Precipitated withdrawal in squirrel monkeys after repeated daily oral administration of alprazolam, diazepam, flunitrazepam or oxazepam

Flunitrazepam intake in male offenders

The abuse of flunitrazepam (FZ) compounds is worldwide, and several studies have reflected on the consequences with regard to violence, aggression and criminal lifestyle of FZ users. Criminals take high doses of FZ or some other benzodiazepines to "calm down" before the planned crime. There is support from earlier studies that most likely, all benzodiazepines may increase aggression in vulnerable males. Chronic intake of high doses of FZ increases aggression in male rats. Because psychopathy involves aggression, we have examined whether psychopathy as well as any of the four facets of the Psychopathy Checklist-Revised (PCL-R) (Interpersonal, Affective, Lifestyle and Antisocial) are related to different substance use disorders, with the focus on FZ. We have also examined the relationship between each PCL-R item and FZ use. Participants were 114 male offenders aged 14-35 years, all of whom were convicted for severe, predominantly violent, offences. Substance use, including FZ, was not more common in those who scored high in psychopathy. Use of FZ was more common in offenders who scored high in Facet 4 (Antisocial) of the PCL-R (odds ratio = 4.30, 95% CI 1.86-9.94). Only one of the PCL-R items, "Criminal versatility", was significantly associated with FZ use (odds ratio = 3.7). It may be concluded that intake of FZ has a specific relationship to only one of the facets and not to psychopathy per se. The findings have also important theoretical implications because Facet 4 is not a key factor of the construct of psychopathy. Clinical implications of the article: We have used the new two-factor and four-facet theoretical model of psychopathy in the young offender population, many of them with one or more substance use disorders. The present results suggest that antisocial behavior defined by Facet 4 (poor behavioral control, early behavior problems, juvenile delinquency, revocation of conditional release and criminal versatility) in the studied subjects is more typical for FZ users than it is for non-FZ users. This may have implications for assessment and treatment. Clinicians should be aware that criminals with high scores on Facet 4 have a more than fourfold odds of being a FZ user. This conclusion has an important clinical implication because FZ abuse is very common and is not always the focus of a forensic psychiatric assessment.

Comparison of the behavioral effects of bretazenil and flumazenil in triazolam-dependent and non-dependent baboons

Behavioral effects of the benzodiazepine receptor partial agonist bretazenil were compared with those of the benzodiazepine receptor antagonist flumazenil under conditions in which three baboons received continuous intragastric (i.g.) infusion of vehicle and then continuous i.g. infusion of triazolam (1.0 mg/kg/day). In each condition, acute doses of flumazenil (0.01-3.2 mg/kg) and bretazenil (0.01-10.0 mg/kg) were administered every 2 weeks (beginning after 30 days of treatment in the triazolam-dependent condition). Food pellets were available during daily 20-h sessions. Following test injections, 60-min behavioral observations were conducted followed by a fine motor assessment. During chronic vehicle administration, neither drug produced changes in observed behaviors. Bretazenil increased pellets earned and time to complete the fine-motor task (10.0 mg/kg dose). During chronic triazolam dosing, both bretazenil and flumazenil precipitated benzodiazepine withdrawal syndromes, characterized by vomiting, tremors/jerks, and a decrease in pellets earned. Thus, bretazenil can function as an antagonist under conditions of benzodiazepine physical dependence.

Zaleplon and triazolam physical dependence assessed across increasing doses under a once-daily dosing regimen in baboons

The ability of the GABA(A)-receptor-subtype-selective hypnotic zaleplon to produce physical dependence was compared to the nonselective benzodiazepine triazolam. Progressively increasing doses of zaleplon and triazolam were given to baboons by intragastric infusion once each day, with doses increasing every 17 days. Next, the highest dose was given for 10-34 additional days by continuous infusion. Both drugs produced increases in food-maintained lever pressing, ataxia, and time to complete a fine motor task. Plasma levels increased dose-dependently; drug was detectable 24 h after higher doses. Flumazenil produced a mild or intermediate precipitated-withdrawal syndrome on day 14 of all dosing conditions. When drug delivery ended after 85-100 days, a benzodiazepine-type withdrawal syndrome occurred. Physical dependence potential of zaleplon and triazolam appear similar.

Previous experience of withdrawal from chronic diazepam ameliorates the aversiveness of precipitated withdrawal and reduces withdrawal-induced c-fos expression in nucleus accumbens

Flumazenil (20 mg/kg, i.p.)-precipitated withdrawal from chronic treatment with diazepam (DZP, 15 mg/kg, s.c. in sesame oil for 21 days) resulted in a decreased seizure threshold to the convulsant, pentylenetetrazole (PTZ), infused into the tail vein; withdrawal from 21-day chronic diazepam treatment, interspersed with two periods of drug withdrawal, resulted in a greater decrease in convulsant threshold. A separate experiment showed that consumption of a sucrose solution immediately prior to precipitated withdrawal resulted in a decreased subsequent consumption of the sucrose solution; no such evidence of a conditioned taste aversion (CTA) was seen in mice given prior experience of withdrawal. Thus, prior experience of withdrawal enhanced the effects of a subsequent precipitated withdrawal in increasing seizure sensitivity, but weakened the ability of this withdrawal to serve as an aversive unconditioned stimulus (US). The weakening of the aversive properties of precipitated withdrawal may reflect habituation to the withdrawal stimulus, and was accompanied by a loss of the ability of withdrawal to induce c-fos expression in the shell of the nucleus accumbens, an area sensitive to both novel, and stressful, as well as rewarding stimuli.

Binding profiles and physical dependence liabilities of selected benzodiazepine receptor ligands

In vitro binding profiles were determined for selected benzodiazepine receptor (BZR) ligands by quantitative radioautography in rat brain. The ligands represent subtype-selective agonists (zolpidem) or nonselective BZR agonists (diazepam), as well as BZR partial agonists (bretazenil, Ro 43-9624, and Ro 19-8022). In addition, these compounds were evaluated in a precipitated withdrawal paradigm in monkeys. The physical dependence liability was not clearly related to the in vitro brain BZR binding profiles of these compounds. Therefore, diazepam, bretazenil, Ro 19-8022, and Ro 43-9624 had regional affinities for the 13 selected rat brain regions that were close to the mean values across regions, despite the clearly greater physical dependence potential of diazepam. Zolpidem, on the other hand, had regional affinities for the 13 rat brain regions that diverged significantly from the mean value across regions and exhibited a lower physical dependence potential than diazepam. These results raise the possibility that a combination of BZR subtype selectivity with partial agonism could yield a marked reduction of physical dependence liability.

Sarmazenil-precipitated withdrawal: a reliable method for assessing dependence liability of benzodiazepine receptor ligands

The benzodiazepine receptor partial inverse agonist sarmazenil exhibits in vivo proconvulsive, but not convulsant, effects in different paradigms in rodents. Intravenous sarmazenil challenge given at several fixed intervals following the termination of repeated treatment with a markedly sedative dose of diazepam in squirrel monkeys was effective in precipitating withdrawal signs, but had no comparable effects in vehicle-treated controls. The precipitated withdrawal reaction was not only robust, but it was consistently observed in all of the diazepam-treated monkeys. Thus, the use of sarmazenil challenge in the precipitated withdrawal paradigm provides a reliable method for assessing the development of physical dependence during repeated treatment with benzodiazepine receptor agonists.

Alprazolam, diazepam, yohimbine, clonidine: in vivo CA1 hippocampal norepinephrine and serotonin release profiles under chloral hydrate anesthesia

1. Although the GABA-A receptor complex has been the main focus of anti-anxiety therapy, the neural interaction in the septohippocampal circuit between GABA-A and the neurotransmitter, 5-HT, compels a study of the monoamine, 5-HT, in anxiety as well. 2. Neurochemistry for anxiety is also intimately involved with the neurotransmitter, NE. Indeed, 5-HT is a component of the dorsal ascending noradrenergic bundle and both neurotransmitters, NE and 5-HT, have been implicated in clinical depression. 3. In vivo microvoltammetric studies were performed using miniature carbon based sensors to detect NE release and concurrent 5-HT release, with 2 separate neural electrochemical signals, within CA1 region of hippocampus, in the chloral hydrate anesthetized rat. 4. Time course studies showed that both the triazolobenzodiazepine (TBZD), alprazolam, and the benzodiazepine (BZD), diazepam, decreased hippocampal NE release. 5. The in vivo and on line neurochemical profile of hippocampal 5-HT release for alprazolam differed from that of diazepam, i.e. alprazolam increased hippocampal 5-HT release, whereas diazepam decreased hippocampal 5-HT release. 6. Time course studies showed that the alpha 2-adrenergic antagonist, yohimbine, an anxiogenic agent, increased both NE and 5-HT release in CA1 region of hippocampus; the alpha 2-adrenergic agonist, clonidine, decreased NE release and increased 5-HT release in the same region. 7. Neither the profile for the TBZD, alprazolam, nor that of the BZD, diazepam, mimicked the neurochemical profile for the anxiogenic agent, yohimbine; the neurochemical profile for the TBZD, alprazolam, was similar to that of the alpha 2-adrenergic agonist, clonidine. 8. Interestingly, alprazolam's hippocampal 5-HT/NE interaction is similar to clonidine's 5-HT/NE action at alpha 2-adrenergic autoreceptors, resulting in enhanced 5-HT release. 9. Enhanced 5-HT release in hippocampus, exhibited by the atypical TBZD, alprazolam, and not by the typical BZD, diazepam, may be an underlying mechanism for the antidepressant activity exhibited by alprazolam.

Abuse liability of flunitrazepam

Flunitrazepam is among the most frequently prescribed hypnotics in many countries. Although it was never marketed in the United States, flunitrazepam, in recent years, has been smuggled into the country, and reports of abuse--including alleged use of the drug to facilitate "date rape"--have attracted a great deal of scrutiny. It has been suggested that flunitrazepam may have greater liability for abuse than other benzodiazepines; such suggestions are supported by surveys of opioid abusers, many of whom report a distinct preference for flunitrazepam over other benzodiazepines. Experimental studies of animals and normal human subjects indicate that, although flunitrazepam has high efficacy and is very potent, it is pharmacologically similar to most other benzodiazepines. Although the studies are limited in number and scope, the data show no apparent differences between flunitrazepam and other benzodiazepines in ability to produce drug-taking or drug-seeking behavior, in capacity to produce physiologic dependence, nor in the characteristics of withdrawal after administration of an antagonist or discontinuation of treatment. Similar to other benzodiazepines, flunitrazepam produces dose-dependent effects on psychomotor performance and recall. Flunitrazepam does not seem to be involved in medical emergencies more often than other benzodiazepines, and there is no indication that flunitrazepam is more toxic than other benzodiazepines when taken in overdose by drug abusers or other individuals. Survey research among typical patient populations suggests that flunitrazepam is characteristic of benzodiazepines in that it is used appropriately and conservatively, with low liability for abuse. Thus the reported preference for flunitrazepam among opioid abusers seems to be the only way in which flunitrazepam is distinguished from other benzodiazepines; it is unclear what characteristics of the drug may be responsible for this reported preference. The evidence considered in this review indicates that abuse of flunitrazepam in this special population is not associated with any distinctive threats to the health of the general public.

Discriminative stimulus effects of flumazenil in rhesus monkeys treated chronically with chlordiazepoxide

Discriminative stimulus effects of the benzodiazepine antagonist flumazenil were studied in two rhesus monkeys receiving 3.2 mg/kg/12 h of chlordiazepoxide while discriminating between vehicle and 0.056 mg/kg of flumazenil. In a drug discrimination component responding was maintained under a FR 10 schedule of stimulus-shock termination; in a non-discrimination component responding was maintained under a FR 10 schedule of food presentation. Flumazenil and Ro 15-4513 occasioned >80% flumazenil-lever responding at doses larger than 0.032 and 0.056 mg/kg, respectively. Pentylenetetrazole, ethyl-beta-carboline-3-carboxylate (betaCCE), ketamine and spiradoline failed to substitute for flumazenil although >80% drug-lever responding was observed for two of the compounds in one monkey. Flumazenil, Ro 15-4513, pentylenetetrazole, betaCCE but not ketamine or spiradoline decreased rates of responding in the food component at doses that had little effect on rates in the stimulus-shock termination component. When chlordiazepoxide injections were discontinued and saline was administered before the session, monkeys did not respond on the flumazenil lever; when flumazenil was administered under the same conditions, monkeys responded on the flumazenil lever despite not having received chlordiazepoxide for nine days. Drug stimulus control was established with flumazenil in monkeys receiving chlordiazepoxide and substitution studies suggest that this effect of flumazenil might result from antagonist actions at benzodiazepine receptors: however, lack of withdrawal-related effects after termination of chlordiazepoxide treatment precludes validation of this procedure for studying benzodiazepine dependence.

Intrathecally administered flumazenil and PK 11195 precipitate abstinence syndrome in freely moving diazepam dependent rats

The central and peripheral benzodiazepine (BZ) receptor antagonists, flumazenil (FLU) and PK 11195 (PK), administered intrathecally (IT) to diazepam (DZ)-dependent rats produced a precipitated abstinence syndrome. The scores for abstinence increased with increasing dose of FLU but not with increasing dose of PK. Twitches and jerks increased with increased doses of both. Head and body tremors were produced by FLU, but not by PK. Neither FLU nor PK precipitated abstinence in controls. In DZ-dependent rats IT administered FLU and PK did not significantly change the spectral content and the total power of the EEG. The data indicate that an abstinence syndrome is precipitated at the spinal level in DZ-dependent rats and that both central and peripheral BZ receptors are involved.

Pharmacology of flumazenil

Flumazenil, an imidazobenzodiazepine, is the first benzodiazepine antagonist available for clinical use. It is a specific competitive antagonist at benzodiazepine receptors, which are associated with receptors for gamma-aminobutyric acid, the most important inhibitory neurotransmitter in the central nervous system. Administered orally, it has a low bioavailability and the preferred route is intravenous. Its usual clinical role is to reverse the effects of benzodiazepine sedation; however, administered before, or with, other benzodiazepines, it modifies their effects, the extent of such modification depending on the dose, duration of effect and relative receptor affinity of the agonist. Flumazenil also reverses adverse physiological effects of benzodiazepines. Its indications include reversal of benzodiazepine-induced sedation, termination of benzodiazepine-induced anaesthesia, return of spontaneous respiration and consciousness in intensive care patients and the treatment of paradoxical reactions to benzodiazepines. Other potential indications include its use in hepatic encephalopathy, alcohol intoxication and coma; however, these claims still require substantiation. Following sedation reversed with flumazenil, minimal residual effects of the agonist can sometimes be detected using psychomotor tests and are due to the relatively short half-life of flumazenil, but are of no clinical consequence. There is concern that flumazenil could precipitate an acute withdrawal syndrome following long-term benzodiazepine administration; however, the available evidence suggests otherwise and that it could be useful in the treatment of benzodiazepine tolerance. The existence of flumazenil is important, with implications for future research and the development of minimally invasive therapy and day-case surgery. With increasing pressures on non-anaesthetically trained practitioners to perform sedation, flumazenil has important implications for safety.