether a discrete tone/light conditioned stimulus could elicit conditioned withdrawal responses in acute dependence, rats trained on a fixed-ratio-15 operant schedule for food reward received morphine (5.6 mg/kg) 4x at daily or weekly intervals, with each morphine injection followed at 4 h by naloxone (1.0 mg/kg) and an operant session. The conditioned stimulus was presented to a Paired group after each naloxone injection. Separate control groups experienced the conditioned stimulus either at a different time of the day or on a different day of the week than naloxone (Unpaired), received naloxone without any conditioned stimulus exposure [Paired-no conditioned stimulus (Paired-NO CS)] or received vehicle instead of naloxone before conditioned stimulus presentation (NaI-Naive). On the test day, all rats received vehicle before conditioned stimulus exposure. The conditioned stimulus alone reliably suppressed responding in Paired groups relative to control conditions with either daily or weekly intervals between conditioning sessions. The administration of morphine 4 h before conditioned stimulus exposure on the test day was not necessary to observe conditioned withdrawal. Thus, conditioned withdrawal is reliably established to discrete cues associated with naloxone-precipitated withdrawal from acute, infrequent (weekly) opioid exposure.

Evaluation of the role of abstinence in heroin overdose deaths using segmental hair analysis

In the body heroin is rapidly metabolized to 6-acetylmorphine and morphine. Victims of lethal heroin overdose often present with fairly low blood concentrations of morphine. Reduced tolerance due to abstinence has been proposed to account for this finding. The aim of the present study was to examine the role of abstinence in drug-related deaths by comparing recent and past exposure to opioids using segmental hair analysis with the postmortem blood morphine concentrations in deceased heroin users. The study included 60 deceased drug addicts in the Stockholm area, Sweden. In 32 cases, death was not related to heroin intake. In 18 of the 28 heroin fatalities, opioids were absent in the most recent hair segment, suggesting a reduced tolerance to opioids. However, the blood morphine levels were similar to those found in the 10 subjects that showed continuous opioid use. Hair and blood analysis disclosed an extensive use of additional drugs that directly or indirectly may influence the opioid system. The results suggest that abstinence is not a critical factor for heroin overdose death. Obviously tolerant subjects die after intake of similar doses. Other factors, particularly polydrug use, seem to be more causally important for these deaths.

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

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

A case report: Pavlovian conditioning as a risk factor of heroin 'overdose' death

BACKGROUND

The authors present a case illustrating a mechanism leading directly to death which is not rare but has received little attention.

CASE PRESENTATION

The case was evaluated by autopsy, investigation of morphine concentration in the blood, and clinical data. The heroin dose causing the 'overdose' death of a young man who had previously been treated a number of times for heroin addiction did not differ from his dose of the previous day taken in the accustomed circumstances. The accustomed dose taken in a strange environment caused fatal complications because the conditioned tolerance failed to operate. The concentration of morphine in the blood did not exceed the level measured during earlier treatment.

CONCLUSION

These results are in line with the data in the literature indicating that morphine concentrations measured in cases of drug-related death do not differ substantially from those measured in cases where the outcome is not fatal. A knowledge of the conditioning mechanism can contribute to prevention of fatal cases of a similar type. The harm reduction approach places great stress on preventive intervention based on data related to drug-related death.

A theory of drug tolerance and dependence I: a conceptual analysis

A mathematical model of drug tolerance and its underlying theory is presented. The model extends a first approach, published previously. The model is essentially more complex than the generally used model of homeostasis, which is demonstrated to fail in describing tolerance development to repeated drug administrations. The model assumes the development of tolerance to a repeatedly administered drug to be the result of a regulated adaptive process. The oral detection and analysis of exogenous substances is proposed to be the primary stimulus for the mechanism of drug tolerance. Anticipation and environmental cues are in the model considered secondary stimuli, becoming primary only in dependence and addiction or when the drug administration bypasses the natural-oral-route, as is the case when drugs are administered intravenously. The model considers adaptation to the effect of a drug and adaptation to the interval between drug taking autonomous tolerance processes. Simulations with the mathematical model demonstrate the model's behavior to be consistent with important characteristics of the development of tolerance to repeatedly administered drugs: the gradual decrease in drug effect when tolerance develops, the high sensitivity to small changes in drug dose, the rebound phenomenon and the large reactions following withdrawal in dependence. The mathematical model verifies the proposed theory and provides a basis for the implementation of mathematical models of specific physiological processes. In addition, it establishes a relation between the drug dose at any moment, and the resulting drug effect and relates the magnitude of the reactions following withdrawal to the rate of tolerance and other parameters involved in the tolerance process. The present paper analyses the concept behind the model. The next paper discusses the mathematical model.

An extinction cue reduces spontaneous recovery of ataxic ethanol tolerance in rats

RATIONALE AND OBJECTIVES

Ethanol ataxia experiments with rats investigated cue effects on conditioned tolerance. Spontaneous recovery (SR) was assessed 1 day and 18 days after extinction with conditioned stimuli (CSs) paired or unpaired with an ethanol unconditioned stimulus (US). Behavioral tolerance was assessed by not tilting the apparatus during conditioning. Non-associative processes were assessed post-conditioning with or without a buzzer cue. Bouton's (1993, Psychol Bull 114:80-99) memory theory was tested using an extinction cue and an associatively neutral cue presented during SR testing.

METHODS

Tolerance was conditioned to a room + strobelight CS by ethanol injections experienced on a tilting floor (standard conditioning). Controls received no ethanol or ethanol, either during the CS without the floor tilting or 11 h post-CS. SR testing occurred 1 day or 18 days after extinction (experiment 1). Conditioning was followed by tolerance and CR tests either with or without a 15-s buzzer cue (experiment 2). In extinction, the CS and cue occurred without ethanol; the cue occurred before 7% or none of the extinction trials. Testing occurred 18 days after extinction with or without that cue (experiment 3), or with an equally familiar ("neutral'') cue presented before conditioning (experiment 4).

RESULTS

Tolerance developed without floor tilting. CS-US unpairings prevented tolerance. Tolerance SR occurred 18 days but not 1 day after extinction only after CS-US pairings (experiment 1). Post-conditioning tests showed no unconditioned effects of the cue (experiment 2). Testing with no cue 1 day after extinction with the cue resulted in no tolerance increase. The extinction cue reduced SR (experiments 3 and 4); the neutral cue did not (experiment 4).

CONCLUSIONS

Cues correlated with extinction reduce SR. Non-associative and practice processes, Bouton's (1993, Psychol Bull 114:80-99) memory theory, alternative interpretations, and clinical implications are discussed.

Stimulation site determines the conditioned effects of kindling in rats: anterior neocortex versus amygdala

Rats received 53 stimulations to either the left basolateral amygdala (BA) or left anterior neocortex (AN) in one environment (CS+) and 53 sham stimulations (the stimulation lead was attached but no current was delivered) in another environment (CS-), quasirandomly over 54 days. Confirming a previous report [Barnes, S.J., Pinel, J.P., Francis, L.H. & Wig, G.S. (2001) Behav. Neurosci., 115, 1065-1072], as BA kindling progressed, the CS+ began to elicit more defensive behaviours (i.e. less activity, more freezing and avoidance of the CS+) than the CS-, and at the end of the experiment, convulsions elicited in the CS+ were more severe than those elicited in the CS-. Like BA kindling, AN kindling led to less activity in the CS+; but unlike BA kindling, AN kindling led to more wet-dog-shakes and less, rather than more, severe convulsions in the CS+. During AN kindling, the mean number of wet-dog-shakes in the CS+ was negatively correlated with the mean convulsion class, suggesting that wet-dog-shakes contribute to the inherent variability of AN kindling. These findings confirm that inherent conditioned effects influence kindled convulsions and interictal behaviour and establish for the first time that the pattern of these conditioned effects is a function of the kindling site.

Applying laboratory research: drug anticipation and the treatment of drug addiction

Basic research concerning drug tolerance and withdrawal may inform clinical practice, and vice versa. Three areas that integrate the work of the laboratory and the clinic are discussed: (a) drug overdose, (b) cue exposure treatment of addiction, and (c) pharmacological treatment of withdrawal symptoms. The areas are related in that they indicate the contribution of drug-paired cues to the effects of addictive drugs and the role of Pavlovian conditioning of drug effects in drug tolerance and withdrawal symptoms.

Influence of cue-conditioning on acquisition, maintenance and relapse of cocaine intravenous self-administration

Conditioning theories propose that, through a Pavlovian associative process, discrete stimuli acquire the ability to elicit neural states involved in the maintenance and relapse of a drug-taking behaviour. Experimental evidence indicates that drug-related cues play a role in relapse, however, their influence on the development and maintenance of drug self-administration has been poorly investigated. In this report, we analysed the effects of a drug-associated cue light on acquisition, maintenance and reinstatement of intravenous cocaine self-administration. The results show that a cocaine-associated cue light can act as an incentive in absence of the drug, but does not directly modify drug-reinforcing effects. Contingent and non-contingent presentations of a cocaine-associated cue light reinstated an extinguished self-administration behaviour. However, regardless of whether or not a cue light was associated with cocaine infusions, rats acquire cocaine intravenous self-administration reaching the same levels of intake. Furthermore, after self-administration has been acquired in presence of the cue light, the omission of the cue light or its non-contingent presentation did not modify rat behaviour. In conclusion, our work shows that cocaine-associated explicit cues do not directly interfere with the reinforcing effects of the drug.

Impairing the amphetamine conditioning in rats through the inhibition of hippocampal calcium/calmodulin-dependent protein kinase II activity

Amphetamine is an addictive drug, possessing reinforcing properties that are believed to be associated with an environmental cue, which resembles a behavioral learning process. This study investigates the role of calcium/calmodulin-dependent protein kinase II (CaM-kinase II) in the acquisition of the amphetamine-produced conditioned place preference (CPP). In Experiment I, rats were trained in an amphetamine-produced (2 mg/kg, i.p.) CPP task. The amphetamine-saline pairing rats spent significantly more time in the box that was associated with the amphetamine injection. Moreover, these rats' hippocampal CaM-kinase II showed significantly higher Ca(2+)-independent activity than that of the controls. In experiment II, the rats received an intra-hippocampal or intra-accumbens injection of specific CaM-kinase II inhibitor (KN-93) or a controlled agent (KN-92) before training in the amphetamine-produced CPP task. The rats receiving the preconditioning intra-hippocampal KN-93 injection showed no amphetamine-produced CPP effect. These results, taken together, indicate that the biological basis of amphetamine-produced place preference behavior might be regulated by the hippocampal CaM-kinase II activity.

Immersive virtual environments in cue exposure

Cue reactivity to drug-related stimuli is a frequently observed phenomenon in drug addiction. Cue reactivity refers to a classical conditioned response pattern that occurs when an addicted subject is exposed to drug-related stimuli. This response consists of physiological and cognitive reactions. Craving, a subjective desire to use the drug of choice, is believed to play an important role in the occurrence of relapse in the natural setting. Besides craving, other subjective cue-elicited reactions have been reported, including withdrawal symptoms, drug-agonistic effects, and mood swings. Physiological reactions that have been investigated include skin conductance, heart rate, salivation, and body temperature. Conditioned reactivity to cues is an important factor in addiction to alcohol, nicotine, opiates, and cocaine. Cue exposure treatment (CET) refers to a manualized, repeated exposure to drug-related cues, aimed at the reduction of cue reactivity by extinction. In CET, different stimuli are presented, for example, slides, video tapes, pictures, or paraphernalia in nonrealistic, experimental settings. Most often assessments consist in subjective ratings by craving scales. Our pilot study will show that immersive virtual reality (IVR) is as good or even better in eliciting subjective and physiological craving symptoms as classical devices.

D3 dopamine receptor, behavioral sensitization, and psychosis

Behavioral sensitization is a progressive, enduring enhancement of behaviors that develops following repeated stimulant administration. It is mediated in part by dopaminergic pathways that also modulate a number of psychiatric conditions including the development of psychosis. We propose that down-regulation of D3 dopamine receptor function in critical brain regions contributes to sensitization. Rodent locomotion, a sensitizable behavior, is regulated by the opposing influence of dopamine receptor subtypes, with D3 stimulation opposing concurrent D1 and D2 receptor activation. The D3 dopamine receptor has a 70-fold greater affinity for dopamine than D1 or D2 dopamine receptors. This imbalance in ligand affinity dictates greater occupancy for D3 than D1 or D2 receptors at typical dopamine concentrations following stimulant drug administration, resulting in differences in the relative tolerance at D3 vs D1 and D2 receptors. Sensitization may therefore result in part from accommodation of the inhibitory D3 receptor 'brake' on D1/D2 mediated behaviors, leading to a progressive locomotion increase following repeated stimulant exposure. The requirement for differential tolerance at D3 vs D1 and D2 receptors may explain the observed development of sensitization following application of cocaine, but not amphetamine, directly into nucleus accumbens. If correct, the 'D3 Dopamine Receptor Hypothesis' suggests D3 antagonists could prevent sensitization, and may interrupt the development of psychosis when administered during the prodromal phase of psychotic illness. Additional study is needed to clarify the role of the D3 dopamine receptor in sensitization and psychosis.

Cholinergic agents and the McCollough effect

The strength of the McCollough effect (ME), a pattern-contingent colour aftereffect, has been shown to be inversely related to acetylcholine, being significantly strengthened by (anticholinergic) scopolamine and weakened by (cholinergic) physostigmine delivered before adapting to the ME stimuli. The purpose of the present study was (i) to establish whether the effect of pre-adaptation scopolamine is linearly dose-dependent and (ii) to investigate the effects of scopolamine and physostigmine delivered between adaptation and testing. In experiment 1, ten healthy male volunteers who received placebo, or 0.6 mg, 1.2 mg, or 1.8 mg scopolamine before adapting to ME stimuli showed a significant linear dose-dependence over tests repeated from 10 to 70 min after adaptation. In experiment 2 twelve male volunteers adapted to ME stimuli and then received placebo, 1.2 mg oral scopolamine, or 0.75 mg subcutaneous physostigmine. On subsequent repeated testing, strength of the ME was increased by scopolamine and decreased by physostigmine relative to placebo. Both experiments were double-blind double-dummy repeated measures. These data support the view that the ME is a product of inhibitory mechanisms in the visual system rather than processes involved in associative learning.

Specificity of effects of chronically administered diazepam on the responding of rats under two different spaced-responding schedules

Lever pressing of rats was maintained in different chambers during two different sessions each day. At 0900 h, responding was maintained under a two-component multiple schedule in which responses initiated an interval that had to elapse before delivery of food (time delay of 20 s and 40 s). In this schedule, a 'response-pause' sequence preceded reinforcers, and acutely administered diazepam only decreased responding. At 1400 h, responding by the same subjects was maintained under a different two-component multiple schedule, in which individual responses initiated an interval that had to be terminated by another response before delivery of food (DRL 20 s and 40 s). In this second schedule, a 'response-pause-response' sequence preceded reinforcers, and acutely administered diazepam increased responding. After studying the acute behavioral effects of diazepam during each separate 'timing' schedule, animals systematically received 1.7 mg/kg per day diazepam 2-5 min prior to their different schedule components, in order to study the influence of reinforcement contingency on the chronic effects of this drug. Diminution of the initial effects of diazepam during daily drug administration prior to DRL 20 s responding did not extend to DRL 40 s responding or to time-delay responding, and tolerance did not develop at all for time-delay responding. When diazepam was again administered after all the daily schedules for approximately 1 month, and then given before the individual DRL schedules, DRL responding was increased again as it had been prior to chronic drug administration. These results suggest that the behavioral effects of acutely administered diazepam are influenced by different 'timing' requirements, and that the behavioral effects of chronically administered diazepam are influenced by 'timing' requirements and by drug- and chamber-related stimuli.

A locus and mechanism of action for associative morphine tolerance

Repeated administration of an opioid in the presence of specific environmental cues can induce tolerance specific to that setting (associative tolerance). Prolonged or repeated administration of an opioid without consistent contextual pairing yields non-associative tolerance. Here we demonstrate that cholecystokinin acting at the cholecystokinin-B receptor is required for associative but not non-associative morphine tolerance. Morphine given in the morphine-associated context increased Fos-like immunoreactivity in the lateral amygdala and hippocampal area CA1. Microinjection of the cholecystokinin B antagonist L-365,260 into the amygdala blocked associative tolerance. These results indicate that cholecystokinin acting in the amygdala is necessary for associative tolerance to morphine's analgesic effect.

Multiple chemical sensitivity as a conditional response

Pavlovian conditioning may contribute to some cases of multiple chemical sensitivity (MCS). On the basis of the conditioning analysis, environmental stimuli (especially olfactory cues) present at the time of a toxicant overdose become associated with the toxicant and elicit aversive conditional responses. Similar associations have been reported in patients receiving chemotherapy, and the literature on such 'pretreatment nausea' in cancer patients is relevant to understanding the role of conditioning in MCS. Evaluation of the contribution of conditioning to MCS has been complicated by confounding interpretations that emphasize conditional responses with interpretations which emphasize the psychiatric status of the patient. Appreciation of the contribution of Pavlovian conditioning to MCS will lead to a better understanding of this complex disorder.

Further analysis of the separate and interactive effects of methylphenidate and common classroom contingencies

We evaluated separate and interactive effects between common classroom contingencies and methylphenidate (MPH) on disruptive and off-task behaviors for 4 children with a diagnosis of attention deficit hyperactivity disorder. Analogue conditions consisting of contingent teacher reprimands, brief time-out, no interaction, and alone were conducted in a multielement design. Medication status (MPH or placebo) was alternated across days in a superordinate multielement design. Results indicate that (a) the behavioral effects of MPH were influenced by one or more of the analogue conditions for each participant, and (b) time-out was associated with zero or near-zero levels of both disruptive and off-task behavior for 3 of the 4 participants during MPH and placebo conditions. Implications for the clinical effectiveness of MPH and possible behavioral mechanisms of action of MPH in applied settings are discussed.

Learning and tolerance to the ataxic effect of ethanol

It has been well documented that drug-associated cues are important for the development and expression of drug tolerance. The Pavlovian conditioning analysis of tolerance emphasizes the importance of a drug-associated cues to tolerance by equating a drug administration with a learning trial. According to this analysis, tolerance should be subject to external inhibition, the disruption of a conditional response by a novel stimulus. We previously reported that tolerance to the ataxic effect of ethanol was attenuated by a novel strobe/noise presentation (31). In this article we report evidence of a compensatory CR in rats tolerant to the ataxic effect of ethanol as tested on the tilting plane. Both the compensatory CR and tolerance were disrupted by the presentation of a novel strobe/noise stimulus providing converging evidence that the attenuation of tolerance by a novel stimulus results from external inhibition of Pavlovian conditioning. The disruption of ethanol tolerance and the conditional response mediating tolerance was also apparent when the novel omission of the strobe/noise stimulus was used as the external inhibitor in rats made tolerant to ethanol with the stimulus on. Finally, we have shown that the disruptive effect of a novel stimulus on ethanol tolerance is decreased when there is a 10-day delay between the final tolerance development session and testing, demonstrating that the interval between training and testing is important when assessing associative tolerance.

Pavlovian conditioning and multiple chemical sensitivity

Pavlovian conditioning processes may contribute to some symptoms of multiple chemical sensitivity (MCS). This review summarizes the potential relevance of the literature on conditional taste and olfactory aversions, conditional sensitization, and conditional immunomodulation to understanding MCS. A conditioning-based perspective on MCS suggests novel research and treatment strategies.

Disruption of tolerance to the ataxic effect of ethanol by an extraneous stimulus

According to a conditioning analysis, pharmacological conditional responses (CRs) contribute to tolerance. We previously reported that, as expected on the basis of this model, tolerance to the hypothermic effect of ethanol is attenuated by "external inhibition," for instance, by presentation of a novel stimulus (a strobe). However, results of more recent research indicate that novel stimuli augment the hypothermic effect of ethanol in rats receiving the drug for the first time. It is possible, therefore, that a novel stimulus apparently attenuates ethanol tolerance because it augments ethanol-hypothermia, rather than because it functions as an external inhibitor. Two experiments were designed to evaluate external inhibition of tolerance to another effect of ethanol-ataxia. Although the initial ataxic effect of the drug (unlike the hypothermic effect) is not enhanced by a novel stimulus, the stimulus reinstated ethanol-induced ataxia in tolerant rats. The results demonstrate external inhibition of ethanol tolerance in a preparation not confounded by the effects of the novel stimulus on initial responding to ethanol.

Pavlovian conditioning of morphine hyperthermia: assessment of interstimulus interval and CS-US overlap

The present study examined the effect of interstimulus interval on acquisition of conditioned thermal responses produced by trials in which a light/noise stimulus (CS) was repeatedly paired with infusion of morphine sulphate (US). Rats were implanted with a chronic intravenous catheter for drug delivery and a biotelemetry device for remote monitoring of core body temperature. In experiment 1, different groups received morphine either 0.5 (group P0.5) or 15 min (group P15) after onset of the 15-min CS. A third group was exposed to an identical number of CS and US presentations but in an explicitly unpaired manner (group UP). After repeated exposure to morphine, all groups showed a more rapid rise in body temperature in response to drug infusion. Test presentations of CS alone revealed conditioned hyperthermic responses to CS in groups P0.5 and P15. However, the response of the P15 group was smaller than that of the P0.5 group, suggesting weaker conditioning at the longer interstimulus interval. The contribution of CS-US overlap to the diminished associative strength observed in the P15 group was assessed in experiment 2. Groups P0.5/15 and P0.5/30 received infusions of morphine 0.5 min after onset of a 15- or 30-min CS, respectively. Group P15/30 received morphine 15 min after onset of a 30 min CS, whereas group UP/30 received explicitly unpaired presentations of the US and a 30-min CS. Enhancement of the hyperthermic effect of morphine was observed in all groups after ten conditioning trials. Test presentations of the CS without drug revealed that all paired groups had acquired conditioned hyperthermic responses. These results support the conclusion that drug-induced conditioning can occur at relatively long interstimulus intervals when there is sufficient temporal overlap between the CS and unconditioned response evoked by the drug US.

Loss of tolerance to morphine after a change in route of administration: control of within-session tolerance by interoceptive conditioned stimuli

Tolerance to morphine analgesia (tail-immersion test) was examined after manipulation of two aspects of a tolerance test: 1) the route of drug administration and 2) the time interval between the test dosing and the tolerance test. The intravenous (IV) and intraperitoneal (IP) routes were used, together with a novel test for tolerance in which the test morphine was infused IV just 2 min before measuring the opiate effect. The first experiment validated this test as an assay for tolerance by examining the log dose-response (LDR) curve changes produced by daily IP injection with 0, 20 or 200 mg/kg morphine; the IV test confirmed the expected parallel shift to the right and flattening of the LDR curve. In the second experiment, all rats of two groups were injected once daily for 3 weeks with 20 mg/kg morphine and with saline except that one group received the morphine IV (and saline IP), the other morphine IP (saline IV). The results indicated route-specific tolerance. On a test using 20 mg/kg given IV morphine, tolerance was significantly greater in rats treated with IV morphine than in those treated IP. However, a larger effect on tolerance was produced by a pretest application of 5 mg/kg morphine 30 min before the actual tolerance test. This manipulation was designed to "prime" short-term, adaptive processes hypothesized to occur within a normal tolerance test session as morphine is taking effect. The tolerance on the test increased (equivalent to 2 to 3 fold shift in the LDR curve) when the pretest morphine was given with the same route as the chronic morphine, regardless of treatment group. It was concluded that opiate tolerance may be modulated by conditioned stimuli produced by morphine acting through different routes. These interoceptive cues appear to modulate rapidly acquired and short-lived adaptive processes taking place within a given test session.

Opioid use in advanced malignant disease: why do different centers use vastly different doses? A plea for standardized reporting

This paper reviews several recent publications concerning the use of opioids to control cancer pain and highlights the wide variation in mean daily dose. Present methods of reporting do not provide an explanation for these widely different doses used. It is essential that we understand the circumstances in which high doses are required, as higher doses are associated with greater toxicity and higher cost. Several factors that may influence the dose of opioid required are discussed. It is suggested that reporting of cancer pain, patient population, pharmacological and nonpharmacological interventions, and toxicity be standardized to allow for rational guidelines to be established for opioid use in pain due to advanced cancer.

Context-specific sensitization to naloxone-precipitated withdrawal in hamsters: effect of pimozide

Three experiments were conducted to investigate the development of context-specific sensitization to naloxone-precipitated withdrawal in hamsters. In Experiment 1, animals in group M/S were given morphine (15 mg/kg) injections in a distinctive environment and saline in the home cage. Animals in group S/M were given saline in the distinctive environment and morphine in the home cage, and animals in group S/S were given saline in both environments. All groups were challenged subsequently with naloxone (0.4 mg/kg) in the distinctive environment and then observed for signs of opiate withdrawal. The results showed that group M/S gave more naloxone-precipitated withdrawal signs than each of the other groups, which did not differ from one another. Experiment 2 was designed to test the effect of pimozide on context-specific sensitization to naloxone-precipitated withdrawal. The design was similar to that of Experiment 1 but group P/M/S, which received an injection of pimozide (0.5 mg/kg) 4 h prior to morphine, was added. The results indicated that context-specific sensitization developed as in Experiment 1, except among animals treated with pimozide. Experiment 3 was designed to determine whether pimozide interferes with the development or the expression of context-specific sensitization. Six groups, differing in the frequency and timing of the pimozide injection, were employed. The results indicated that pimozide interfered with context-specific sensitization, whenever it was given. It is concluded that pimozide interferes with the expression of context-specific sensitization, although a separate effect on the development of sensitization is not ruled out.

Psychotropic drug consumption and other factors associated with heroin overdose

In clinical or forensic practice there are few studies assessing which risk factors are associated with heroin overdoses. A series of 76 consecutive non-fatal heroin overdoses were compared to 22 consecutive subjects who self-injected heroin within 1 h before admission to the emergency room. Whereas blood levels of alcohol and IgE and urinary cocaine metabolite levels were similar in both groups, higher benzodiazepine plasma levels were detected in the heroin overdose group. The assessment of methadone, dextropropoxyphene, amphetamines and cannabis in urine analysis did not show differences between both groups. The interview revealed that only 48% of subjects in the heroin overdose group self-administered the last dose of heroin before admission in the usual setting as compared to 100% of subjects in the non-overdose group. The application of a log-linear regression model identified self-injection of heroin in an unusual place and plasma concentrations of total morphine and benzodiazepines as risk factors for heroin overdose.