Pharmacokinetics, Efficacy, and Safety of a SARS-CoV-2 Antibody Treatment in Pediatric Participants: An Open-Label Addendum of a Placebo-Controlled, Randomized Phase 2/3 Trial

INTRODUCTION

Bamlanivimab and etesevimab (BAM + ETE) are monoclonal antibodies (mAbs) effective in reducing COVID-19-related hospitalizations and all-cause mortality in adult participants at increased risk for severe disease. We present pharmacokinetic (PK), efficacy, and safety results from pediatric participants (< 18 years of age) with COVID-19 who were treated with BAM + ETE.

METHODS

In an addendum to the phase 2/3 BLAZE-1 clinical trial (NCT04427501), pediatric participants received open-label weight-based dosing (WBD, n = 94) based on exposure-matching to the authorized dose of BAM + ETE in adult participants. For efficacy and safety assessments, placebo (n = 14) and BAM + ETE (n = 20)-treated adolescent participants (> 12 to < 18 years of age) from the BLAZE-1 trial were included in the overall pediatric population (N = 128). All participants had mild to moderate COVID-19 upon enrollment and ≥ 1 risk factor for severe COVID-19. The primary objective was to characterize the PK of BAM and ETE in the WBD population.

RESULTS

The median age of the participants was 11.2 years, 46.1% were female, 57.9% were Black/African American, and 19.7% were Hispanic/Latino. The area under the curve for BAM and ETE in the WBD population was similar to that previously observed in adults. There were no COVID-19-related hospitalizations or deaths. All adverse events (AE) except one were mild or moderate, with one participant reporting a serious AE.

CONCLUSION

WBD in pediatric participants achieved similar drug exposures compared to adult participants that received the authorized BAM + ETE dose. The pediatric efficacy and safety data were consistent with adults receiving mAbs for COVID-19.

TRIAL REGISTRATION NUMBER

NCT04427501.

Maternal and fetal outcomes following exposure to duloxetine in pregnancy: cohort study

OBJECTIVE

To evaluate the risk of adverse maternal and infant outcomes following in utero exposure to duloxetine.

DESIGN

Cohort study nested in the Medicaid Analytic eXtract for 2004-13.

SETTING

Publicly insured pregnancies in the United States.

PARTICIPANTS

Pregnant women 18 to 55 years of age and their liveborn infants.

INTERVENTIONS

Duloxetine exposure during the etiologically relevant time window, compared with no exposure to duloxetine, exposure to selective serotonin reuptake inhibitors, exposure to venlafaxine, and exposure to duloxetine before but not during pregnancy.

MAIN OUTCOME MEASURES

Congenital malformations overall, cardiac malformations, preterm birth, small for gestational age infant, pre-eclampsia, and postpartum hemorrhage.

RESULTS

Cohort sizes ranged from 1.3 to 4.1 million, depending on the outcome. The number of women exposed to duloxetine varied by cohort and exposure contrast and was around 2500-3000 for early pregnancy exposure and 900-950 for late pregnancy exposure. The base risk per 1000 unexposed women was 36.6 (95% confidence interval 36.3 to 36.9) for congenital malformations overall, 13.7 (13.5 to 13.9) for cardiovascular malformations, 107.8 (107.3 to 108.3) for preterm birth, 20.4 (20.1 to 20.6) for small for gestational age infant, 33.6 (33.3 to 33.9) for pre-eclampsia, and 23.3 (23.1 to 23.4) for postpartum hemorrhage. After adjustment for measured potential confounding variables, all baseline characteristics were well balanced for all exposure contrasts. In propensity score adjusted analyses versus unexposed pregnancies, the relative risk was 1.11 (95% confidence interval 0.93 to 1.33) for congenital malformations overall and 1.29 (0.99 to 1.68) for cardiovascular malformations. For preterm birth, the relative risk was 1.01 (0.92 to 1.10) for early exposure and 1.19 (1.04 to 1.37) for late exposure. For small for gestational age infants the relative risks were 1.14 (0.92 to 1.41) and 1.20 (0.83 to 1.72) for early and late pregnancy exposure, respectively, and for pre-eclampsia they were 1.12 (0.96 to 1.31) and 1.04 (0.80 to 1.35). The relative risk for postpartum hemorrhage was 1.53 (1.08 to 2.18). Results from sensitivity analyses were generally consistent with the findings from the main analyses.

CONCLUSIONS

On the basis of the evidence available to date, duloxetine is unlikely to be a major teratogen but may be associated with an increased risk of postpartum hemorrhage and a small increased risk of cardiac malformations. While continuing to monitor the safety of duloxetine as data accumulate over time, these potential small increases in risk of relatively uncommon outcomes must be weighed against the benefits of treating depression and pain during pregnancy in a given patient.

TRIAL REGISTRATION

EUPAS 15946.

Efficacy and safety of duloxetine versus placebo in adolescents with juvenile fibromyalgia: results from a randomized controlled trial

BACKGROUND

Currently, there are no medications approved for the treatment of juvenile fibromyalgia (JFM). We evaluated the safety and efficacy of duloxetine 30/60 mg once daily (QD) versus placebo in adolescents with JFM.

METHODS

In this Phase 3b, multisite (US, Argentina, Puerto Rico, and India) trial, patients aged 13-17 years with JFM and a score of ≥4 on the Brief Pain Inventory-Modified Short Form: Adolescent Version (BPI) 24-h average pain severity score were randomized to duloxetine or placebo for the 13-week double-blind period. The starting duloxetine dose was 30 mg, with a target dose of 60 mg QD, as tolerated. The primary endpoint was the mean change in 24-h average pain severity of the Brief Pain Inventory (BPI) from baseline to Week 13, analyzed using mixed-model repeated measures (MMRM) technique. Secondary measures were BPI severity and interference scores; treatment response (≥30%, ≥50% reductions on BPI average pain severity); Pediatric Pain Questionnaire; Clinical Global Impression of Severity: Overall and Mental Illness scales; Functional Disability Inventory: child and parent versions; Children's Depression Inventory; Multidimensional Anxiety Scale for Children; and safety and tolerability. Continuous secondary efficacy measures were analyzed using analysis of covariance or MMRM, and categorical data using Cochran-Mantel-Haenszel test and Fisher's exact test, where appropriate.

RESULTS

A total of 184 patients with JFM received duloxetine (N = 91) or placebo (N = 93), of which 149 patients (81.0%) completed the 13-week double-blind treatment period. Baseline characteristics were comparable between groups; majority of the patients were Caucasian (77.17%) and females (75.0%), with a mean age of 15.53 years. For the primary measure, BPI average pain severity, the mean change was not statistically different between duloxetine and placebo (- 1.62 vs. -0.97, respectively; p = .052). For secondary efficacy outcomes, statistically significantly more duloxetine- versus placebo-treated patients had a treatment response (≥30% and ≥50% reductions on BPI average pain severity) and improvement of the general activity and relationships items on the BPI interference subscale. The percentage of patients reporting at least 1 treatment-emergent adverse event was higher in the duloxetine versus placebo groups (82.42% vs. 62.37%, respectively; p = .003). The overall safety profile of duloxetine in this study was similar to that reported previously in duloxetine pediatric trials of other indications.

CONCLUSIONS

The primary study outcome, mean change in 24-h BPI average pain severity rating from baseline to Week 13, did not significantly improve with duloxetine compared to placebo in patients with JFM. However, significantly more patients on duloxetine compared to placebo had a ≥30% and ≥50% reduction in pain severity. There were no new safety concerns related to duloxetine in the study population.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01237587 . Registered 08 November, /2010.

Postinjection delirium/sedation syndrome in patients with schizophrenia receiving olanzapine long-acting injection: results from a large observational study

BACKGROUND

Postinjection delirium/sedation syndrome (PDSS) has been reported uncommonly during treatment with olanzapine long-acting injection (LAI), a sustained-release formulation of olanzapine.

AIMS

The primary aim of the study was to estimate the incidence per injection and per patient of PDSS events in adult patients with schizophrenia who were receiving olanzapine LAI in real-world clinical practice. Secondary aims were to further characterise the clinical presentation of PDSS events, to identify potential risk factors associated with PDSS events and to characterise hospitalisations at baseline and post-baseline.

METHOD

A prospective observational study of adult patients with schizophrenia receiving olanzapine LAI from 24 countries. Data were collected on patient characteristics, olanzapine LAI treatment and any adverse events (AEs). All AEs were reviewed and adjudicated for PDSS using predetermined criteria.

RESULTS

There were 46 confirmed PDSS events (0.044% of the 103 505 injections) in 45 patients (1.17% of the 3858 patients). Based on 45 confirmed events with time-to-onset information, 91.1% (n=41) occurred within 1 h of injection. Time-to-recovery from the event was within 72 h for 95.6% of patients (range 6 h to 11 days). Risk factors for PDSS (per-injection) included high dose (odds ratio (OR)_high/low=3.95; P=0.006) and male gender (OR_female/male=0.42; P=0.017).

CONCLUSIONS

Results of this study confirm previously reported PDSS rates, time to onset and recovery, and the severity of PDSS events, and suggest that higher doses and male gender are potential risk factors associated with PDSS.

DECLARATION OF INTEREST

All authors are full-time employees and hold stock/stock options in Eli Lilly, which funded this study. This post-authorisation safety study (PASS) was proposed by Eli Lilly when submitting the original marketing authorisation application for olanzapine LAI in 2007. The protocol and final study report for this European Union regulatory commitment are publicly accessible via the European Network of Centres for Pharmacoepidemiology and Pharmacovigilance (ENCePP) European Union PASS Register (www.encepp.eu/encepp/viewResource.htm?id=16847). The current manuscript describes the results within the final study report.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Assessment of effects of atomoxetine in adult patients with ADHD: consistency among three geographic regions in a response maintenance study

A previous study (Upadhyaya et al. in Eur J Psychiatry 2013b; 27:185-205) reported that adults with attention-deficit/hyperactivity disorder (ADHD) demonstrated maintenance of response for up to 25 weeks after initially responding to atomoxetine treatment. In the present report, the consistency of treatment effect across three geographic regions (Europe, United States/Canada [US/Can], and Latin America [Latin Am]) was explored. Data were analyzed from a phase 3, multicenter, randomized, double-blind, maintenance-of-response (randomized withdrawal) trial of atomoxetine versus placebo in adults with ADHD. Patients were randomized to atomoxetine (N = 266) or placebo (N = 258) for 25 weeks. Consistency assessments included the interaction test, pairwise t tests, noninferiority, and the criteria from Basic Principles on Global Clinical Trials (Ministry of Health, Labour and Welfare of Japan 2007). Atomoxetine-treated patients maintained the improved ADHD symptoms relative to placebo-treated patients on the Conners' Adult ADHD Rating Scale Investigator-Rated: Screening Version 18-Item (CAARS-Inv:SV) total score in all three regions (atomoxetine-placebo mean difference = -4.55, -3.18, and -0.07 for Europe, US/Can, and Latin Am, respectively). For the Latin Am region, the mean change in total score (0.41) was notably smaller for the placebo group than for Europe (5.87) and US/Can (4.39). Similar results were observed for the CAARS-Inv:SV hyperactivity/impulsivity and inattention subscale scores. Overall, patients maintained the response with atomoxetine treatment compared to placebo; however, the magnitude of treatment effect differed among the regions studied, being numerically higher in the EU and US/Can than Latin Am. Trial registration http://www.clinicaltrials.gov/(NCT00700427 ).

CYP2D6 predicted metabolizer status and safety in adult patients with attention-deficit hyperactivity disorder participating in a large placebo-controlled atomoxetine maintenance of response clinical trial

Atomoxetine, which is indicated for treatment of attention-deficit hyperactivity disorder (ADHD), is predominantly metabolized by genetically polymorphic cytochrome P450 2D6 (CYP2D6). Based on identified CYP2D6 genotypes, individuals can be categorized into 4 phenotypic metabolizer groups as ultrarapid, extensive, intermediate, and poor. Previous studies have focused on observed differences between poor and extensive metabolizers, but it is not well understood whether the safety profile of intermediate metabolizers differs from that of ultrarapid and extensive metabolizers. This study compared safety and tolerability among the different CYP2D6 metabolizer groups in the 12-week open-label phase of an atomoxetine study in adult patients with ADHD. Genotyping identified 1039 patients as extensive/ultrarapid metabolizers, 780 patients as intermediate metabolizers, and 117 patients as poor metabolizers. Common (≥5% frequency) treatment-emergent adverse events did not significantly differ between extensive/ultrarapid and intermediate metabolizers (odds ratios were <2.0 or >0.5). Poor metabolizers had higher frequencies of dry mouth, erectile dysfunction, hyperhidrosis, insomnia, and urinary retention compared with the other metabolizer groups. There were no significant differences between extensive/ultrarapid and intermediate metabolizers in changes from baseline in vital signs. These results suggest that data from CYP2D6 intermediate and extensive/ultrarapid metabolizers can be combined when considering safety analyses related to atomoxetine.

The efficacy of atomoxetine for the treatment of children and adolescents with attention-deficit/hyperactivity disorder: a comprehensive review of over a decade of clinical research

Atomoxetine was first licensed to treat attention-deficit/hyperactivity disorder (ADHD) in children and adolescents in the US in 2002. The aim of this paper is to comprehensively review subsequent publications addressing the efficacy of atomoxetine in 6- to 18-year-olds with ADHD. We identified 125 eligible papers using a predefined search strategy. Overall, these papers demonstrate that atomoxetine is an effective treatment for the core ADHD symptoms (effect sizes 0.6-1.3, vs. placebo, at 6-18 weeks), and improves functional outcomes and quality of life, in various pediatric populations with ADHD (i.e., males/females, patients with co-morbidities, children/adolescents, and with/without prior exposure to other ADHD medications). Initial responses to atomoxetine may be apparent within 1 week of treatment, but can take longer (median 23 days in a 6-week study; n=72). Responses often build gradually over time, and may not be robust until after 3 months. A pooled analysis of six randomized placebo-controlled trials (n=618) indicated that responses at 4 weeks may predict response at 6-9 weeks, although another pooled analysis of open-label data (n=338) suggests that the probability of a robust response to atomoxetine [≥40% decrease in ADHD-Rating Scale (ADHD-RS) scores] may continue to increase beyond 6-9 weeks. Atomoxetine may demonstrate similar efficacy to methylphenidate, particularly immediate-release methylphenidate, although randomized controlled trials are generally limited by short durations (3-12 weeks). In conclusion, notwithstanding these positive findings, before initiating treatment with atomoxetine, it is important that the clinician sets appropriate expectations for the patient and their family with regard to the likelihood of a gradual response, which often builds over time.

Menstrual cycle phase effects in the gender dimorphic stress cue reactivity of smokers

INTRODUCTION

We previously reported that female smokers evidence greater subjective craving and stress/emotional reactivity to personalized stress cues than males. The present study employed the same dataset to assess whether females in the follicular versus luteal phase of the menstrual cycle accounted for the gender differences.

METHODS

Two objective criteria, onset of menses and luteinizing hormone surge (evaluated via home testing kits), were used to determine whether female smokers were in either the follicular (n = 22) or the luteal (n = 15) phase of their menstrual cycle, respectively. The females and a sample of male smokers (n = 53) were then administered a laboratory-based cue reactivity paradigm that involved assessment of craving, stress, and emotional reactivity in response to counterbalanced presentations of both a personalized stress script and neutral/relaxed script.

RESULTS

While there were no significant differences between females in the follicular versus luteal phase on any outcome measure, females in the luteal menstrual phase reported greater craving than males whereas females in the follicular phase reported greater stress and arousal than males and perceived the stress cues as more emotionally aversive than males.

CONCLUSIONS

This preliminary investigation suggests that gender differences in craving versus affective responding to stress cues may, in part, be explained variation by menstrual cycle phase. Study limitations and implications of the findings for future research and treatment are briefly discussed.

Underdiagnosis of attention-deficit/hyperactivity disorder in adult patients: a review of the literature

OBJECTIVE

To raise awareness of attention-deficit/hyperactivity disorder (ADHD) as an underdiagnosed, undertreated, often comorbid, and debilitating condition in adults.

DATA SOURCES

PubMed was searched using combinations of keywords, including ADHD, adult, diagnosis, identify, prevalence, and comorbid, to find articles published between 1976 and 2013.

STUDY SELECTION

In total, 99 articles were selected for inclusion on the basis of their relevance to the objective and importance to and representation of ADHD research, including international guidelines for adults with ADHD.

RESULTS

In a large proportion of children with ADHD, symptoms persist into adulthood. However, although adults with ADHD often experience chaotic lifestyles, with impaired educational and vocational achievement and higher risks of substance abuse and imprisonment, many remain undiagnosed and/or untreated. ADHD is usually accompanied by other psychiatric comorbidities (such as major depressive disorder, anxiety disorder, and alcohol abuse). Indeed, adults with ADHD are more likely to present to a psychiatric clinic for treatment of their comorbid disorders than for ADHD, and their ADHD symptoms are often mistaken for those of their comorbidities. Untreated ADHD in adults with psychiatric comorbidities leads to poor clinical and functional outcomes for the patient even if comorbidities are treated. Effective treatment of adults' ADHD improves symptoms, emotional lability, and patient functioning, often leading to favorable outcomes (eg, safer driving, reduced criminality). A few medications have now been approved for use in adults with ADHD, while a multimodal approach involving psychotherapy has also shown promising results. Conclusions General psychiatrists should familiarize themselves with the symptoms of ADHD in adults in order to diagnose and manage ADHD and comorbidities appropriately in these patients.

Craving, cue reactivity, and stimulus control among early-stage young smokers: effects of smoking intensity and gender

INTRODUCTION

Smoking initiation usually begins in adolescence, but how and for whom nicotine dependence emerges during this period is unclear. The cue-reactivity paradigm is well suited to examine one marker of dependence: craving-related stimulus control, i.e., the ability of environmental cues to elicit craving to smoke. This study examined the effects of both level of smoking involvement (daily vs. occasional smoking) and gender on reactivity to both smoking and alcohol cues.

METHODS

Young (age range 16-20; 42% female) daily (n = 55) and occasional (n = 52) smokers were exposed to each of three counterbalanced cues: (a) in vivo smoking (e.g., sight, smell, lighting of cigarette), (b) alcohol (e.g., opening, pouring, and smell of preferred beverage), and (c) neutral cue.

RESULTS

Daily smokers exhibited higher levels of tonic (i.e., noncue-elicited) craving than did occasional smokers. Both groups showed significant increases in craving in response to cues (i.e., cue-elicited craving), with little evidence that cue-elicited craving differed between groups. Females were more cue reactive to both the alcohol and smoking cues than males, particularly for the positively reinforced aspects of smoking (i.e., hedonic craving). There were no gender × group interaction effects in response to either the alcohol or the smoking cue.

CONCLUSIONS

Findings show the presence of cue-elicited craving even among occasional smokers and are consistent with literature demonstrating heightened sensitivity to environmental cues among females. Cue-elicited craving may be one mechanism that contributes to the maintenance of smoking behavior and perhaps to the development of nicotine dependence within early stage smokers.

Validity of conners' adult attention-deficit/hyperactivity disorder rating Scale-investigator rated: screening version in patients from within and outside of Europe

In adult patients with attention-deficit/hyperactivity disorder from within and outside of Europe, Conners' Adult Attention-Deficit/Hyperactivity Disorder (ADHD) Rating Scale-Investigator Rated: Screening Version showed good internal consistency (Cronbach's α=0.930 and 0.938, respectively) and convergent validity with the Clinical (Pearson's correlation coefficients: 0.65-0.82, P<0.001) Global Impression-ADHD-Severity scale over 12 weeks of pharmacological treatment.

A meta-analysis of the consistency of atomoxetine treatment effects in pediatric patients with attention-deficit/hyperactivity disorder from 15 clinical trials across four geographic regions

OBJECTIVE

Atomoxetine has been approved as a treatment for children and adolescents with attention-deficit/hyperactivity disorder (ADHD) in the United States, throughout Europe, and in other countries. This meta-analysis was to assess the consistency of the treatment effect of atomoxetine across four global geographic regions.

METHODS

Data from 15 acute, double-blind, placebo-controlled trials were pooled (2 in Asia, 4 in Europe, 8 in North America, and 1 in Russia), yielding 2569 pediatric patients with ADHD. Improvements during 6-10 weeks of atomoxetine treatment were evaluated using the ADHD Rating Scale-IV or the Swanson, Nolan, and Pelham Scale-Revised. Consistency across regions was assessed by an interaction test and Higgins I(2). Consistency of one region versus other regions was assessed by effect sizes of individual regions and pairwise differences.

RESULTS

Patient demographics were generally similar across regions. More patients from Asia met diagnostic criteria for ADHD inattentive subtype and fewer for combined subtype compared with patients from Europe, North America, or Russia. Asian patients had a lower mean baseline ADHD total score and mean hyperactivity/impulsivity subscore. Treatment effects showed marginal inconsistency and moderate heterogeneity among the regions (percentage of patients achieving a 40% decrease from baseline ADHD scores, atomoxetine versus placebo: Asia 39.6%, 24.0%; Europe 40.2%, 12.1%; North America 45.3%, 21.7%; Russia 54.2%, 33.3%). Inconsistency was observed primarily in Asia versus the other regions. Completion rates with atomoxetine were higher in Asia and Russia (94.4% and 94.3%, respectively) than in Europe (84.3%) or North America (80.4%).

CONCLUSIONS

Atomoxetine was demonstrated as an effective treatment for ADHD in 15 clinical trials from four global regions. The current meta-analysis has revealed a degree of heterogeneity in treatment efficacy across regions, most notably in the comparison of Asian patients relative to those from the other regions.

Substance use disorders in children and adolescents with attention-deficit/hyperactivity disorder: implications for treatment and the role of the primary care physician

OBJECTIVES

Review the association between attention-deficit/hyperactivity disorder (ADHD) and substance use disorder (SUD) in children and adolescents. Discuss treatment implications and the role of the primary care physician in the management of this comorbidity.

DATA SOURCES

Articles published from 1991 to 2007 were identified through a MEDLINE search using the search terms attention-deficit/hyperactivity disorder and substance use disorder.

STUDY SELECTION

Publications cited include reviews of substance use disorders in children and adolescents with ADHD, manuals of diagnostic tests, and 69 studies of substance use disorders in children and adolescents with ADHD. No non-English-language publications were identified.

DATA SYNTHESIS

Recent reports identify SUD in a high proportion of respondents with ADHD and ADHD in a high proportion of respondents with many types of SUD. Factors that appear to increase the risk for SUD include comorbid psychiatric disorders, particularly conduct disorder. Pharmacotherapy for ADHD appears not to increase the risk for subsequent SUD. Guidelines for the evaluation and treatment of patients with comorbid ADHD and SUD are outlined. Psycho-stimulants carry the risk for misuse by both patients and family members through diversion. Although nonstimulants such as atomoxetine have low abuse potential, they appear to be less efficacious than stimulants. Formulations that have the potential to lower the abuse liability of stimulants are being developed. These include a transdermal form of methylphenidate that has been shown to be efficacious in the treatment of ADHD and a prodrug stimulant, lisdexamfetamine, recently approved for the treatment of ADHD. Clinical data indicate that lisdexamfetamine is efficacious, and significantly lower likability scores were seen with lisdexamfetamine than with equivalent oral doses of d-amphetamine sulfate.

CONCLUSIONS

Pharmacotherapy may reduce the risk for SUD in patients with ADHD. Psycho-stimulants remain the first-line therapy for the core symptoms of ADHD. New formulations of pharmacologic agents with a reduced potential for abuse are being developed.

Gender differences in craving and cue reactivity to smoking and negative affect/stress cues

There is evidence that women may be less successful when attempting to quit smoking than men. One potential contributory cause of this gender difference is differential craving and stress reactivity to smoking- and negative affect/stress-related cues. The present human laboratory study investigated the effects of gender on reactivity to smoking and negative affect/stress cues by exposing nicotine dependent women (n = 37) and men (n = 53) smokers to two active cue types, each with an associated control cue: (1) in vivo smoking cues and in vivo neutral control cues, and (2) imagery-based negative affect/stress script and a neutral/relaxing control script. Both before and after each cue/script, participants provided subjective reports of smoking-related craving and affective reactions. Heart rate (HR) and skin conductance (SC) responses were also measured. Results indicated that participants reported greater craving and SC in response to smoking versus neutral cues and greater subjective stress in response to the negative affect/stress versus neutral/relaxing script. With respect to gender differences, women evidenced greater craving, stress and arousal ratings and lower valence ratings (greater negative emotion) in response to the negative affect/stressful script. While there were no gender differences in responses to smoking cues, women trended towards higher arousal ratings. Implications of the findings for treatment and tobacco-related morbidity and mortality are discussed.

Correlates of alcohol use in adults with ADHD and comorbid alcohol use disorders: exploratory analysis of a placebo-controlled trial of atomoxetine

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) and substance use disorder are often comorbid in adults. The effects of ADHD treatment on comorbid alcohol use disorder have not been extensively studied.

OBJECTIVE

To assess correlates of ADHD and alcohol use outcomes in ADHD with comorbid alcohol use disorders, via a post-hoc exploratory subgroup analysis of a previously conducted, randomized, double-blind, placebo-controlled study of recently abstinent adults.

METHODS

Adults who had ADHD and alcohol use disorders and were abstinent for 4-30 days were randomized to daily atomoxetine 25-100 mg (mean final dose = 89.9 mg) or placebo for 12 weeks. Changes in ADHD symptoms from baseline to endpoint were assessed using the ADHD Investigator Symptom Rating Scale (AISRS) total score, alcohol use by the timeline followback method, and alcohol cravings by the Obsessive Compulsive Drinking Scale.

RESULTS

Of 147 subjects receiving atomoxetine (n = 72) or placebo (n = 75) in the primary study, 80 (54%) completed 12 weeks (n = 32 atomoxetine; n = 48 placebo). Improvements in ADHD symptoms on the AISRS correlated significantly with decreases in alcohol cravings (Pearson's r = 0.28; 95% confidence interval [CI] = 0.11-0.43; p = 0.002), and the correlation was most notable with atomoxetine (r = 0.29; CI [0.04 - 0.51]; p = 0.023) rather than with placebo (r = 0.24; CI [0.00-0.46]; p = 0.055). On-treatment drinking levels correlated with AISRS scores (r = 0.12; CI [0.05 -0.19]; p = 0.001). Relapse to alcohol abuse significantly correlated with worse ADHD symptoms on 15 of 18 items of the AISRS in the placebo group (p < 0.05 for each).

CONCLUSIONS

No baseline predictor (other than degree of sobriety) of alcohol use or ADHD outcomes emerged. ADHD symptom improvements correlated significantly with reductions in alcohol cravings, and relapse to alcohol abuse correlated significantly with worsening of most ADHD symptoms in the placebo group, but not in the atomoxetine group. This post-hoc subgroup analysis is of a hypothesis-generating nature, and the generalizability of the findings may be limited by exclusion of adults with common ADHD comorbidities from the base study. Further, prospective clinical trials in larger and more heterogeneous patient populations are warranted to confirm or reject these preliminary associations. TRIAL REGISTRATION (BASE STUDY): ClinicalTrials.gov identifier: NCT00190957.

Varenicline versus bupropion XL for smoking cessation in older adolescents: a randomized, double-blind pilot trial

INTRODUCTION

Despite tremendous potential public health impact, little work has focused on development of evidence-based smoking cessation treatments for adolescents, including pharmacotherapies. No prior studies have explored the feasibility and safety of varenicline and bupropion XL, 2 potentially promising pharmacotherapies, as smoking cessation treatments in adolescents.

METHODS

Treatment-seeking older adolescent smokers (ages 15-20) were randomized (double-blind) to varenicline (n = 15) or bupropion XL (n = 14), with 1-week titration and active treatment for 7 weeks. Structured safety, tolerability, and efficacy assessments (cotinine-confirmed 7-day point prevalence abstinence) were conducted weekly.

RESULTS

There were no serious adverse events. Two participants discontinued bupropion XL due to adverse effects, and none discontinued varenicline. Over the course of treatment, participants receiving varenicline reduced from 14.1 ± 6.3 (mean ± SD) to 0.9 ± 2.1 cigarettes/day (CPD, 4 achieved abstinence), while those receiving bupropion XL reduced from 15.8 ± 4.4 to 3.1 ± 4.0 CPD (2 achieved abstinence).

CONCLUSIONS

These preliminary results support the feasibility and safety of conducting adequately powered, placebo-controlled efficacy studies of varenicline and bupropion XL for adolescent smoking cessation.

Attention-deficit/hyperactivity disorder confounds nicotine withdrawal self-report in adolescent smokers

Individuals with attention-deficit/hyperactivity disorder (ADHD) are more likely than those without ADHD to initiate smoking and develop nicotine dependence. Recent research indicates that adults with ADHD experience more severe nicotine withdrawal symptoms than those without ADHD. However, little is known about nicotine withdrawal in adolescent smokers with history of ADHD. Among a sample of 134 nicotine-dependent adolescents entering a smoking cessation research study, participants completed the Minnesota Nicotine Withdrawal Scale (MNWS) and lifetime diagnostic assessment for ADHD during the baseline visit. Responses on individual items and MNWS total score were compared between participants with and without history of ADHD. In addition, correlations between MNWS responses and current ADHD symptoms were investigated among participants with history of ADHD. Forty-eight participants (36%) met lifetime ADHD criteria. Adolescent smokers with history of ADHD scored significantly higher on MNWS than those without history of ADHD. Among participants with history of ADHD, responses on the MNWS difficulty concentrating, restlessness/impatience, and anxiety/nervousness items each correlated positively with several current ADHD symptoms. Treatment-seeking adolescent smokers with history of ADHD are more likely to endorse nicotine withdrawal symptoms than those without history of ADHD. However, it does not appear that the symptoms reported in this sample represent a valid "withdrawal syndrome," particularly because these smokers had not yet formally attempted to quit. Rather, the data likely reflect common features between ADHD and nicotine withdrawal. Smoking research, particularly among adolescents in whom ADHD is so common, should carefully consider the complex issue of comorbid ADHD and nicotine dependence.

Assessment of nicotine dependence among adolescent and young adult smokers: a comparison of measures

INTRODUCTION

Tobacco use often starts in adolescence, yet assessment of dependence among adolescent smokers remains a challenge, particularly given the potential discord between self-reports of smoking behavior and actual use. We could find no prior study, among adolescents, that directly compares the association between objective biomarkers of tobacco exposure (e.g., cotinine) and multiple measures of dependence. This study examined the concurrent validity of two common dependence measures: the Fagerström Test for Nicotine Dependence (FTND) and the Hooked on Nicotine Checklist (HONC). We further examined the FTND by removing the one item on cigarettes smoked per day.

METHODS

Based within a parent clinical trial for adolescent smoking cessation, eligible participants were 12-21years old, smoking >/=5cigarettes per day on average, and with urine cotinine >100ng/ml at baseline. Results are based on participants who completed each measure and who provided a urine cotinine sample at baseline (N=73).

RESULTS

Results showed that the FTND was associated with cotinine (p<0.001; R(2)=0.25), and that this relationship held true for the revised FTND as well (p<0.001; R(2)=0.18). However, the HONC was only marginally associated with cotinine (p=0.06; R(2)=0.09).

DISCUSSION

Our results suggest that the FTND may be better associated with actual smoking behavior in adolescents as compared to the HONC. Pending replication, our data provide caution with regard to assessment of nicotine dependence at least among established adolescent smokers who have more entrenched smoking behavior.

Bupropion SR and contingency management for adolescent smoking cessation

There is a significant need for evidence-based treatments for adolescent smoking cessation. Prior research, although limited, has suggested potential roles for bupropion sustained-release (SR) and contingency management (CM), but no previous studies have assessed their combined effect. In a double-blind, placebo-controlled design, 134 adolescent smokers were randomized to receive a 6-week course of bupropion SR + CM, bupropion SR + non-CM, placebo + CM, or placebo + non-CM, with final follow-up at 12 weeks. The primary outcome was 7-day cotinine-verified point prevalence abstinence, allowing for a 2-week grace period. Combined bupropion SR + CM treatment yielded significantly superior abstinence rates during active treatment when compared with placebo + non-CM treatment. In addition, combined treatment showed greater efficacy at multiple time points than did either bupropion SR + non-CM or placebo + CM treatment. Combined bupropion SR and CM appears efficacious, at least in the short-term, for adolescent smoking cessation and may be superior to either intervention alone.

Stimulant formulation and motivation for nonmedical use of prescription attention-deficit/hyperactivity disorder medications in a college-aged population

There is relatively little research examining motives for nonmedical use (NMU) of attention-deficit/hyperactivity disorder (ADHD) medications and predictors of motivation. We present results of a secondary analysis of an Internet-based epidemiological survey to explore the relationship between stimulant formulation and motivation for NMU of ADHD stimulant medications in a college-aged population. Demographic predictors of motivation to engage in NMU were also explored to investigate the potential correlates of recreational versus performance-enhancement motivations. Respondents scoring higher on the Adult ADHD Self-Report Scale were significantly more likely to engage in NMU of ADHD stimulant medications. Those using extended release (ER) stimulant formulations were less likely to endorse "staying awake" as a reason for NMU compared to those using immediate release (IR) stimulant formulations. 

Evidence for greater cue reactivity among low-dependent vs. high-dependent smokers

INTRODUCTION

Cue reactivity paradigms are well-established laboratory procedures used to examine subjective craving in response to substance-related cues. For smokers, the relationship between nicotine dependence and cue reactivity has not been clearly established. The main aim of the present study was to further examine this relationship.

METHODS

Participants (N=90) were between the ages 18-40 and smoked > or =10 cigarettes per day. Average nicotine dependence (Fagerström Test for Nicotine Dependence; FTND) at baseline was 4.9 (SD=2.1). Participants completed four cue reactivity sessions consisting of two in vivo cues (smoking and neutral) and two affective imagery cues (stressful and relaxed), all counterbalanced. Craving in response to cues was assessed following each cue exposure using the Questionnaire of Smoking Urges-Brief (QSU-B). Differential cue reactivity was operationally defined as the difference in QSU scores between the smoking and neutral cues, and between the stressful and relaxed cues.

RESULTS

Nicotine dependence was significantly and negatively associated with differential cue reactivity scores in regard to hedonic craving (QSU factor 1) for both in vivo and imagery cues, such that those who had low FTND scores demonstrated greater differential cue reactivity than those with higher FTND scores (beta=-.082; p=.037; beta=-.101; p=.023, respectively). Similar trends were found for the Total QSU and for negative reinforcement craving (QSU factor 2), but did not reach statistical significance.

DISCUSSION

Under partially sated conditions, less dependent smokers may be more differentially cue reactive to smoking cues as compared to heavily dependent smokers. These findings offer methodological and interpretative implications for cue reactivity studies.

Menstrual cycle and cue reactivity in women smokers

INTRODUCTION

Emerging research suggests potential effects of the menstrual cycle on various aspects of smoking behavior in women, but results to date have been mixed. The present study sought to explore the influence of menstrual cycle phase on reactivity to smoking in vivo and stressful imagery cues in a sample of non-treatment-seeking women smokers.

METHODS

Via a within-subjects design, nicotine-dependent women (N = 37) participated in a series of four cue reactivity sessions, each during a distinct biologically verified phase of the menstrual cycle (early follicular [EF], mid-follicular [MF], mid-luteal [ML], and late luteal [LL]). Subjective (Questionnaire of Smoking Urges-Brief; QSU-B) and physiological (skin conductance and heart rate) measures of craving and reactivity were collected and compared across phases.

RESULTS

Subjective reactive craving (QSU-B) to smoking in vivo cues varied significantly across the menstrual cycle (p = .02) and was higher in both EF and MF phases versus ML and LL phases, but this finding was not sustained when controlling for reactivity to neutral cues. Heart rate reactivity to stressful imagery cues (p = .01) and skin conductance reactivity to smoking in vivo cues (p = .05) varied significantly across the menstrual cycle upon controlling for reactivity to neutral cues, with highest reactivity during the MF phase.

DISCUSSION

Menstrual cycle phase may have an effect on reactivity to smoking-related and stressful cues among women smokers. These findings contribute to an expanding literature, suggesting menstrual cycle effects on smoking behaviors in women.

Tobacco smoking in individuals with attention-deficit hyperactivity disorder: epidemiology and pharmacological approaches to cessation

The co-occurrence of attention-deficit hyperactivity disorder (ADHD) and nicotine dependence is common. Individuals with ADHD are more likely to initiate smoking and become dependent on nicotine than their non-ADHD counterparts, and recent evidence suggests that they may have more difficulty quitting smoking. Little is known about how to best approach treating these co-morbidities to optimize clinical outcome. Clinicians treating individuals with either ADHD or nicotine dependence should be aware of their common co-occurrence and the need to address both in treatment. This review of ADHD and nicotine dependence provides an overview of relevant epidemiology, bidirectional interactions and implications for pharmacological and adjunctive psychosocial treatment. Incorporating the current evidence base and their clinical experience, the authors propose a stepwise approach to treating patients with co-morbid ADHD and nicotine dependence. Given the potential for ADHD symptoms to interfere with smoking cessation success, the first priority is to stabilize ADHD. The first-line pharmacological approach should be a long-acting psychostimulant. Upon ADHD stabilization, motivational techniques should be used to encourage readiness for a smoking cessation attempt. In the context of behavioural cessation interventions sensitive to the patient's needs and developmental stage, pharmacological intervention targeting smoking cessation may be initiated. The authors recommend varenicline as a first-line agent, given its superior effect size among available medication treatments. Symptoms of ADHD, as well as nicotine withdrawal and craving symptoms, should be monitored closely during the cessation attempt, and adjustments to therapy should be considered if warranted. The authors conclude that, while current treatments may potentially be effective for co-morbid ADHD and nicotine dependence, further research is needed to parse the complex associations between these disorders and prospectively study combined treatments.

Laboratory-based, cue-elicited craving and cue reactivity as predictors of naturally occurring smoking behavior

Cigarette craving, one hallmark sign of nicotine dependence, is often measured in laboratory settings using cue reactivity methods. How lab measures of cue reactivity relate to real world smoking behavior is unclear, particularly among non-treatment seeking smokers. Within a larger study of hormonal effects on cue reactivity (N=78), we examined the predictive relationship of cue reactivity to smoking, each measured in several ways. Results indicated that cue-evoked craving in response to stressful imagery, and to a lesser extent, in vivo smoking cues, significantly predicted smoking behavior during the week following testing. However, this predictive relationship was absent upon controlling for reactivity to neutral cues. Nicotine dependence may moderate the relationship between cue reactivity and actual smoking, such that this predictive relationship is less robust among highly dependent smokers than among smokers low in nicotine dependence. The question of whether cue-elicited craving predicts smoking among smokers not in treatment is best answered with a qualified yes, depending on how craving is manipulated and measured. Our findings highlight important methodological and theoretical considerations for cue reactivity research.

Cue reactivity in young marijuana smokers: a preliminary investigation

To develop and evaluate the feasibility of a cue reactivity paradigm for young marijuana smokers, the authors set up a laboratory procedure involving neutral and marijuana-related imagery, video, and in vivo cues. Fifteen adolescents and young adults with cannabis use disorders completed the procedure, which included continuous measurement of skin conductance and heart rate. Participants also completed questionnaires regarding marijuana craving before, during, and after cue presentations. Higher levels of craving and skin conductance were observed during marijuana cue presentations. The procedure appears to elicit cue reactivity among adolescents and young adults with cannabis use disorders and should be further evaluated and refined with a larger sample. Implications for future studies are discussed.

The impact of loss to follow-up on hypothesis tests of the treatment effect for several statistical methods in substance abuse clinical trials

"Loss to follow-up" can be substantial in substance abuse clinical trials. When extensive losses to follow-up occur, one must cautiously analyze and interpret the findings of a research study. Aims of this project were to introduce the types of missing data mechanisms and describe several methods for analyzing data with loss to follow-up. Furthermore, a simulation study compared Type I error and power of several methods when missing data amount and mechanism varies. Methods compared were the following: Last observation carried forward (LOCF), multiple imputation (MI), modified stratified summary statistics (SSS), and mixed effects models. Results demonstrated nominal Type I error for all methods; power was high for all methods except LOCF. Mixed effect model, modified SSS, and MI are generally recommended for use; however, many methods require that the data are missing at random or missing completely at random (i.e., "ignorable"). If the missing data are presumed to be nonignorable, a sensitivity analysis is recommended.

Tolerability and effects of oral Delta9-tetrahydrocannabinol in older adolescents with marijuana use disorders

OBJECTIVE

The tolerability and effects of oral Delta9-tetrahydrocannabinol (THC) have been previously investigated in adult marijuana abusers. However, no studies have included adolescent participants. This double-blind laboratory study investigated the tolerability and effects of oral THC in a group of older adolescents with marijuana use disorders.

METHODS

Eight participants (ages 16-21 years), smoking an average of 5.2 days/week and 2.5 "joints"/day, completed this four-session study, during which they received one of four oral THC doses (0, 2.5, 5, 10 mg) each session. Administration of oral THC doses was counterbalanced across participants. During each session, participants completed the Digit-Symbol Substitution Task (DSST) and subjective-effect ratings at baseline and 1, 2, and 3 h after oral THC administration.

RESULTS

Oral THC (5 mg and 10 mg) increased several "positive" subjective-effect ratings (e.g., "Good Drug Effect"), while producing no significant effects on cardiovascular measures, DSST performance, or "negative" subjective-effect ratings.

CONCLUSIONS

These results indicate that oral THC was well tolerated and suggest further study of this medication in adolescent marijuana abusers.

Is attention deficit hyperactivity disorder (ADHD) symptom severity associated with tobacco use?

Several studies report a strong link between ADHD and tobacco use; however, the nature of this relationship is not entirely clear. We examined the relationship between attention deficit hyperactivity disorder (ADHD) symptoms and tobacco use within a sample of college students. Although tobacco use was the main focus, we also examined alcohol and marijuana use. We examined the association between the number of ADHD symptoms endorsed (severity), and tobacco, alcohol, and marijuana use in a convenience sample of 334 college students in the southeastern United States. Survey data were based on the annual Core Alcohol and Drug Survey for substance use, and the Current Symptom Scale (CSS) for ADHD, conduct disorder (CD), and antisocial personality disorder (ASPD) symptoms. Among ever users of a substance, the number (severity) of current ADHD symptoms, including inattentive and hyperactive symptoms, were significantly associated with the frequency of tobacco and marijuana use in the past month and past year, as well as to the frequency of alcohol use in the past month. The results suggest that the number of ADHD symptoms is proportionally associated with tobacco, alcohol, and marijuana use.

Menstrual phase effects on smoking cessation: a pilot feasibility study

BACKGROUND AND OBJECTIVES

A growing body of research suggests that nicotine withdrawal and cigarette craving may vary across the menstrual cycle and that the luteal phase of the cycle may be associated with increases in each. This potential relationship suggests that careful timing of quit attempts during the menstrual cycle may improve initial success at abstinence, although there are no direct tests of this approach yet published. Our objectives were to preliminarily test the effect of timing of quit attempts for smoking cessation relative to menstrual cycle and to identify methodological procedures that could guide subsequent, larger clinical trials.

METHODS

In this pilot study, we randomized female smokers aged 18-40 who were not currently using hormonal contraception to quit smoking during either the follicular (n = 25) or luteal phase (n = 19) of their menstrual cycle. Participants were provided with two sessions of smoking cessation counseling (90 minutes total). All participants were provided with a transdermal nicotine patch contingent on maintenance of abstinence throughout the course of the 6-week study.

RESULTS

Among participants who initiated treatment, received the patch, and made a quit attempt (n = 35), carbon monoxide-verified repeated point prevalence abstinence 2 weeks after the target quit date was higher in the follicular than the luteal group (32% vs. 19%, respectively; OR = 2.0, 95% CI = 0.4-9.8). Within the overall study population, this difference was slightly lower (24% vs. 16%; OR = 1.7, 95% CI = 0.4-7.8).

CONCLUSIONS

Timing quit attempts based on menstrual phase is feasible. Insights gained from this study and the recommendations made herein may inform future research on this important clinical question.

Effects of gender and cigarette smoking on reactivity to psychological and pharmacological stress provocation

We examined the influence of gender and smoking status on reactivity in two human laboratory stress paradigms. Participants were 46 (21 men, 25 women) healthy individuals who completed the Trier Social Stress Task (i.e., performed speech and math calculations in front of an audience) and a pharmacological stress provocation (i.e., administration of corticotrophin releasing hormone (CRH)) after an overnight hospital stay. Approximately half (53%) of the participants were smokers. Cortisol, adrenocorticotrophin hormone (ACTH), physiologic measures (heart rate, blood pressure), and subjective stress were assessed at baseline and at several time points post-task. Men demonstrated higher baseline ACTH and blood pressure as compared to women; however, ACTH and blood pressure responses were more pronounced in women. Women smokers evidenced a more blunted cortisol response as compared to non-smoking women, whereas smoking status did not affect the cortisol response in men. Finally, there was a more robust cardiovascular and subjective response to the Trier as compared to the CRH. Although preliminary, the findings suggest that women may be more sensitive than men to the impact of cigarette smoking on cortisol response. In addition, there is some evidence for a more robust neuroendocrine and physiologic response to acute laboratory stress in women as compared to men.

Managing attention-deficit/hyperactivity disorder in the presence of substance use disorder

Patients with attention-deficit/hyperactivity disorder (ADHD), especially adolescents and young adults, commonly have comorbid conditions, including substance use disorder (SUD), which can complicate the treatment and management of both illnesses. Patients with ADHD and SUD have an earlier age at onset of SUD, may take longer to achieve remission than those with only SUD, and are likely to have a longer course, poorer outcome, and higher rates of other psychiatric comorbidities. There is evidence of misuse and diversion with stimulant medications, which raises several safety concerns. Studies of pharmacotherapy for ADHD and comorbid SUD are limited but have shown that stimulant medications probably do not exacerbate the SUD. Nonstimulant medications for ADHD and extended-release stimulant formulations are available and may be less likely to be misused or diverted. Understanding the motives for drug use and misuse is important in treating patients with ADHD and comorbid SUD. A number of tools are available to the clinician to detect substance use problems in patients with ADHD, including drug and alcohol screening questionnaires and toxicology screens. Clinical recommendations for treating this dual diagnosis include using nonstimulant agents or extended-release stimulant formulations in conjunction with psychosocial therapies to treat both the ADHD and the SUD.

Reactivity to nicotine cues over repeated cue reactivity sessions

The present study investigated whether reactivity to nicotine-related cues would attenuate across four experimental sessions held 1 week apart. Participants were nineteen non-treatment seeking, nicotine-dependent males. Cue reactivity sessions were performed in an outpatient research center using in vivo cues consisting of standardized smoking-related paraphernalia (e.g., cigarettes) and neutral comparison paraphernalia (e.g., pencils). Craving ratings were collected before and after both cue presentations while physiological measures (heart rate, skin conductance) were collected before and during the cue presentations. Although craving levels decreased across sessions, smoking-related cues consistently evoked significantly greater increases in craving relative to neutral cues over all four experimental sessions. Skin conductance was higher in response to smoking cues, though this effect was not as robust as that observed for craving. Results suggest that, under the described experimental parameters, craving can be reliably elicited over repeated cue reactivity sessions.

Daily stressor sensitivity, abuse effects, and cocaine use in cocaine dependence

This study highlights respondent sensitivity to daily hassles as it relates to situational cocaine use and perceived long-term effects of adverse events in childhood. Data were drawn from a larger study on stress reactivity in cocaine dependent individuals. Participants (n=104) were cocaine dependent men and women without comorbid posttraumatic stress disorder (PTSD). They completed the Early Trauma Inventory (ETI), the Daily Hassles Scale (DHS), the Inventory of Drug-Taking Situations (IDTS), and the Time-Line Follow-Back (TLFB; for 90 days prior to interview). There were no gender differences in the amount or frequency of cocaine use, although the patterns of use differed between male and female users. Overall, there were some associations in the patterns of cocaine use and sensitivity to daily hassles, particularly the use in response to conflict with others. Early negative life events were positively related to response to daily hassles, but current triggers were more relevant. Reactivity to cocaine cues was related to daily hassle sensitivity among women only. Limitations and implications of the findings are discussed.

The effect of stimulant treatment for ADHD on later substance abuse and the potential for medication misuse, abuse, and diversion

Attention-deficit/hyperactivity disorder (ADHD) is known to be a strong risk factor for substance use disorders (SUD) in adolescence and in adulthood. Research shows that stimulant treatment does not increase the risk of SUD in adolescents or adults with ADHD but rather that stimulant treatments may have a protective effect. However, 2 in 10 youths with ADHD misuse their medication. Recent evidence suggests that slow uptake of medication in the brain allows for effective treatment without patients experiencing the euphoric qualities of immediate-release agents that lead to abuse or diversion. As a result, extended-release products and different formulations, such as lisdexamfetamine dimesylate (LDX), are less likely to be misused and diverted and may have lower abuse potential.

Impact of substance use disorder on ADHD and its treatment

Attention deficit/hyperactivity disorder (ADHD) is associated with a high rate of psychiatric comorbidity. Substance use disorder (SUD) is common, affecting 1 in 5 adults with ADHD. Adolescents with ADHD are twice as likely to become cigarette smokers as those without ADHD, and cigarette smoking is a significant risk factor for the development of subsequent SUD in adulthood. Patients with SUD and ADHD have been shown to have lower retention in SUD treatment programs, lower rates of SUD remission, and longer courses of SUD. SUD also complicates the diagnosis of adult ADHD. Fortunately, pharmacologic treatment of ADHD does not appear to increase the risk for development of SUD in ADHD patients.

Diagnosing ADHD in adults with substance use disorder: DSM-IV criteria and differential diagnosis

Individuals with ADHD have a high rate of comorbid psychiatric disorders, especially substance use disorders. Similarly, ADHD is overrepresented in the SUD population. This high rate of comorbidity can make ADHD difficult to diagnose and treat. Comorbid SUD in individuals with ADHD can have a negative impact on course of illness and quality of life. The stringent DSM-IV criteria for ADHD may make diagnosing ADHD in adults difficult, which may lead to an underdiagnosis of ADHD in the adult population. This may be especially true for patients with SUD, because cognitive deficits associated with substance abuse can hinder their ability to recall ADHD symptoms for appropriate diagnostic purposes. On the other hand, SUD symptoms may mimic ADHD symptoms, which can lead to an overdiagnosis of ADHD in the SUD population. If proper attention is paid to age-appropriate symptoms of ADHD, and careful longitudinal data are obtained from patients presenting with ADHD or SUD, proper treatment can be given to patients with these comorbid disorders.

The impact of alcohol dependence and posttraumatic stress disorder on cold pressor task response

OBJECTIVE

Posttraumatic stress disorder (PTSD) is commonly comorbid with alcohol-use disorders. Abnormalities in the hypothalamic-pituitary-adrenal (HPA) axis response are common in both disorders. The objective of this study was to investigate HPA axis reactivity to the cold pressor task (CPT) among individuals with alcohol dependence, PTSD, and comorbid alcohol dependence and PTSD.

METHOD

Participants were 119 individuals with alcohol dependence only (n = 31), comorbid alcohol dependence and PTSD (n = 28), PTSD without alcohol dependence (n = 30), and a control group (n = 30). Subjective response, adrenal corticotropic hormone (ACTH), and cortisol were measured before, immediately after, and for 120 minutes after each subject completed the CPT.

RESULTS

There were significant group and gender differences found in the subjective and ACTH response, with significantly higher subjective stress ratings and decreased ACTH response in the alcohol-dependent, PTSD, and comorbid alcohol dependent-PTSD groups compared with the control group.

CONCLUSIONS

There were differences in the HPA axis and subjective response to the CPT between the control group and both the alcohol and PTSD groups. The HPA response in the comorbid alcohol-PTSD group was not significantly different than that of the alcohol-only or PTSD-only groups.

Menstrual cycle phase effects on nicotine withdrawal and cigarette craving: a review

Evidence suggests that women are less likely to quit smoking than are men. This may reflect differences in nicotine dependence and, more specifically perhaps, nicotine withdrawal and craving. However, there is conflicting research on gender differences on the experience of withdrawal and craving. Menstrual cycle effects may moderate this relationship. Given hormonal changes during the menstrual cycle, abstinence-related symptoms such as withdrawal and craving may vary as a function of menstrual phase as well. This qualitative review summarizes the modest but expanding body of research in this area. One of the challenges inherent in interpreting this literature is the difficulty in distinguishing withdrawal symptomatology from premenstrual symptomatology. Methodological variation, including limited sample size and possible selection bias, in which several studies finding null effects excluded women with severe premenstrual dysphoric disorder, may explain some of the inconsistent findings across studies. Nonetheless, some of the 13 studies included in this review found heightened experiences of withdrawal or craving within the latter days of the menstrual cycle (i.e., the luteal phase). Further research is necessary to replicate these findings, but they may suggest the need for focused cessation treatment during the luteal phase or quit attempts that are well timed relative to specific menstrual phases.

Cold pressor task reactivity: predictors of alcohol use among alcohol-dependent individuals with and without comorbid posttraumatic stress disorder

BACKGROUND

The association between stress and alcohol dependence has been well established. Abnormalities in stress reactivity and hypothalamic-pituitary-adrenal axis (HPA) function may be involved in the mechanistic connection between stress and the initiation, development, and/or maintenance of alcohol dependence. Posttraumatic stress disorder (PTSD) commonly co-occurs with alcohol dependence and is characterized by HPA axis abnormalities. This study investigated the relationship between subjective and neuroendocrine stress reactivity to the cold pressor task (CPT) and prospective alcohol use among individuals with alcohol dependence, with and without comorbid PTSD.

METHODS

Participants were 63 individuals with (a) alcohol dependence only (n=35) or (b) comorbid alcohol dependence and PTSD (n=28). Participants completed the CPT, a widely used physical laboratory stressor. Subjective stress, craving, adrenocorticotrophin (ACTH), and cortisol were measured before, immediately after, and at 5, 30, 60, and 120 minutes after the CPT. Alcohol use during 1 month following testing was also assessed.

RESULTS

For the alcohol-only group, change in craving immediately following the CPT and craving during the 120-minute recovery phase were predictive of follow-up alcohol use. For the alcohol/PTSD group, change in craving was not predictive of follow-up use. Baseline drinking was, however, predictive of followup alcohol use for the alcohol/PTSD group. For the alcohol-only group, a blunted ACTH response coupled with a higher change in craving following the CPT was associated with significantly greater frequency and intensity of drinking during the follow-up phase.

CONCLUSIONS

These preliminary findings demonstrate significant differences between the alcohol-only and the alcohol/PTSD group in predictors of relapse. For the alcohol-only group, reactivity to an acute laboratory stressor may be predictive of subsequent alcohol use. This was not true for the alcohol/PTSD group. Although preliminary, the findings may help shed light on the mechanistic relationship between stress reactivity and increased risk for alcohol relapse and dependence in individuals with and without other Axis I comorbidity.

Reactivity to in vivo smoking cues in older adolescent cigarette smokers

Most smokers initiate smoking in adolescence, and craving for cigarettes may play an important role in maintenance of smoking behavior and relapse to smoking during a quit attempt. Although a significant body of literature explores cue-reactivity in adult smokers, little has been published on cue-reactivity among adolescent smokers. In a previously published work, we found that videotaped smoking cues may not be robust in eliciting craving among adolescent smokers. Hence, in this preliminary study, we examined reactivity to in vivo smoking cues among adolescent smokers (N = 11, average age = 18.1 years, range = 15-19 years, predominantly female). Participants were presented with in vivo smoking and neutral cues (counterbalanced). We recorded subjective craving and real-time heart rate in response to each type of cue. Adolescent smokers had a significantly greater "desire" to smoke (p < .05) in response to smoking cues vs. both baseline and neutral cues. Participants had faster heart rates after the smoking cues during the epochs of 21-30 s and 31-40 s (p values<.05) as compared with baseline, and mean heart rate was higher during the smoking cues relative to neutral cues among participants who received the smoking cues first (p < .05). Results of this preliminary study further demonstrate the feasibility of conducting cue-reactivity studies with adolescent cigarette smokers. Findings from this study suggest that adolescent smokers may show patterns of responding to smoking cues similar to those of adult smokers. Implications for future laboratory studies with adolescent smokers are discussed.

Advances in diagnosis of adolescent substance abuse

Screening and diagnosis of adolescent substance abuse is a challenging but achievable component of primary care practice. Successful integration of these procedures into office visits requires an understanding of prevalence, risk factors, and strategies for prevention and treatment. The authors provide a synopsis of recent advances and important issues in this area and propose a stepwise, evidence-based approach to evaluation of substance abuse in adolescents.

Attention-deficit/hyperactivity disorder, medication treatment, and substance use patterns among adolescents and young adults

OBJECTIVE

The aim of this study was to examine the relationship between current active attention-deficit/hyperactivity disorder (ADHD) symptoms, medication treatment, and substance use patterns among college students.

METHOD

Three hundred and thirty-four students at a local college were surveyed for current ADHD symptoms and psychopharmacological treatment. The survey was conducted in conjunction with an annual national survey that probes students about their substance use patterns and attitudes.

RESULTS

Participants with ADHD as ascertained by medication treatment of ADHD had greater past-year tobacco and marijuana use. Among those with ADHD, participants with active ADHD symptoms were more likely to have past-year tobacco and other drug (besides tobacco, alcohol, and marijuana) use as compared to those without active ADHD symptoms. In addition, participants with active ADHD symptoms were more likely to have past-month "other" drug use as compared to those without active ADHD symptoms. Among those prescribed medications for ADHD, 25% reported ever using their medication to "get high" and almost 29% reported ever giving or selling their medication to someone else.

CONCLUSIONS

Results of our preliminary study indicated that ADHD symptom control may be important to protect against increased risk of substance use (particularly tobacco and drugs other than alcohol and marijuana) among college-age students with ADHD. Further studies of misuse/diversion of prescription stimulant medication among college students are needed.

Reactivity to smoking cues in adolescent cigarette smokers

This study examined reactivity to smoking cues in adolescent smokers (n=12) and nonsmokers (n=32), between 14 and 19 years of age. Participants were presented with videotaped smoking and neutral cues in a counterbalanced order. Subjective and physiological responses to each cue type were obtained. Findings indicated that smokers reported greater desire to smoke cigarettes in response to smoking cues, relative to neutral cues, when the smoking cues were presented first. Smokers also reported greater dominance (i.e., sense of control) during smoking-cue presentations, but only when these cues were presented second. Finally, smokers' heart rate was faster during the initial portion of the smoking-related video, relative to the neutral cue. Overall, this study demonstrates the feasibility of conducting laboratory-based cue-reactivity studies with adolescent smokers. Findings suggest that adolescents smokers show similar patterns of responding to smoking cues as adult smokers, although effects were not particularly robust in this sample and subjective effects were dependent on cue order.

Bupropion SR in adolescents with comorbid ADHD and nicotine dependence: a pilot study

OBJECTIVE

Bupropion SR has been shown to be effective for the treatment of nicotine dependence in adults. This open-label pilot study was designed to examine the feasibility and preliminary tolerability of bupropion SR in adolescents with nicotine dependence.

METHOD

Sixteen adolescents aged 12 to 19 years were enrolled in the study. Eleven of the 16 participants also had comorbid attention-deficit/hyperactivity disorder (ADHD). Participants were titrated over 1 week to bupropion SR 150 mg b.i.d. and maintained at this dosage for 6 weeks. Participants also received two brief smoking cessation counseling sessions.

RESULTS

Nine participants received at least 4 weeks of medication. There was a significant decrease in the average number of cigarettes smoked (p <.00) and carbon monoxide levels (p =.04) over the course of treatment. Intent-to-treat analysis showed that 31.25% of the adolescents were completely abstinent (5/16) after 4 weeks of taking bupropion SR. Participants' weight did not change significantly during the study (p =.55). There was a no significant change in ADHD symptoms during the study (p =.1).

CONCLUSIONS

Bupropion SR along with brief counseling may be safe and potentially efficacious for adolescents with nicotine dependence with and without ADHD. Smoking cessation trials in adolescents need to focus on strategies to increase retention for optimal effect.

Neuroendocrine and behavioral responses to dopaminergic agonists in adolescents with alcohol abuse

RATIONALE

Dopaminergic systems are involved in the pathophysiology of alcohol use disorders, but there is little research investigating the role of these systems in adolescents.

OBJECTIVES

In this study, we investigated dopaminergic systems in adolescents with alcohol abuse by determining neuroendocrine and behavioral responses to dopaminergic drug challenges.

METHODS

Twenty-six participants (11 with DSM IV alcohol abuse and 15 controls) were enrolled in the study. Neuroendocrine and behavioral response to the dopaminergic indirect agonist methylphenidate (10 mg) and the direct agonist pergolide (50 mcg), were examined. The primary response measures were spontaneous eye-blink rate, plasma prolactin (PRL), and growth hormone (GH). Additionally, participants completed a visual analog mood scale (VAMS).

RESULTS

The rate of increase in plasma GH level was blunted for adolescents with alcohol abuse compared to the control group, after methylphenidate administration [ t=-2.75, P=0.0066, 95% confidence interval (CI) -0.3, -0.048]. The rate of decrease in PRL level after pergolide administration was greater in adolescents with alcohol abuse as compared to the control group ( t=-3.05, P=0.0028, 95% CI -0.01923, -0.00409). Adolescents with alcohol abuse rated themselves as less "energized" in comparison to the control group after methylphenidate (rate difference=-0.4, P=0.0231).

CONCLUSIONS

This preliminary study suggests that adolescents with alcohol abuse may have a differential response to dopaminergic agonists, as also reported for adults with alcohol use disorders. Further studies investigating gender differences, and other neurotransmitter systems are needed to understand the differential dopaminergic response in adolescents with alcohol use disorders.