Understanding polydrug use: review of heroin and cocaine co-use

Are all drug addicts impulsive? Effects of antisociality and extent of multidrug use on cognitive and motor impulsivity

The purpose of this investigation was to examine the influence of antisociality and extent of multidrug use on cognitive and motor impulsivity among substance-dependent individuals (SDIs) that used primarily cocaine and/or heroin. One hundred currently abstinent male SDIs participated in the study. Extent of multidrug use and degree of antisociality, assessed with the Socialization Scale of the California Psychological Inventory (So-CPI), were used to classify participants into one of four groups: high antisocial/low multidrug use, high antisocial/high multidrug use, low antisocial/low multidrug use, and low antisocial/high multidrug use. All subjects completed the Iowa Gambling Task to assess cognitive impulsivity and the Stroop Task to measure motor impulsivity. Contrary to expectations, antisociality was associated with more advantageous performance on the Iowa Gambling Task, independent of extent of multidrug use. In contrast, greater multidrug use was associated with general psychomotor slowing on the Stroop Task. Results suggest that a subclinical form of antisociality may have a paradoxically facilitating effect on decision-making and cognitive impulsivity among SDIs.

Efficacy of central nervous system stimulant treatment for cocaine dependence: a systematic review and meta-analysis of randomized controlled clinical trials

AIMS

To evaluate the efficacy of central nervous system (CNS) stimulants compared with placebo for the treatment of cocaine dependence.

METHODS

A systematic review and meta-analysis was carried out. Bibliographic databases were searched, reference lists of retrieved studies were hand-searched and the first authors of each study were contacted. All randomized controlled clinical trials (RCCT) comparing the efficacy of any CNS stimulant with placebo in cocaine-dependent patients were included. Quantitative data synthesis was performed for each single CNS stimulant and for all CNS stimulants.

RESULTS

Nine RCCT met the inclusion criteria. These RCCT included 640 patients and compared five CNS stimulants: mazindol, dextroamphetamine, methylphenidate, modafinil and bupropion with placebo. No CNS stimulant improved study retention [RR = 0.94 (0.81-1.09)] or cocaine use [RR = 0.90 (0.79-1.02)]. An exploratory analysis using indirect estimations of cocaine use showed that the proportion of cocaine-positive urine screens was lower with dexamphetamine than with placebo [RR = 0.73 (0.60-0.90)] and that all CNS stimulants pooled together also suggested a significant decrease of cocaine use [RR = 0.87 (0.77-0.99)]. Data on craving could not be meta-analysed due to heterogeneity, but no RCCT found differences in cocaine craving between active drug and placebo except one, whose outcome favoured dexamphetamine. No serious adverse event (AE) was reported. Average of AE-induced dropouts was low and was greater for CNS stimulants than placebo: 4.4% versus 1.3% (P = 0.03).

CONCLUSION

The main outcomes of this study do not support the use of CNS stimulants for cocaine dependence. Nevertheless, secondary analyses provide some hopeful results that encourage further research with these drugs, mainly with dexamphetamine and modafinil.

[Multiple psychoactive substance use (alcohol, tobacco and cannabis) in the French general population in 2005]

OBJECTIVE

To quantify the different forms of polydrug use in the French population and the principal factors associated with it.

METHODS

Data came from the Baromètre Santé 2005, a general population study. Polydrug use was approached by 2 indicators: regular use of at least 2 products among alcohol, tobacco and cannabis, and the use during the year of at least 2 illegal drugs besides cannabis (not necessarily concomitantly).

RESULTS

Regular use of some combination of alcohol, tobacco and cannabis was reported by 8.3% of the population. Those aged 20-24 years combined tobacco and cannabis most frequently, with 11.6% reporting this joint use. Regular consumption of all 3 products was rare, reported by less than 1% of those aged 15-64 years. It was highest among those aged 20-29 years, but still less than 2% of the age group. The principal combination for those aged 35 years or older was alcohol and tobacco, and those in this group rarely combined cannabis with another substance. There was a strong association between cannabis use and use of other illicit psychoactive substances. Lifetime use of illicit psychoactive substances except for cannabis was reported by 10.0% of the 15-34 year-olds; for use during the previous year, it was 2.3%. The factors associated with these practices were unemployment, male gender, and youth. Postsecondary education appeared to distance young adults from the different forms of polydrug use.

DISCUSSION

Because use of multiple psychoactive substances is often associated with risk-taking or vulnerability, particular attention to these practices is justified. Surveys in the general population do not cover the most vulnerable or most "desocialized" populations and do not allow the most dangerous forms of polydrug use to be described. They supply useful information for assessing the extent of the most common combined uses in the population and their probable health and social repercussions.

Mono- versus polydrug abuse patterns among publicly funded clients

To examine patterns of mono- versus polydrug abuse, data were obtained from intake records of 69,891 admissions to publicly funded treatment programs in Tennessee between 1998 and 2004. While descriptive statistics were employed to report frequency and patterns of mono- and polydrug abuse by demographic variables and by study years, bivariate logistic regression was applied to assess the probability of being a mono- or polydrug abuser for a number of demographic variables. The researchers found that during the study period 51.3% of admissions reported monodrug abuse and 48.7% reported polydrug abuse. Alcohol, cocaine, and marijuana were the most commonly abused substances, both alone and in combination. Odds ratio favored polydrug abuse for all but one drug category-other drugs. Gender did not affect drug abuse patterns; however, admissions for African Americans and those living in urban areas exhibited higher probabilities of polydrug abuse. Age group also appeared to affect drug abuse patterns, with higher odds of monodrug abuse among minors and adults over 45 years old. The discernable prevalence of polydrug abuse suggests a need for developing effective prevention strategies and treatment plans specific to polydrug abuse.

Crack-heroin speedball injection and its implications for vein care: qualitative study

BACKGROUND

We report on an exploratory qualitative study investigating drug injectors' narratives of vein damage and groin (femoral vein) injection associated with the injection of crack-heroin speedball.

METHODS

We undertook 44 in-depth qualitative interviews among injectors of crack-heroin speedball in Bristol and London, England, in 2006.

FINDINGS

The data suggest an emerging culture of crack-based speedball injection. Injectors' narratives link speedball injection with shifts towards groin injection articulated as an acceptable risk, and not merely as a last resort in the face of increased vein deterioration associated with speedball. Accounts of vein damage linked to speedball emphasize 'missed hits' related to the local anaesthetic action of crack, the excess use of citric in the preparation of speedball injections and 'flushing' when making a hit. We find that groin injection persists despite an awareness of health risks and medical complications.

CONCLUSIONS

We emphasize an urgent need for reviewing harm reduction in relation to vein care in the context of shifts to crack-based speedball injection, and the use of the femoral vein, among UK injectors. There is an additional need for interventions to promote safer groin and speedball injecting as well as to prevent transitions toward groin and crack injection.

A behavioral economic analysis of cocaine and remifentanil self-administration in rhesus monkeys

RATIONALE

Behavioral economics can be used to evaluate the relative reinforcing effectiveness of drugs and the economic interaction between drugs, information which may help to explain patterns of polydrug abuse in humans.

OBJECTIVES

In phase 1, the reinforcing effectiveness of the opiate remifentanil and the stimulant cocaine was compared using a demand-curve analysis. In phase 2, the economic relation between these drugs was determined.

MATERIALS AND METHODS

Rhesus monkeys pressed levers according to fixed-ratio schedules for intravenous drug infusions. A demand-curve analysis was conducted (phase 1) in which drug consumption was measured as the response requirement, or price, was increased, and the rate at which consumption decreased with increases in price (demand elasticity) provided an index of the reinforcing effectiveness of each drug. Cocaine and remifentanil were then available concurrently (phase 2), and the price of one drug was increased (the manipulated-price alternative) while the price of the other drug was held constant (the fixed-price alternative). Consumption of the fixed-price alternative was measured as a function of increases in the price of the manipulated-price alternative, and demand for the manipulated-price alternative was assessed.

RESULTS

The reinforcing effectiveness of cocaine and remifentanil did not significantly differ, and these drugs functioned as economic substitutes. As the price of the manipulated-price alternative increased, consumption of the fixed-price alternative increased. In addition, demand for the manipulated-price alternative became more elastic with the concurrent availability of the fixed-price alternative.

CONCLUSION

Polydrug use involving stimulants and opiates may occur because these drugs are highly substitutable.

Fatalities associated with fentanyl and co-administered cocaine or opiates

Fatalities associated with fentanyl hydrochloride are increasingly seen in Massachusetts. Between September 2005 and November 2006, 5009 medicolegal investigations associated 107 deaths with licit or illicit fentanyl use, along with a co-detection of an opiate/opioid or cocaine/benzoylecognine, or both. Deaths associated with illicit fentanyl use occur in younger people (39.4 vs. 61.5 years) with higher fentanyl (17.1 ng/mL vs. 4.4 ng/mL) and lower morphine (76.9 ng/mL vs. 284.2 ng/mL) postmortem blood concentrations, and more frequent cocaine co-intoxication (65% vs. 3%), than deaths associated with illicit fentanyl use. A wide range of postmortem blood concentrations of fentanyl was detected (trace-280 ng/mL), with a minimum concentration of 7 ng/mL of fentanyl strongly associated with illicit use of fentanyl in poly-drug cases. The most commonly detected opiates/opioids in illicit fentanyl users were: morphine (29%), oxycodone (14.5%), and methadone (14.5%). Ethanol, cannabinoids, diazepam, citalopram, and diphenhydramine were each detected in greater than 10% of the licit fentanyl cases. Most fentanyl abusers died at their own home and their deaths were most often classified as accidental. Mapping of primary residences of decedents revealed conspicuous clustering of the illicit fentanyl use cases, as opposed to the random pattern in licit use cases. Fentanyl misuse is a public health problem in Massachusetts.

Involvement of free radicals followed by the activation of phospholipase A2 in the mechanism that underlies the combined effects of methamphetamine and morphine on subacute toxicity or lethality in mice: Comparison of the therapeutic potential of fullerene, mepacrine, and cooling

An increase in polydrug abuse is a major problem worldwide. The coadministration of methamphetamine and morphine increased subacute toxicity or lethality in rodents. However, the underlying mechanisms by which lethality is increased by the coadministration of methamphetamine and morphine are not yet fully understood. Coadministered methamphetamine and morphine induced lethality by more than 80% in BALB/c mice, accompanied by the rupture of cells in the kidney and liver, and an increase in poly (ADP-ribose) polymerase (PARP)-immunoreactive cells in the heart, kidney and liver. The lethal effect and the increase in the incidence of rupture or PARP-immunoreactive cells induced by the coadministration of methamphetamine and morphine was significantly attenuated by pretreatment with mepacrine (phospholipase A(2) inhibitor) or fullerene (a radical scavenger), or by cooling from 30 to 90 min after drug administration. Furthermore, based on the results of the electron spin resonance spin-trapping technique, hydroxyl radicals were increased by the administration of methamphetamine and morphine, and these increased hydroxyl radicals were potently attenuated by fullerene and cooling. These results suggest that hydroxyl radicals plays an important role in the increased lethality induced by the coadministration of methamphetamine plus morphine. The potency of cooling or drugs for decreasing the subacute toxicity or lethality induced by the coadministration of methamphetamine and morphine was in the order fullerene=cooling>mepacrine. These results indicate that fullerene and cooling are beneficial for preventing death that is induced by the coadministration of methamphetamine and morphine.

Spectroscopic and electrochemical studies of cocaine–opioid interactions

The drugs of abuse cocaine (C), heroin (H), and morphine (M) have been studied to enable understanding of the occurrence of cocaine-opioid interactions at a molecular level. Electrochemical, Raman, and NMR studies of the free drugs and their mixtures were used to study drug-drug interactions. The results were analyzed using data obtained from quantum-mechanical calculations. For the cocaine-morphine mixture (C-MH), formation of a binary complex was detected; this involved the 3-phenolic group and the heterocyclic oxygen of morphine and the carbonyl oxygen and the methyl protons of cocaine's methyl ester group. NMR studies conducted simultaneously also revealed C-MH binding geometry consistent with theoretical predictions and with electrochemical and vibrational spectroscopy results. These results provide evidence for the occurrence of a cocaine-morphine interaction, both in the solid state and in solution, particularly for the hydrochloride form. A slight interaction, in solution, was also detected by NMR for the cocaine-heroin mixture.

Modulation of heroin and cocaine self-administration by dopamine D1- and D2-like receptor agonists in rhesus monkeys

Cocaine-heroin combinations ("speedballs") are commonly self-administered by polydrug abusers. Speedball self-administration may reflect in part an enhancement of the reinforcing effects of the drug combination compared with either drug alone. The present study investigated the degree to which the dopamine receptor system plays a role in cocaine-induced enhancement of heroin self-administration. In rhesus monkeys trained under a progressive ratio schedule of i.v. drug injection, combining heroin with cocaine shifted the heroin dose-response function leftward, and isobolographic analysis indicated that the combined effects were dose-additive. Likewise, combining heroin with the D1-like receptor agonists 6-chloro-7,8-dihydroxy-1-phenyl-2,3,4,5-tetrahydro-(1H)-3-benzazepine HCl (SKF 81297) and 6-chloro-N-allyl-7,8-dihydroxy-1-phenyl-2,3,4,5-tetrahydro-[1H]-3-benzazepine (SKF 82958) resulted in a leftward shift in the heroin dose-response function that was dose-additive. In contrast, combining heroin with the D2-like agonists R-(-)-propylnorapomorphine (NPA) and quinpirole shifted the heroin dose-response function to the right. Isobolographic analysis of the combined effects of heroin with NPA and quinpirole revealed infra-additive interactions in both cases. When combined with cocaine instead of heroin, both the D1-like receptor agonist SKF 81297 and the D2-like receptor agonist NPA enhanced cocaine self-administration. The combinations of SKF 81297 with cocaine were dose additive; however, the NPA-cocaine interaction was infra-additive. Together, the results suggest that D1- and D2-like receptor mechanisms may play qualitatively different roles in the combined self-administration of heroin and cocaine. In particular, stimulation of D1-like receptors enhances self-administration of heroin or cocaine individually, similar to the effects of combining cocaine with heroin, whereas stimulation of D2-like receptors seems to play primarily an inhibitory role.

New developments in the pharmacotherapy of cocaine abuse

Despite huge advances in the neuroscience of substance abuse and dependence in the past 20 years, no approved pharmacological treatment exists for cocaine abuse. The available drugs for the treatment of cocaine abuse are poorly effective, hence the need for new compounds to be screened and tested for efficacy: targeting symptoms might improve the effectiveness of the treatment of cocaine abuse and dependence. On the basis of the known neurochemistry of cocaine, some target compounds have been studied: among others, BP-897, a D3 partial agonist; vanoxerine, a highly selective inhibitor of dopamine uptake; aripiprazole, a partial mixed-action agonist approved for the treatment of schizophrenia. Recently modafinil, approved for the treatment of narcolepsy, proved effective in favouring cocaine abstinence in cocaine-abusing people. Some placebo-controlled studies also reported the effectiveness of topiramate, a licensed antiepileptic drug, and of tiagabine, a gamma-aminobutyric acid (GABA) re-uptake inhibitor also approved as an anticonvulsant; both compounds increased cocaine abstinence with no serious adverse events. Promising results came from two more compounds acting on the GABA circuits, baclofen and valproic acid. Finally disulfiram, prescribed with active psychosocial therapy, was found to favour higher retention rates and longer abstinence periods from both alcohol and cocaine in polydrug-abusing patients. An alternative approach rests on the use of vaccines, to date in the experimental stage still. Psychosocial treatments are a useful companion in the pharmacotherapy of cocaine abuse, with group therapy and contingency management therapies improving motivation and social functioning, particularly in patients abusing alcohol as well.

Pharmacotherapy of dual substance abuse and dependence

The US FDA has approved a limited number of treatments for alcohol, nicotine and opioid dependence; however, no treatments for other abused drugs such as marijuana, cocaine or methamphetamine are approved. This review focuses on research into drug pharmacotherapies, particularly single-drug therapies, for substance abuse and dependence contributing to the most important dual substance use disorders (SUDs). Given the implications of poly-substance abuse, it is essential that clinicians and researchers be aware of potential pharmacotherapies for the treatment of dual SUDs.A substantial number of patients abuse more than one drug concurrently, complicating the treatment of SUD and leaving clinicians with few FDA-approved drug options for their patients. In this era of evidence-based medicine, such patients are typically treated with therapeutically proven medications, but in ways that are outside the scope of a drug's original indication by the FDA. Such 'off-label' prescribing has become an important therapeutic strategy for practitioners seeking treatments for other diseases in subpopulations such as paediatrics and gerontology or for medical conditions such as oncology or mental illness. Similarly, the information that most clinicians use to make their decisions for treating patients abusing multiple drugs stems from trials treating a single SUD, anecdotal experiences from their own practice or that of their colleagues, or single-case studies reported in the literature. The existing evidence suggests there are few treatments for SUDs that confer significant reductions in substance use across a broad patient population. Moreover, even fewer clinical efficacy trials have been conducted that provide evidence of therapeutic benefit for these drugs. Recognising the difficulty in making the proper drug choice for facilitating maximum treatment success, this review highlights the single drugs or drug combinations that show some potential for treating dual SUDs. This review finds strongest support for the use of disulfiram for treatment of alcohol and cocaine dependence (with or without concomitant methadone maintenance), baclofen for alcohol and cocaine dependence (but not opioid-dependent cocaine users), tiagabine for cocaine dependence in methadone-maintained patients, and topiramate for alcohol, nicotine and cocaine dependence. While ondansetron and olanzapine show some efficacy in treating alcohol and cocaine dependence, more research is needed to better delineate the subpopulation in which these drugs may provide their maximum effect.

Cognitive impulsivity in cocaine and heroin polysubstance abusers

RATIONALE

Chronic abuse of psychoactive substances produces significant deficits in executive control functions (ECF). These deficits are prominent in different domains associated with cognitive impulsivity, including response inhibition and decision-making. The extent and nature of these deficits may depend on the principal substance of abuse.

OBJECTIVES

To analyse response inhibition and decision-making performance in abstinent polysubstance abusers (PSA) of cocaine and heroin, and healthy participants.

METHODS

We used univariate and multivariate analyses of variance to compare the performances of cocaine and heroin PSA and healthy controls on several well-validated measures of response inhibition (Stroop, 5-Digit Test and Go/No Go Task) and decision-making (Iowa Gambling Task). Post-hoc exploratory analyses of the results from the Go/No Go task were conducted to examine specific effects of task switching on the pattern of omission/commission errors in the PSA groups.

RESULTS

Cocaine but not heroin PSA showed significant deficits on several measures of response inhibition, when compared to controls. Reversal of task contingencies in the Go/No Go task primarily altered the commission error rate in cocaine PSA, and the omission error rate in heroin PSA. In contrast, both cocaine and heroin PSA showed poorer performance on decision-making compared to controls.

CONCLUSIONS

Assuming the relevance of polysubstance involvement, cocaine abuse seems to differentially correlate with motor impulsivity skills, while both substances seem to be equally linked to the inability to decide advantageously in complex decision-making tasks. Possible discrepancies in the neurological and psychological effects of these drugs are discussed.

Using latent class analysis (LCA) to analyze patterns of drug use in a population of illegal opioid users

BACKGROUND

The objective of this paper is to empirically determine a categorization of illegal opioid users in Canada in order to describe and analyze drug use patterns within this population.

METHODS

Drug use patterns of 679 eligible illegal opioid users outside treatment from the OPICAN study, a pan-Canadian cohort (recruited March to December, 2002) involving the cities of Toronto, Montreal, Vancouver, Edmonton and Quebec City, were empirically examined using latent class analysis. These latent classes were then further analyzed for associations using chi-square and t-test statistics.

FINDINGS

The opioid and other drug user sample surveyed were categorized into three latent classes. Class 1 (N=256) was characterized by the use of Tylenol 3 and benzodiazepines along with high levels of depression and self-reported pain. Class 2 (N=68) was described by the non-injection use of both heroin and crack while having a high level of homelessness. Class 3 (N=344) was shown to consist of injection drug users of heroin and cocaine exhibiting the highest levels of HIV and Hepatitis C infections amongst the classes.

CONCLUSIONS

Using latent class analysis we found distinct patterns of drug use amongst illegal opioid users differing in terms of type of drugs co-used, social context, and co-morbid pathologies. These data may be useful as the empirical basis for the planning of specific prevention and treatment interventions.

Clonidine attenuates morphine withdrawal and subsequent drug sensitization in rhesus monkeys

AIM

Clonidine is an alpha2 adrenoceptor agonist that is frequently used to reduce withdrawal symptoms during opioid detoxification in humans. The long-term effects of clonidine on withdrawal symptoms and its effects on subsequent drug exposure have not been thoroughly documented. The aim of the study was to determine if clonidine administered during morphine withdrawal in rhesus monkeys produces long-lasting effects on withdrawal symptoms and alters the effects of subsequently taken drugs of abuse.

METHODS

Adult male rhesus monkeys were treated with increasing doses of morphine for 90 d to induce opiate (narcotic) dependence. The immediate and long-lasting effects of 1 week's administration of clonidine were measured via the recording of morphine withdrawal signs and the subsequent effects of challenge injections of morphine or cocaine.

RESULTS

Monkeys chronically treated with morphine displayed withdrawal signs that lasted 2 weeks after cessation of morphine administration and displayed sensitized responses to subsequent morphine and cocaine injections. Clonidine significantly reduced certain morphine withdrawal signs and overall withdrawal score, but these effects did not persist upon cessation of clonidine treatment. Sensitization to the effects of morphine and cocaine were significantly reduced in monkeys previously treated with clonidine.

CONCLUSION

Our results suggest that in addition to its short-term alleviating effect on morphine withdrawal signs, clonidine may reduce subsequent effects of drugs of abuse after prolonged abstinence.

History of cocaine self-administration alters morphine reinforcement in the rat

It has been shown repeatedly that cocaine pre-exposure may sensitise neurochemical and behavioural responses to opioid drugs. The aim of the present study was to investigate effects of a prior history of cocaine self-administration on morphine reinforcement in the rat. Male Sprague-Dawley rats were allowed to acquire intravenous cocaine self-administration (0.3 mg/kg/infusion) for 20 days. When operant responding for cocaine had stabilised, morphine was introduced instead of cocaine in the next self-administration session. One group of cocaine-exposed rats was allowed to respond for 0.56 mg/kg/infusion of morphine (i.e. the dose which was willingly self-administered by drug-naive controls). The second group was allowed to respond for 0.056 mg/kg/infusion of morphine (i.e. the dose which did not maintain self-administration behaviour in the drug-naive rats). The subjects with the history of cocaine self-administration, in contrast to the drug-naive group, did not maintain operant responding for 0.56 mg/kg/infusion of morphine. These rats easily self-administered the ten times lower dose of the opioid (0.056 mg/kg/infusion). An opioid receptor antagonist, naltrexone (1 mg/kg i.p.) restored the positive reinforcing properties of the higher dose of morphine in the cocaine-exposed rats. Concluding, the present results suggest that prior history of cocaine self-administration sensitises rats to the positive reinforcing properties of morphine.

Buprenorphine misuse among heroin and amphetamine users in Malmo, Sweden: purpose of misuse and route of administration

Buprenorphine misuse by injecting drug users was assessed in a survey of 350 needle exchangers, either amphetamine (57%) or heroin users (42%). 89% of heroin users and 24% of amphetamine users reported using buprenorphine at some time during the previous year. Most users reported illicit acquisition. Among illicit users, 87% of heroin users reported intake for withdrawal treatment or self-detoxification, and 11% for euphoria. Euphoria seeking was more common among amphetamine users (62%, p < 0.001). Intravenous misuse was reported by 43% of illicit users, and snorting by 29%. Sole sublingual intake was more common among heroin users than among amphetamine users (46 vs. 20%, p < 0.05), and less common among patients reporting euphoria seeking (20 vs. 46%, p < 0.05).

Drug use patterns and drug-related disorders of cocaine users in a sample of the general population in Germany

AIMS

The prevalence of cocaine use is still very low in Germany, but rates have been increasing over the past few decades. Patterns of drug consumption and related adverse consequences in individuals who have used cocaine were investigated in order to distinguish different types of cocaine users.

METHODS

Data come from two national representative surveys on substance abuse in the German general population conducted in 1997 and 2000 using self- administered questionnaires. Overall response rates were 65 and 51%, respectively. The two samples were pooled (n = 16,159) and latent cluster analysis was conducted using a sub-sample of 272 lifetime cocaine users.

RESULTS

Three clusters were derived: the majority belonged to the group of mainly unproblematic users (UPG, 80%), the second group comprised non-amphetamine poly-problem drug users (NAPPG, 12%), and a small group was composed of poly-problem drug users (PPG, 8%). Comparisons of sociodemographic characteristics, consumption patterns and age of onset for licit and illicit drug use revealed significant differences between the groups.

CONCLUSIONS

The majority of cocaine users in the general population are experimental or occasional users of licit and illicit drugs. Rather than being a major drug, cocaine is one of many other licit and illicit drugs. Cocaine use as part of predominantly poly-drug use behaviour is strongly associated with substance-related disorders.

Factors associated with the initiation of cocaine and heroin among problem drug users: reflections on interventions

OBJECTIVE

This study identifies self-reported factors facilitating initiation of cocaine and heroin among young problem users in Amsterdam to enable interventions to be targeted at issues personally relevant for this population.

METHOD

A qualitative study using in-depth interviews to obtain retrospective drug use histories. Recruitment took place both directly (by street outreach, outreach at methadone outposts) and indirectly (by respondent-driven sampling). The study started in the year 2001 and included 50 problem drug users, aged 18-30, of whom 72% were male, 64% were polydrug users, and 36% were homeless.

RESULTS

The seven most common self-reported factors facilitating initiation of cocaine and heroin are desire for affect regulation, drug availability, curiosity, desire to be part of a group, misinformation, desire for energy, and starting because it has a depressant effect.

CONCLUSION

Some factors perceived to facilitate initiation of cocaine and/or heroin revealed in this study are hardly addressed by current prevention programs and could inform future initiatives. Programs can be targeted at young people who we identified to be at high risk. Research using quantitative methods is likely to be valuable in determining the relative importance of mentioned factors for different groups of young people. The study's limitations are noted.

Differential effects of μ-opioid, δ-opioid and κ-opioid receptor agonists on dopamine receptor agonist-induced climbing behavior in mice

Interactions between the dopaminergic system and opioids have not been adequately clarified. The present study was designed to investigate the effects of micro-opioid (morphine), delta-opioid (SNC80) and kappa-opioid (U50 488H) receptor agonists on dopamine receptor agonist-induced climbing behavior in mice. Apomorphine (dopamine-receptor agonist) increased stereotyped climbing behavior, unlike methamphetamine, morphine, U-50 488H and (+/-)7-hydroxy-N,N-di-n-propyl-2-aminotetralin hydrobromide (D2-like receptor agonist). Furthermore, SKF81297 (D1 receptor agonist) and SNC80 caused climbing behavior. In addition, while morphine (20 mg/kg), but not U50 488H or SNC80, significantly attenuated high-dose apomorphine (2.0 mg/kg)-induced climbing behavior, it significantly potentiated low-dose apomorphine (0.5 mg/kg)-induced climbing behavior. These results suggest that morphine may have dual effects on the behavioral effects induced by apomorphine. Furthermore, we interestingly showed that the combination of apomorphine or SKF81297 and SNC80 enhanced frequent nonstereotypic climbing behavior, suggesting that delta/D1 interactions may play a prominent role in the expression of certain types of behavior in mice. Thus, micro-opioid, delta-opioid and kappa-opioid receptor agonists induce possible differential effects on the dopaminergic system in mice.

Behavioral economic analysis of opioid consumption in heroin-dependent individuals: effects of unit price and pre-session drug supply

Behavioral economic analysis has been used to investigate factors underlying drug consumption in laboratory animals and, increasingly, in human drug abusers. However, there are few studies in heroin abusers, especially those who are not in treatment; such studies may be valuable for understanding the mechanisms of persistent drug use. This study investigated effects of unit price (UP) and pre-session supply of hydromorphone (HYD) on choice and consumption of HYD. Heroin-dependent research volunteers (n=13) stabilized on buprenorphine 8 mg/day completed this eight-session inpatient study. In sessions 1-2, participants sampled two total HYD doses (12 and 24 mg IM) that could be earned in later sessions. In each of the final six sessions, volunteers were given access to a 12-trial choice progressive ratio schedule lasting 3h. On each trial, volunteers could earn a HYD unit dose (1 or 2 mg, for a maximum of 12 or 24 mg, respectively) or money (US dollars 2, for a maximum of US dollars 24). Fixed ratio requirements increased exponentially, generating 24 unit prices for behavioral economic analysis. Before some choice sessions, volunteers could choose (FR 1) to receive extra HYD (12 or 24 mg; at 0915), whereas on other days no supplement was available. HYD choice and peak responding (breakpoint, O(max)) measures increased with unit dose, decreased with pre-session supplements, and were greater among volunteers who used cocaine prior to the experiment. Taking pre-session supplements decreased P(max) and made group-percent HYD consumption more demand-elastic. Consumption was functionally equivalent at differing FR/unit dose combinations. Thus, opioid demand in heroin-dependent individuals not in treatment is a function of drug supply, unit price, and cocaine use.

[New developments in the pharmacotherapy of cocaine dependence]

New possibilities with medications for the treatment of cocaine dependence have begun to emerge. For example, in a randomised controlled study, disulfiram succeeded for the first time in significantly reducing cocaine consumption. In October 2003, a phase IIb study was started in the USA testing active immunisation against cocaine dependence. There is also an ongoing study in Switzerland testing methylphenidate treatment in combination with cognitive behavioural therapy. Pilot studies indicate that vigabatrin, selegiline, and topiramate are promising candidates for further clinical substance testing.

Illicit opioid use and its key characteristics: a select overview and evidence from a Canadian multisite cohort of illicit opioid users (OPICAN)

OBJECTIVES

To summarize key characteristics and consequences of illicit opioid use from the literature and to present corresponding data from a multisite sample of illicit opioid users in 5 Canadian cities (OPICAN study).

METHOD

We undertook an overview of recent literature from North America, Australia, and Europe. We obtained data from the multicity OPICAN cohort study, which consisted of an interviewer-administered questionnaire, a standardized mental health instrument (the Composite International Diagnostic Interview Short Form for depression), and saliva-antibody tests for infectious disease (that is, HIV and hepatitis C virus). The baseline sample (n=679) was collected in 2002.

RESULTS

Illicit opioid use in Canada and elsewhere is becoming increasingly heterogeneous in terms of opioid drugs used, with heroin playing an increasingly minor role; further, it predominantly occurs in a context of polydrug use (for example, cocaine-crack or benzodiazepines). Large proportions of illicit opioid users have physical and (or) mental health comorbidities, including infectious disease and (or) depression, and therefore require integrated interventions. Finally, morbidity risks among illicit opioid users are often predicted by social marginalization factors, for example, housing status or involvement in

CONCLUSIONS

Given the epidemiologic profile and high disease burden associated with contemporary forms of illicit opioid use, more effective treatment approaches are urgently needed in Canada and elsewhere. Specifically, treatment must adjust to the extensive polysubstance use realities, yet it must also more effectively address the complex physical and (or) mental health comorbidities presented by this high-risk population.

Methamphetamine, Morphine, and Their Combination: Acute Changes in Striatal Dopaminergic Transmission Evaluated by Microdialysis in Awake Rats

The co-administration of methamphetamine (METH) and MOR (MOR)-like compounds is becoming increasingly popular among drug abusers. Recently, it was demonstrated that rats would self-inject METH-heroin combination and that this combination produced a greater rewarding effect than the identical doses of METH alone and it was further suggested that enhanced reward might underlie the popularity of this combination. However, there is null information on the effects of the MOR-METH combination on striatal dopaminergic transmission. In the present article, in vivo brain microdialysis was used to examine the effects of two METH doses (1 and 5 mg/kg, i.p.; [METH1: hyperlocomotion-inducing] and [METH5: stereotypy-inducing], respectively) and MOR (10 mg/kg, i.p. [MOR10]) either alone or in combination on dopamine (DA) and 3,4-dihydroxyphenylacetic acid (DOPAC) release in caudate putamen (CPu) in freely moving rats. METH1 evoked a transient threefold increase in DA overflow in only one-third of dosed rats. On the contrary, METH5 elicited a 11-fold increase in the extracellular DA levels 30 min after dosing and stayed significantly (P < 0.05) above control levels up to 1.5 h. On the other hand, MOR10 did not significantly change DA extracellular levels. MOR10-METH1 combination prolonged DA outflow for 1 h in all rats dosed without changing peak effect compared to METH1. On the other hand, MOR10-METH5 combination did not change the peak effect nor the DA outflow profile compared to METH5 alone. Consistently, there is a concentration-dependent decrease in DOPAC efflux evoked by METH: METH1 evoked a smaller decrease in DOPAC outflow showing a tendency for returning to basal values whereas METH5 kept DOPAC extracellular levels reduced throughout the experiment. Again, MOR10 did not significantly change DOPAC extracellular levels. MOR delayed the onset without changing METH effect on the DOPAC output. These findings provide suggestive evidence that MOR potentiated the increase in extracellular DA levels induced by a low dose of METH. Thus, this combination yields a profile of action that might underlie the reinforcing properties sought by drug addicts.

Gender differences in illicit substance use among middle-aged drug users with or at risk for HIV infection

OBJECTIVE

The objective of the present study was to examine gender differences and other factors associated with current heroin and cocaine use among middle-aged drug users.

METHODS

Baseline data were merged from 2 studies of men and of women with or at risk for HIV infection. Analysis was restricted to study participants who had ever used heroin or cocaine and who were 49-60 years of age at the time that they were interviewed. HIV-antibody status, drug-use history, and psychosocial and sociodemographic data were examined. Logistic regression models were used to assess factors independently associated with current heroin and cocaine use.

RESULTS

Of 627 persons who ever used heroin and/or cocaine, 250 (39.9%) reported using these drugs within 6 months of the study interview conducted at baseline. Men were more likely to be using drugs currently, compared with women (42.3% vs. 28.2%; P = .007). In multivariate analysis, men, unemployed persons, and HIV-seronegative persons were more likely to be using heroin or cocaine at the time of the interview. In addition, current marijuana users, persons drinking alcohol on a daily basis, and persons who had been homeless in the 6 months before the interview were also more likely to be using these drugs.

CONCLUSION

A relatively high proportion of middle-aged substance users with or at risk for HIV infection, especially men, may continue to use illicit drugs into the sixth decade of life. The differences noted between men and women who have used heroin and/or cocaine at some point in their lives suggest that special attention be given to aging and gender issues in framing HIV-prevention and drug-treatment programs.

Patterns of simultaneous polysubstance use in drug using university students

Simultaneous polysubstance use (SPU) is a common phenomenon, yet little is known about how various substances are used with one another. In the present study 149 drug-using university students completed structured interviews about their use of various substances. For each substance ever used, participants provided details about the type, order and amount of all substances co-administered during its most recent administration. Alcohol, tobacco and cannabis were frequently co-administered with each other and with all other substances. Chi-squared tests revealed that when alcohol was used in combination with any of cannabis, psilocybin, MDMA, cocaine, amphetamine, methylphenidate (ps < 0.01) or LSD (p < 0.05) its initial use preceded the administration of the other substance. Paired samples t-tests revealed that when alcohol was used with cocaine (p < 0.01) or methylphenidate (p < 0.05) it was ingested in greater quantities than when used in their absence. Patterns of cannabis use were not systematically related to other substances administered. Finally, using one-sample t-tests, tobacco use was demonstrated to be increased relative to 'sober' smoking rates when used with alcohol, cannabis, psilocybin, MDMA, cocaine, amphetamine (ps < 0.001), LSD (p < 0.01) or methylphenidate (p < 0.05). Results suggest that many substances are routinely used in a SPU context and that the pattern in which a substance is used may be related to other substances co-administered.

Profile of executive and memory function associated with amphetamine and opiate dependence

Cognitive function was assessed in chronic drug users on neurocognitive measures of executive and memory function. Current amphetamine users were contrasted with current opiate users, and these two groups were compared with former users of these substances (abstinent for at least one year). Four groups of participants were recruited: amphetamine-dependent individuals, opiate-dependent individuals, former users of amphetamines, and/or opiates and healthy non-drug taking controls. Participants were administered the Tower of London (TOL) planning task and the 3D-IDED attentional set-shifting task to assess executive function, and Paired Associates Learning and Delayed Pattern Recognition Memory tasks to assess visual memory function. The three groups of substance users showed significant impairments on TOL planning, Pattern Recognition Memory and Paired Associates Learning. Current amphetamine users displayed a greater degree of impairment than current opiate users. Consistent with previous research showing that healthy men are performing better on visuo-spatial tests than women, our male controls remembered significantly more paired associates than their female counterparts. This relationship was reversed in drug users. While performance of female drug users was normal, male drug users showed significant impairment compared to both their female counterparts and male controls. There was no difference in performance between current and former drug users. Neither years of drug abuse nor years of drug abstinence were associated with performance. Chronic drug users display pronounced neuropsychological impairment in the domains of executive and memory function. Impairment persists after several years of drug abstinence and may reflect neuropathology in frontal and temporal cortices.

Effects of mu-, delta- and kappa-opioid receptor agonists on methamphetamine-induced self-injurious behavior in mice

Opioid receptor agonists can differentially modify the behavioral effects of direct/indirect dopamine receptor agonists, such as methamphetamine, cocaine and apomorphine. However, the effects of opioid receptor agonists on high-dose methamphetamine-induced behavior have not yet been clarified. Therefore, the present study was undertaken to investigate the effects of mu (morphine)-, delta (SNC80)- and kappa (U50,488H)-opioid receptor agonists on methamphetamine-induced self-injurious behavior and locomotor activity in mice. Methamphetamine (20 mg/kg) induced severe self-injurious behavior. In a combination test, some opioid receptor agonists significantly attenuated methamphetamine-induced self-injurious behavior, with potencies in the order morphine>buprenorphine (mu-opioid and kappa-opioid receptor agonist/antagonist) >U50,488H, as maximum effects. These results suggest that the stimulation of mu- and kappa-opioid receptors plays an inhibitory role in high-dose methamphetamine-induced stereotypic self-injurious behavior in mice, without affecting locomotor activity.

An exploratory qualitative study of polydrug use histories among recently initiated injection drug users in San Juan, Puerto Rico

It is well documented that drug users often modulate the effects of their primary drugs of use (e.g., cocaine) by using other drugs (e.g., alcohol), yet the effect of modulating and primary drug interactions on transitions from one class of drugs to another and from noninjected drugs to injected drugs is not clear. This issue, which is critical for understanding polydrug abuse,1 is explored in formative research based on in-depth qualitative interviews conducted during 2003-2004 with 25 recently initiated drug injectors residing in San Juan, Puerto Rico. This study suggests that increased use of a primary drug (e.g., cocaine) was influenced by enhancing or attenuating drugs, which were used in a particular order (e.g., alcohol, heroin) reflecting effectiveness in modulating primary drugs at different use intensities, as well as by participants' perceptions of the relative dangers associated with different drugs. Neither availability nor access appeared to affect the order in which participants used modulating drugs.

Patterns of opioid and cocaine co-use: a descriptive study in a Canadian sample of untreated opioid-dependent individuals

This study examined prevalence and patterns of co-use of opioids and cocaine in regular users of illicit opioids (N = 729) recruited from 5 Canadian cities. Fifty-seven percent (n = 417) reported having used both opioids and cocaine in the month and week preceding the interview; of these, 73% (n = 304) were able to identify a typical pattern of daily co-use. In a typical day, injectors of opioids and cocaine (n = 119) and injectors of opioids who inhaled cocaine (n = 111) showed stable opioid use but variable cocaine use, which peaked at 21 hr. Overall, 30% of the individuals used both drugs exclusively in a sequential fashion, 35% reported taking opioids and cocaine within the same hour, and 35% reported taking them together at the same time or mixing them. These findings indicate that different individuals display different patterns of opioids and cocaine co-use.

HIV infection, drug use, and onset of natural menopause

OBJECTIVE

To study the relationship of HIV infection and drug use with the onset of natural menopause.

METHODS

Our analyses used the World Health Organization's definition of menopause (i.e., the date of the last menstrual period is confirmed after 12 months of amenorrhea) and baseline data from a prospective study. Semiannual interviews were conducted. Levels of HIV antibody and CD4+ cell counts were obtained. Menopause was identified at baseline or during 12 months of follow-up. Women ingesting reproductive hormones were excluded. Logistic regression analyses were used to assess factors associated with menopause.

RESULTS

Of 571 women, 53% were HIV infected, and 52% had used heroin or cocaine in the previous 5 years. The median age was 43 years (interquartile range [IQR], 40-46 years); 48.9% of the women were black, 40.4% were Hispanic, and 10.7% were white. The median body mass index was 29.1 kg/m2, and 90.4% of participants were current or former cigarette smokers. Menopause was identified in 102 women: 62 HIV-infected women (median age, 46 years; interquartile range [IQR], 39-49 years) and 40 uninfected women (median age, 47 years; IQR, 44.5-48 years). Factors independently associated with menopause included HIV infection (adjusted odds ratio [OR], 1.73; 95% confidence interval [CI], 1.075-2.795), drug use (adjusted OR, 2.633; 95% CI, 1.610-4.308), and physical activity (adjusted OR, 0.895; 95% CI, 0.844-0.950). Among HIV-infected women, factors independently associated with menopause included CD4+ cell counts of >500 cells/mm3 (adjusted OR, 0.191; 95% CI, 0.076-0.4848) and 200-500 cells/mm3 (adjusted OR, 0.356; 95% CI, 0.147-0.813).

CONCLUSION

Our study shows that HIV infection and immunosuppression are associated with an earlier age at the onset of menopause. Whether early onset of menopause in HIV-infected women increases their risk of osteoporosis and heart disease requires further study.

Influence of psychotherapy attendance on buprenorphine treatment outcome

We evaluated the influence of psychotherapy attendance on treatment outcome in 90 dually (cocaine and heroin) dependent outpatients who completed 70 days of a controlled clinical trial of sublingual buprenorphine (16 mg, 8 mg, or 2 mg daily, or 16 mg every other day) plus weekly individual standardized interpersonal cognitive psychotherapy. Treatment outcome was evaluated by quantitative urine benzoylecgonine (BZE) and morphine levels (log-transformed), performed three times per week. Repeated-measures linear regression was used to assess the effects of psychotherapy attendance (percent of visits kept), medication group, and study week on urine drug metabolite levels. Mean psychotherapy attendance was 71% of scheduled visits. Higher psychotherapy attendance was associated with lower urine BZE levels, and this association grew more pronounced as the study progressed (p=0.04). The inverse relationship between psychotherapy attendance and urine morphine levels varied by medication group, being most pronounced for subjects receiving 16 mg every other day (p=0.02). These results suggest that psychotherapy can improve the outcome of buprenorphine maintenance treatment for patients with dual (cocaine and opioid) dependence.

Underlying mechanism of combined effect of methamphetamine and morphine on lethality in mice and therapeutic potential of cooling

An increase in polydrug abuse is a major problem worldwide. A previous study showed that coadministration of methamphetamine and morphine induced lethality in rodents and humans. However, the underlying mechanisms by which the lethality is increased by the coadministration of methamphetamine and morphine have not been fully understood. Therefore, the present study was designed to determine the mechanism of increased lethality induced by methamphetamine and morphine. Coadministered methamphetamine and morphine increased the lethality by more than 70% in BALB/c mice. Pretreatment with NMDA-receptor antagonists, such as MK-801 and 3-((R)-2-carboxypiperazin-4-yl) propyl-1-phosphonic acid (CPP), and benzamide [poly(ADP-ribose) polymerase (PARP) inhibitor] significantly attenuated the increased lethality induced by methamphetamine and morphine. Furthermore, the lethal effect induced by methamphetamine and morphine was completely attenuated by immediate cooling after the coadministration of methamphetamine and morphine. It has been reported that methamphetamine-induced neurotoxicity can be blocked by lowering the temperature, and this effect might be mediated by a reduction of release of free radicals. These results suggest that activation of NMDA receptors and PARP play an important role in the increased lethality induced by methamphetamine and morphine.

Rats maintained chronically on buprenorphine show reduced heroin and cocaine seeking in tests of extinction and drug-induced reinstatement

Buprenorphine is being introduced as a maintenance therapy in opioid addiction, but it is not clear how buprenorphine will affect co-use of cocaine in opioid users. We examined the effects of chronic buprenorphine (BUP0: 0.0 mg/kg/day; BUP1.5: 1.5 mg/kg/day; BUP3: 3.0 mg/kg/day) on the locomotor activity effects of acute heroin (0.25 mg/kg, subcutaneously (s.c.)) and cocaine (20 mg/kg, intraperitoneally (i.p.)). Buprenorphine had no effect on the stimulatory effect of heroin, but potentiated the locomotor response to cocaine. To investigate further the interactions between buprenorphine (BUP1.5 and BUP3), heroin (0.125, 0.25 and 0.375 mg/kg, s.c.), and cocaine (10, 20 and 30 mg/kg, i.p.), we used in vivo microdialysis and high-performance liquid chromatography to analyze extracellular levels of dopamine (DA) in the nucleus accumbens (NAc). Buprenorphine attenuated the heroin-induced rise in NAc DA, but greatly potentiated the cocaine-induced rise. Finally, we examined the potential of the highest dose of buprenorphine (BUP3) to reduce heroin and cocaine seeking in the presence of drug-associated cues under extinction conditions and in tests for reinstatement induced by heroin (0.25 mg/kg, s.c.), cocaine (20 mg/kg, i.p.), and 15-min footshock stress (0.8 mA, 0.5 s/shock, 40 s mean OFF time) in rats trained to self-administer both drugs. Buprenorphine reduced heroin and cocaine seeking during extinction and following acute heroin and cocaine priming injections, but had no effect on stress-induced reinstatement. These results indicate that the suppression of responding following priming injections of drugs did not result from reduced motor activity, but possibly from a reduction in the salience of drug-associated cues induced by chronic buprenorphine treatment.

Cocaine-related myocardial infarction: concomitant heroin use can cloud the picture

Cocaine-related myocardial infarction is a well-known phenomenon. Concurrent heroin use can mask signs and symptoms of myocardial infarction. We discuss an unusual presentation of myocardial infarction, associated with both cocaine and heroin ("speedball") self-injection, that initially went undiagnosed.

Prediction of relapse to frequent heroin use and the role of methadone prescription: an analysis of the Amsterdam Cohort Study among drug users

The risk of relapse into frequent heroin use was studied among 732 participants of the Amsterdam Cohort Study (ACS) on HIV/AIDS among drug users, who experienced an episode of abstinence from or occasional use of heroin. Participants of the ACS were recruited primarily from easy access ("low-threshold") methadone programs. The duration of abstinence/occasional use and relative risks (RR) of relapse were estimated by analyzing 1577 episodes by means of survival analysis using characteristics of patients and methadone treatment as covariates. The majority of episodes (85.8%) were followed by relapse within 5 years. Less education, intense use of heroin prior to the episode of abstinence or well-controlled use, occasional use of heroin and intense use of cocaine during the episode, and having a drug-using partner or having no partner were significantly associated with a higher risk of relapse. Among frequent attendees of a "low-threshold" methadone program, relapse was associated with the daily dose of methadone: RR for dosages <40 and 40-60 mg, compared with doses of >100mg, were 1.45 (P<0.01) and 1.59 (P<0.01), respectively. No beneficial influence was revealed of methadone dosage or program attendance in itself on the risk of relapse into cocaine. High doses of methadone in a harm-reduction setting extend the duration of an episode of no or occasional use of heroin. Other factors, such as no occasional use of heroin during the episode, no use of cocaine, and having a non-using partner, seem to be equally important.

Comorbid depression among untreated illicit opiate users: results from a multisite Canadian study

OBJECTIVES

This study aimed to describe patterns of major depression (MDD) in a cohort of untreated illicit opiate users recruited from 5 Canadian urban centres, identify sociodemographic characteristics of opiate users that predict MDD, and determine whether opiate users suffering from depression exhibit different drug use patterns than do participants without depression.

METHOD

Baseline data were collected from 679 untreated opiate users in Vancouver, Edmonton, Toronto, Montreal, and Quebec City. Using the Composite International Diagnostic Interview Short Form for Major Depression, we assessed sociodemographics, drug use, health status, health service use, and depression. We examined depression rates across study sites; logistic regression analyses predicted MDD from demographic information and city. Chi-square analyses were used to compare injection drug use and cocaine or crack use among participants with and without depression.

RESULTS

Almost one-half (49.3%) of the sample met the cut-off score for MDD. Being female, white, and living outside Vancouver independently predicted MDD. Opiate users suffering from depression were more likely than users without depression to share injection equipment and paraphernalia and were also more likely to use cocaine (Ps < 0.05).

CONCLUSIONS

Comorbid depression is common among untreated opiate users across Canada; targeted interventions are needed for this population.

Low efficacy of non-opioid drugs in opioid withdrawal symptoms

Opioid withdrawal, stress or cues associated with opioid consumption can induce opioid craving. If opioids are not available, opioid-dependent patients usually search for alternative drugs. Because several non-opioid drugs stimulate the endogenous opioidergic system, this concept may explain their frequent use by opioid-dependent patients. We hypothesized that non-opioid drugs alleviate opioid withdrawal symptoms and are therefore consumed by opioid addicts. We asked 89 opioid-dependent patients participating in an out-patient opioid maintenance program to estimate the potential of several non-opioid drugs in being able to alleviate opioid withdrawal. We applied a five-point Lickert scale (1 = very good reduction of opioid withdrawal; 5 = no reduction of opioid withdrawal). Patients could also indicate a worsening of opioid withdrawal. Values (mean +/- SD) were: for benzodiazepines, 3.2 +/- 1.1; tricyclic antidepressants, 3.6 +/- 1.1; cannabis, 3.6 +/- 1.0; alcohol, 4.1 +/- 1.1; cocaine, 4.2 +/- 1.1; amphetamine, 4.4 +/- 0.9; nicotine, 4.7 +/- 0.7; and caffeine, 4.9 +/- 0.5. A worsening of opioid withdrawal was reported by 62% of the patients for cocaine, 62% for amphetamine, 50% for caffeine, 37.5% for cannabis, 27% for nicotine, 26% for alcohol, 8% for tricyclic antidepressants and 3% for benzodiazepines. Our study shows a low efficacy of non-opioid drugs in alleviating opioid withdrawal symptoms. The data basis of this study was good and the sample was suitable to be asked for estimations of drug-drug interactions. Of the patients, 26 - 62% even reported a worsening of opioid withdrawal for cannabis, alcohol, cocaine and amphetamine. Only benzodiazepines and tricyclic antidepressants were reported to have a moderate positive effect on opioid withdrawal.

Interactions between the reinforcing effects of cocaine and heroin in a drug-vs-food choice procedure in rhesus monkeys: a dose-addition analysis

RATIONALE

Concurrent abuse of cocaine and heroin is a common form of polydrug abuse, but the interactions between the reinforcing effects of cocaine and heroin are poorly understood. Dose-addition analysis is a tool for the quantitative assessment of drug interactions, but this analysis has not been applied to evaluation of the reinforcing effects of cocaine and heroin.

OBJECTIVES

To evaluate interactions between the reinforcing effects of cocaine and heroin using dose-addition analysis.

METHODS

Rhesus monkeys were trained under a concurrent-choice schedule of food delivery (1 gm pellets) and drug injections (cocaine or heroin, 0-0.1 mg kg(-1) injection(-1)). Full dose-effect curves were determined for cocaine alone and heroin alone. Subsequently, full dose-effect curves were determined for three fixed-proportion mixtures of cocaine and heroin (fixed proportions of 1:3.2, 1:1 and 3.2:1 cocaine/heroin). Dose-addition analysis was used to assess whether cocaine/heroin interactions were super-additive, additive, or sub-additive.

RESULTS

Cocaine, heroin, and all cocaine/heroin mixtures maintained dose-dependent and monotonic increases in drug choice and dose-dependent decreases in response rates. Choice dose-effect curves for cocaine/heroin mixtures were shifted to the left of dose-effect curves for cocaine or heroin alone, and dose-addition analysis indicated that cocaine/heroin interactions on drug choice were sub-additive or additive. Cocaine/heroin interactions on response-rate measures were also sub-additive or additive.

CONCLUSIONS

These results confirm that mixtures of cocaine and heroin produce reinforcing effects in rhesus monkeys; however, cocaine/heroin interactions were only or sub-additive or additive. Thus, these results do not support the hypothesis that simultaneously delivered cocaine and heroin produces super-additive reinforcing effects.

Cocaine and heroin ('speedball') self-administration: the involvement of nucleus accumbens dopamine and mu-opiate, but not delta-opiate receptors

RATIONALE

The combined administration of heroin and cocaine ('speedball') is common among intravenous drug users. Dopamine receptors in the nucleus accumbens play a key role in cocaine self-administration; however, their role in speedball self-administration is unknown, as is the role of opiate receptors in this region.

OBJECTIVES

The effect of blocking dopamine D1, D2, mu-opiate or delta-opiate receptors in the nucleus accumbens on the intravenous self-administration of combined heroin and cocaine was examined in rats.

METHODS

Rats with bilateral cannulae implanted into the nucleus accumbens were trained to self-administer intravenous speedball (ratio of cocaine/heroin, 17:1) under a progressive ratio (PR) schedule. Prior to their self-administration session, rats were then microinjected with the dopamine D1 receptor antagonist SCH 23390 (1 and 6 nmol side(-1)), the D2 receptor antagonist raclopride (3 and 10 nmol side(-1)), the mu-opiate receptor antagonist CTOP (0.1, 0.3 and 1.0 nmol side(-1)), the delta-opiate receptor antagonist naltrindole (1.0, 3.0 and 10 nmol side(-1)) or a cocktail of SCH 23390 (1 nmol side(-1)) and CTOP (0.1 nmol side(-1)) into the nucleus accumbens.

RESULTS

Microinjection of SCH 23390, raclopride or CTOP into the nucleus accumbens produced dose-dependent decreases in breakpoints under the PR schedule, while naltrindole was without effect. The highest dose of SCH 23390 also significantly reduced locomotor activity measured during speedball self-administration. The combination of SCH 23390 and CTOP significantly reduced breakpoints, while not affecting locomotor activity.

CONCLUSIONS

These results indicate that dopamine and mu-opiate receptors, but not delta-opiate receptors, in the nucleus accumbens are involved in the reinforcing effects of speedball. Combined administration of D1 and mu-opiate receptor antagonists may be more selective at reducing the reinforcing effects of speedball self-administration than either drug alone.

Methamphetamine-using HIV-positive men who have sex with men: correlates of polydrug use

Methamphetamine use has become a major problem among communities of men having sex with men (MSM), where it has been associated with high-risk behaviors. Methamphetamine is often combined with other drugs that may increase its risks and adverse health consequences. To examine differences in background characteristics, HIVrisk behaviors, and psychosocial variables among polydrug-using HIV-positive MSM, the researchers classified a sample of 261 HIV-positive, methamphetamine-using MSM into three user groups: (1) methamphetamine only; (2) methamphetamine, marijuana, and poppers (light polydrug users); and (3) methamphetamine and other drugs (e.g., cocaine, heroin, hallucinogens, and ketamine; heavy polydrug users). Only 5% reported using only methamphetamine during the past 2 months; 31% were classified as light polydrug users, and 64% were classified as heavy polydrug users. Heavy polydrug users were significantly younger than light polydrug users (35.6 vs. 38.4, P<.01) and reported using methamphetamine for significantly fewer years (10.3 vs. 14.2 years, P<.001), but did not differ in the amount and frequency of methamphetamine or alcohol consumed. Heavy polydrug users reported significantly more sex partners of HIV-negative and unknown serostatus and had more unprotected sex with these partners. Heavy polydrug users had significantly higher scores on impulsivity and negative self-perceptions, as compared with those of light polydrug users. In this sample of HIV-positive MSM, most of those who used methamphetamine had a pattern of polydrug use. Heavy polydrug users reported significantly more high-risk sexual behaviors and tended toward higher levels of impulsivity than light polydrug users. The implications of these findings are two-fold: (1) Longitudinal research is needed to establish causal relationships among methamphetamine use, impulsivity, negative self-perceptions, and sexual risk behavior in this target population; (2) behavioral interventions should evaluate whether methamphetamine use and sexual risk behavior can be reduced by modifying impulsivity and negative self-perceptions.

Self-Administration of cocaine-opioid combinations by rhesus monkeys: evaluation of the role of mu receptor efficacy using labor supply analysis

Cocaine and heroin often are abused by self-administering the drugs in combination as a "speedball". We evaluated the extent to which intrinsic efficacy at the mu-opioid receptor influences combined cocaine-opioid self-administration and used the behavioral economic model termed "labor supply" to quantitatively evaluate the reinforcing effects of cocaine-opioid combinations. Rhesus monkeys (n = 8) were trained under a progressive-ratio schedule of i.v. cocaine injection in which the response requirement increased during the experimental session and the initial response requirement was varied. Combination of cocaine with heroin enhanced self-administration compared with the drugs individually, with ineffective doses of both drugs maintaining self-administration when combined. These effects also were observed with the high-efficacy mu agonist alfentanil and low-efficacy agonist nalbuphine. Using the labor supply economic model, combinations of heroin, alfentanil, or nalbuphine with relatively low doses of cocaine were found to increase the number of injections per session ("income") and total responses per session ("labor"). Combination of a relatively high dose of cocaine with either heroin or alfentanil, but not nalbuphine, also resulted in only a small reduction in income concomitant with increased labor, suggesting that heroin and alfentanil made cocaine consumption more resistant to increasing response costs, or more "inelastic." Collectively, these findings suggest that speedball self-administration may occur even with relatively low levels of intrinsic efficacy at mu-opioid receptors and that an inelastic relationship between drug consumption and labor may contribute to the persistence of speedball abuse.

Challenges in measuring concurrency, agency and intentionality in polydrug research

Polydrug use is of particular interest to researchers concerned with the drug use of youth and young adults because it is associated with progression to regular and addictive drug use. New research shows that polydrug use appears to be taking new forms as youth use multiple drugs concurrently in the same setting, sometimes to achieve specific desired effects. Existing approaches to measuring polydrug use are confusing and inconsistent. This paper calls for new ways of measuring polydrug use that capture concurrency in context to obtain more accurate assessments of drug mixing and its potential physical and social effects.

The association between multiple drug misuse and crime

Research that has investigated the association between specific drug types and crime has tended to focus on the specific drug type in isolation from other drugs. The main problem with this is that it cannot be assumed that the association between specific drug use and crime will be the same regardless of the additional drugs consumed. The research aimed to investigate whether there was a correlation between number and type of drugs used and involvement in crime. The analysis of multiple drug use was based on data collected as part of the New English and Welsh Arrestee Drug Abuse Monitoring program in the United Kingdom. The results showed that both the number of drug types consumed and the particular drug type combinations used explained offending rate. The research concluded that the investigation of links between multiple drug use and crime might help inform antidrugs strategies and treatment services.

Comparison of the reinforcing effects of cocaine and cocaine/heroin combinations under progressive ratio and choice schedules in rats

The co-use of cocaine and heroin is relatively common, with a growing clinical and preclinical literature dedicated to investigating the factors underlying the phenomenon. Specifically, several studies have compared the reinforcing effects of the coadministration of cocaine and heroin, referred to commonly as 'speedball', to either drug alone. The present study assessed whether addition of heroin to a wide range of cocaine doses produces reinforcing effects greater than cocaine alone using both a progressive ratio (PR) schedule and a choice procedure. Patterns of coadministration of cocaine and heroin offered simultaneously were also assessed using double-lumen cannulas. Under the PR schedule, speedball combinations across a range of doses (0.38-3.0 mg/kg/inf cocaine+1.5-48 microg/kg/inf heroin) did not support higher break points than cocaine alone. When cocaine and heroin were made available concurrently (ie on two separate levers), rats self-administered cocaine exclusively. Using a choice procedure, however, a preference was demonstrated for some speedball combinations (eg 0.18 mg/kg/inf cocaine+50 microg/kg/inf heroin; 0.38 mg/kg/inf cocaine+50 microg/kg/inf heroin) over cocaine alone (0.75 mg/kg/inf). So while results obtained using the PR schedule do not support the hypothesis that speedball combinations are more reinforcing than cocaine alone, data from the choice procedure do support this hypothesis. These apparently discrepant results demonstrate that these models are measuring different aspects of drug reinforcement, and suggest that choice procedures in rats provide a useful tool to study speedball self-administration.

Patterns of polydrug use among ketamine injectors in New York City

Polydrug use is an important public health issue since it has been linked to significant adverse health outcomes. Recently, club drugs, including ketamine and other drugs used in dance/rave scenes, have been identified as key substances in new types of polydrug using patterns. While seemingly a self-explanatory concept, "polydrug" use constitutes multiple drug using practices that may impact upon health risks. Ketamine, a club drug commonly administered intranasally among youth for its disassociative properties, has emerged as a drug increasingly prevalent among a new hidden population of injection drug users (IDUs). Using an ethno-epidemiological methodology, we interviewed 40 young (<25 years old) ketamine injectors in New York during 2000-2002 to describe the potential health risks associated with ketamine and polydrug use. Findings indicate that ketamine was typically injected or sniffed in the context of a polydrug using event. Marijuana, alcohol, PCP, and speed were among the most commonly used drugs during recent ketamine using events. Polydrug using events were often quite variable regarding the sequencing of drug use, the drug combinations consumed, the forms of the drug utilized, and the modes of administrating the drug combinations. Future research should be directed towards developing a more comprehensive description of the risks associated with combining ketamine with other drugs, such as drug overdoses, the transmission of bloodborne pathogens, such as HIV and HCV, the short- and long-term effects of drug combinations on cognitive functioning, and other unanticipated consequences associated with polydrug use.

Addiction, a condition of compulsive behaviour? Neuroimaging and neuropsychological evidence of inhibitory dysregulation

AIMS

Addiction has been conceptualized as a shift from controlled experimentation to uncontrolled, compulsive patterns of use. Current neurobiological models of addiction emphasize changes within the brain's reward system, such that drugs of abuse 'hijack' this system and bias behaviour towards further drug use. While this model explains the involuntary nature of craving and the motivational drive to continue drug use, it does not explain fully why some addicted individuals are unable to control their drug use when faced with potentially disastrous consequences. In this review, we argue that such maladaptive and uncontrolled behaviour is underpinned by a failure of the brain's inhibitory control mechanisms.

DESIGN

Relevant neuroimaging, neuropsychological and clinical studies are reviewed, along with data from our own research.

FINDINGS

The current literature suggests that in addition to the brain's reward system, two frontal cortical regions (anterior cingulate and orbitofrontal cortices), critical in inhibitory control over reward-related behaviour, are dysfunctional in addicted individuals. These same regions have been implicated in other compulsive conditions characterized by deficits in inhibitory control over maladaptive behaviours, such as obsessive-compulsive disorder.

CONCLUSIONS

We propose that in chronically addicted individuals, maladaptive behaviours and high relapse rates may be better conceptualized as being 'compulsive' in nature as a result of dysfunction within inhibitory brain circuitry, particularly during symptomatic states. This model may help to explain why some addicts lose control over their drug use, and engage in repetitive self-destructive patterns of drug-seeking and drug-taking that takes place at the expense of other important activities. This model may also have clinical utility, as it allows for the adoption of treatments effective in other disorders of inhibitory dysregulation.

Cocaine seeking over extended withdrawal periods in rats: time dependent increases of responding induced by heroin priming over the first 3 months

RATIONALE

Using a rat relapse model, recent studies reported time dependent increases in cocaine seeking induced by re-exposure to cocaine cues, but not cocaine itself, over withdrawal periods of up to 3 months.

OBJECTIVES

In the present study, we explored the time course of cocaine seeking induced by priming injections of heroin over the first 3 months of withdrawal from cocaine.

METHODS

Rats were trained to self-administer intravenous cocaine for 6 h/day over a period of 10 days. Cocaine seeking induced by heroin priming was then assessed in different groups of rats after 1 day, and 1 and 3 months of withdrawal from cocaine. During the test day, rats were first given six 1-h extinction sessions. Subsequently, reinstatement of cocaine seeking induced by non-contingent saline and heroin injections (0.125 and 0.25 mg/kg, s.c.) was assessed during three 1-h sessions.

RESULTS

As in previous studies, extinction responding was substantially greater after 1 and 3 months of withdrawal than after 1 day. More importantly, we also found that the effect of heroin priming on reinstatement of cocaine seeking is time dependent, with higher responding occurring after 1 and 3 months than after 1 day.

CONCLUSION

The present results replicate previous findings on the time dependent increases in resistance to extinction after withdrawal from cocaine, and further indicate that the duration of the drug withdrawal period is a critical modulator of the effect of heroin priming on cocaine seeking. These data may have implications for the treatment of cocaine relapse induced by other drugs.

Cocaine-like discriminative stimulus effects of heroin: modulation by selective monoamine transport inhibitors

In previous studies, heroin was shown to engender cocaine-like discriminative stimulus (DS) effects; however, the mechanisms underlying the cocaine-like effects of heroin are unknown. The present study evaluated the extent to which the shared DS effects of heroin and cocaine involve common monoaminergic mechanisms of action. In squirrel monkeys discriminating cocaine (0.3 mg/kg) from saline, heroin engendered full or partial substitution for cocaine in three of four monkeys. Pretreatment with the selective dopamine transport inhibitor 1-(2-[bis(4-fluorophenyl)methoxy]ethyl)-4-(3-phenylpropyl)piperazine (GBR 12909) dose dependently enhanced the cocaine-like DS effects of heroin in these three monkeys as well as the DS effects of cocaine in all subjects. Neither talsupram, a noradrenergic transport inhibitor, nor prazosin, a noradrenergic antagonist selective for alpha-1 receptors, systematically altered the cocaine-like DS effects of heroin at doses that enhanced (talsupram) or attenuated (prazosin) the DS effects of cocaine. Pretreatment with the serotonin uptake inhibitor citalopram similarly failed to alter the cocaine-like DS effects of heroin at doses that attenuated the DS effects of cocaine. Altogether, these findings suggest that heroin shares DS effects with cocaine in a subset of monkeys, and these cocaine-like effects are mediated at least in part by enhanced dopaminergic activity. Unlike the DS effects of cocaine itself, however, the cocaine-like DS effects of heroin do not appear to involve either noradrenergic or serotonergic mechanisms.