Archive for the 'Drug Abuse Science' category

Blogrolling: The Dose Makes the Poison

Mar 25 2013 Published by under Blogging, Blogroll, Drug Abuse Science, Drug Fatality

A new blog on drug toxicology has recently appeared and I think some of my Readers will want to bookmark The Dose Makes The Poison.

What is it about? Well, the Intro post indicates:

So, a long time ago in a land far, far away, a brilliant scientist named Paracelsus (who is considered by many a toxicologist throughout time, to be the ‘Father of Toxicology’) wrote:

“Alle Dinge sind Gift, und nichts ist ohn Gift; allein die Dosis macht, dass ein Ding kein Gift ist.”

Trudat! A few more posts have appeared already....

....TV Shows Aren't The Real World

Even though it doesn't really make sense, I still want this mass spec! The sample that was analyzed was gastric contents of a decedent. It identifies "chicken stock", coffee, and cocoa!


Analogue or not an analogue: that is the question!

Currently, cases involving the determination of a controlled substance analogue involve dueling chemists, toxicologists and pharmacologist as there is no consensus in the scientific community regarding what exactly is a controlled substance analogue. Typically, the prosecuting attorneys will have consultation and testimony from the DEA chemists or toxicologists/pharmacologists while the defense will have consultation and testimony from chemists and toxicologists/pharmacologists from other entities. The decision boils down to opinion vs. opinion.

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Failure to Replicate

I should have put that in quotes because it actually appears in the title of this new paper published in Neuropsychopharmacology:

Hart AB, de Wit H, Palmer AA. Candidate gene studies of a promising intermediate phenotype: failure to replicate. Neuropsychopharmacology. 2013 Apr;38(5):802-16. doi: 10.1038/npp.2012.245. Epub 2012 Dec 3. [PubMed]

ResearchBlogging.orgfrom the Abstract alone you can get a sense

We previously conducted a series of 12 candidate gene analyses of acute subjective and physiological responses to amphetamine in 99-162 healthy human volunteers (ADORA2A, SLC6A3, BDNF, SLC6A4, CSNK1E, SLC6A2, DRD2, FAAH, COMT, OPRM1). Here, we report our attempt to replicate these findings in over 200 additional participants ascertained using identical methodology. We were unable to replicate any of our previous findings.

The team, with de Wit's lab expert on the human phenotyping and drug-response side and Palmer's lab expert on the genetics, has been after genetic differences that mediate differential response to amphetamine for some time. There's a human end and a mouse end to the overall program which has been fairly prolific.

In terms of human results, they have previously reported effects as varied as:
-association of an adenosine receptor gene polymorphism with degree of anxiety in response to amphetamine
-association of a dopamine transporter gene promotor polymorphism with feeling the drug effect and diastolic blood pressure
-association of casein-kinase I epsilon gene polymophisms with feeling the drug effect
-association with fatty acid amide hydrolase (FAAH) with Arousal and Fatigue responses to amphetamine
-association of mu 1 opioid receptor gene polymorphisms with Amphetamine scale subjective report in response to amphetamine

There were a dozen in total and for the most part the replication attempt with a new group of subjects failed to confirm the prior observation. The Discussion is almost plaintive at the start:

This study is striking because we were attempting to replicate apparently robust findings related to well-studied candidate genes. We used a relatively large number of new participants for the replication, and their data were collected and analyzed using identical procedures. Thus, our study did not suffer from the heterogeneity in phenotyping procedures implicated in previous failures to replicate other candidate gene studies (Ho et al, 2010; Mathieson et al, 2012). The failure of our associations to replicate suggests that most or all of our original results were false positives.

The authors then go on to discuss a number of obvious issues that may have led to the prior "false positives".

-variation in the ethnic makeup of various samples- one reanalysis using ancestry as covariate didn't change their prior results.

-power in Genome-Wide association studies is low because effect sizes / contribution to variance by rare alleles is small. they point out that candidate gene studies continue to report large effect sizes that are probably very unlikely in the broad scheme of things...and therefore comparatively likely to be false positives.

-multiple comparisons. They point out that not even all of their prior papers applied multiple comparisons corrections against the inflation of alpha (the false positive rate, in essence) and certainly they did no such thing for the 12 findings that were reported in a number of independent publications. As they note, the adjusted p value for the "322 primary tests performed in this study" (i.e., the same number included in the several papers which they were trying to replicate) would be 0.00015.

-publication bias. This discussion covers the usual (ignoring all the negative outcomes) but the interesting thing is the confession on something many of us (yes me) do that isn't really addressed in the formal correction procedures for multiple comparisons.

Similarly, we sometimes considered several alternative methods for calculating phenotypes (eg, peak change score summarization vs area under the curve, which tend to be highly but incompletely correlated). It seems very likely that the candidate gene literature frequently reflects this sort of publication bias, which represents a special case of uncorrected multiple testing.

This is a fascinating read. The authors make no bones about the fact that they've found that no less than 12 papers that they have published were the result of false positives. Not wrong...not fraudulent. Let us be clear. We must assume they were published with peer review, analysis techniques and samples sizes that were (and are?) standard for the field.

But they are not true.

The authors offer up solutions of larger sample sizes, better corrections for multiple comparisons and a need for replication. Of these, the last one seems the best and most likely solution. Like it or not, research funding is limited and there will always be a sliding scale. At first we have pilot experiments or even anecdotal observations to put us on the track. We do one study, limited by the available resources. Positive outcomes justify throwing more resources at the question. Interesting findings can stimulate other labs to join the party. Over time, the essential features of the original observation or finding are either confirmed or consigned to the bin of "likely false alarm".

This is how science progresses. So while we can use experiences like this to define what is a target sample size and scope for a real experiment, I'm not sure that we can ever overcome the problems of publication bias and cherry picking results from amongst multiple analyses of a dataset. At first, anyway. The way to overcome it is for the lab or field to hold a result in mind as tentatively true and then proceed to replicate it in different ways.

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UPDATE: I originally forgot to put in my standard disclaimer that I'm professionally acquainted with one or more of the authors of this work.

Hart, A., de Wit, H., & Palmer, A. (2012). Candidate Gene Studies of a Promising Intermediate Phenotype: Failure to Replicate Neuropsychopharmacology, 38 (5), 802-816 DOI: 10.1038/npp.2012.245

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Effects of MDPV ("Bath Salts") interact with the ambient temperature

Feb 13 2013 Published by under Cathinone, Drug Abuse Science, Neuropharmacology

A new paper from the Fantegrossi laboratory examines the behavioral and physiological effects of the substituted cathinone drug, and "bath salts" constituent, 3,4-methylenedioxypyrovalerone (MDPV) [ Search PubMed ] which is the compound which has dominated the US media reports of averse consequences of bath salts intoxication. To the extent that verification of the drug has been provided in such reports, of course. Additional confirmation can be found here, here.

ResearchBlogging.orgThe current issue of Neuropsychopharmacology has a bath salts image on the cover and contains an article from Baumann and colleagues on MDPV pharmacology (I discussed it here) and this paper from Fantegrossi and colleagues.

William E Fantegrossi, Brenda M Gannon, Sarah M Zimmerman and Kenner C Rice In vivo Effects of Abused ‘Bath Salt’ Constituent 3,4-methylenedioxypyrovalerone (MDPV) in Mice: Drug Discrimination, Thermoregulation, and Locomotor Activity. Neuropsychopharmacology (2013) 38, 563–573; doi:10.1038/npp.2012.233; published online 5 December 2012 [ ArticleLink(free); PDF ]

This is a behavioral pharmacology study in male NIH Swiss mice which first uses drug discrimination techniques to show that when mice are trained to discriminate 0.3 mg/kg i.p. MDPV from saline the subsequent dose response curves for 0.01 to 0.3 mg/kg of MDPV, METH and MDMA are nearly identical. This article has been made freely available so I won't belabor this part of the study.

Fantegrossi13-mdpvFig4What I wanted to focus on was the radiotelemetry studies of body temperature and locomotion. For reasons related to this classic paper on MDMA from Malberg and Seiden, most investigations of the effects of stimulant drugs in rodents should include some consideration of the role of ambient temperature. Fantegrossi and colleagues examined the effects of 0.3-30 mg/kg i.p. MDPV at both 20°C and 28°C. They showed, first of all, that MDPV produces no change in body temperature when administered at 20°C, but induces temperature elevations in a dose-dependent manner when animals are evaluated at 28°C. Even more interesting is what is shown in Figure 4 which I've included here. You can see that the locomotor stimulant effect (total activity counts over 6 hrs; left panel) of MDPV also is more pronounced at the higher ambient temperature with a peak differential observed after the 10 mg/kg i.p. dose (timecourse for this dose shown in right panel). There were also some other interesting phenomenological differences observed with the high ambient temperature condition.

At the highest tested dose of MDPV (30 mg/kg), significant focused stereotypy was observed at 28 1C, but not at 20 1C. Furthermore, four (of six) mice treated with 30 mg/kg MDPV at the high ambient temperature engaged in skin-picking and self-biting, which drew blood, and, in accordance with our IACUC approval, were removed from the study and euthanized. No signs of self-injurious behavior were observed at any dose of MDPV administered at 20 1C.

Repetitive, stereotyped behavior is common with locomotor stimulants and can be observed following high doses of amphetamine, methamphetamine and cocaine among other compounds. So this is probably an expected effect. What was interesting here was the dependency on ambient temperature. Off the top of my head, I can't remember either the stimulant drug sterotypy literature (which focuses on charcterizing the repetitive behaviors) or the locomotor studies (where the "inverted U" dose effect function often reflects the emergence of stereotyped behavior after high doses) focusing too heavily on the ambient temperature issue. No doubt I could stand to go back and review some papers with a closer eye on the ambient temperature.

This study, however, points a finger at environmental issues when trying to figure out the degree to which the drug MDPV might cause sensational media-friendly outcomes in some users. Studies such as the present one may indicate that factors as subtle as how hot it is the day a person takes a given drug can change the experience from relatively benign into something much more severe. Thus, a dose of a drug which has been taken before by the same user may have highly unpredictable effects just based on this one difference in the situation.

ADDITIONAL READING

Watterson et al 2012 demonstrated intravenous self-administration in rats.
Huang et al, 2012 showed locomotor effects of MDPV on activity wheels in rats.
Fuwa et al 2007 shows dopamine responses with microdialysis and locomotor effects [in Japanese, but the Abstract is in English and the figures are easily interpreted]
Meltzer et al 2006 present monoamine pharmacology on a series of pyrovalerone compounds

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Fantegrossi WE, Gannon BM, Zimmerman SM, & Rice KC (2012). In vivo Effects of Abused 'Bath Salt' Constituent 3,4-methylenedioxypyrovalerone (MDPV) in Mice: Drug Discrimination, Thermoregulation, and Locomotor Activity. Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology PMID: 23212455

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Faces of Drug Abuse Research: Jean Lud Cadet, M.D.

Jean Lud Cadet, M.D. [ PubMed, GoogleScholar, DepartmentalPage ] is the Chief of the Molecular Neuropsychiatry Research Branch in the Intramural Resarch Program at the National Institute on Drug Abuse. Within this branch he heads the Molecular Neuropsychiatry section which has maintained major interests in dissecting the toxic effects of methamphetamine, cocaine and MDMA on the brain using rodent models. He has a recent review article Epigenetics of Methamphetamine-Induced Changes in Glutamate Function that you might find of interest.

PhotoCredit: ASBMB

PhotoCredit: NIDA IRP

According to an interview with the American Society for Biochemistry and Molecular Biology Dr Cadet received his MD degree from Columbia University and completed residencies in Psychiatry at Columbia University and in Neurology at Mount Sinai Medical Center. Dr. Cadet indicates in the interview that it was chance notice of an announcement for a fellowship in Pharmacology at the NIMH IRP (which he secured and spent time as a Neuropsychiatry Fellow) that cemented his interest in research. Going by the PubMed record, it was during this time that Dr. Cadet became interested in movement disorder related to dopamine disruptions which foreshadowed his eventual interest in damage to dopaminergic functions caused by stimulant drugs. After the Fellowship, Dr. Cadet became Assistant Professor of Neurology and Psychiatry at Columbia University and then subsequently moved to the NIDA IRP in 1992.

Dr. Cadet is also the Associate Director for Diversity and Outreach within the NIDA IRP and, per an interview with the ASMBM Dr. Cadet states:

As the Associate Director for Diversity and Outreach, my greatest passion is the recruitment of young scientists from under-represented populations into various NIH programs. I have been in charge of recruiting summer students into the NIDA-IRP since 1995. I am also the chair of the Diversity and Outreach Committee (DOC) that is actively recruiting young scientists from under-represented groups. This committee has recently reached out to Patterson High School, a neighborhood high school. Two Patterson junior students are now serving internships in basic science laboratories at the NIDA-IRP. Using funds that were recently provided by the Scientific Director of NIDA-IRP, the DOC has also established a competitive application process that has helped to recruit 6 post-baccalaureate and/or post-doctoral fellows within the NIDA-IRP. I am relentless in my pursuit of Diversity within the NIDA-IRP and my activities together with those of DOC members are helping our intramural program to serve as a beacon to be followed by others.

I thank you Dr. Cadet for both furthering our understanding of the ways in which exposure to stimulant drugs of abuse can disrupt the brain and your efforts to extend opportunities within science to those who are of underrepresented racial or ethnic backgrounds.

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Post-baccalaureate program at NIDA IRP

Prior entries in this series overview the contributions of Yasmin Hurd, Carl Hart, Chana Akins and Percy Julian.

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Presumption of vocational impairment

Dec 08 2012 Published by under Cannabis, Drug Abuse Science, General Politics

Per this article, the question of private employers dealing with off-hours behavior deemed legal by the State.

Gee... If we only had some way to determine if users of marijuana are likely to be vocationally impaired. If only there were some way to get that information. So that we could come up with some guidelines. And do things based on reasonable approximations of fact rather than agenda based random reaction (on either side).

Wouldn't that be useful?

What? What's that you say?

"Science"?

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Mephedrone Brief 11/13/2012: Yes, it was the 4-methylmethcathinone that killed him

Nov 13 2012 Published by under Cathinone, Drug Abuse Science

There's a new Case Report in the Journal of Analytical Toxicology

Adamowicz P, Tokarczyk B, Stanaszek R, Slopianka M. Fatal Mephedrone Intoxication--A Case Report. J Anal Toxicol. 2012 Nov 7. [Epub ahead of print] [PubMed][DOI]

The victim was a 30 year old male, found in a stairwell in a "critical state". Emergency response was ineffectual and the individual died at the scene. The toxicology testing found his blood and vitreous humour positive for mephedrone (5.5 and 7.1 ug/mL, respectively). There was no alcohol in the individual, no positives on "routine screening analysis" nor any sign of amphetamine, methamphetamine or MDMA. The 2C-B compound initially suspected by police (based on some field assay, looks like) was not confirmed in the powder in his possession nor in tissue samples.

That's it, short and sweet. The mephedrone (aka 4-methylmethcathinone) killed him.

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Additional reading on the substituted cathinone designer drugs of abuse can be found in my archive.

Related reading on MDMA-induced fatality can be found in the MDMA Archive.

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Gaining clarity on the pharmacology of the bath salt MDPV

There are two new pharmacological investigations on the substituted cathinone drugs that have been discussed here on occasion.

Each of

Baumann MH, Partilla JS, Lehner KR, Thorndike EB, Hoffman AF, Holy M, Rothman RB, Goldberg SR, Lupica CR, Sitte HH, Brandt SD, Tella SR, Cozzi NV, Schindler CW.Powerful Cocaine-Like Actions of 3,4-Methylenedioxypyrovalerone (MDPV), a Principal Constituent of Psychoactive 'Bath Salts' Products. Neuropsychopharmacology. 2012 Oct 17. doi: 10.1038/npp.2012.204.

and

Simmler LD, Buser TA, Donzelli M, Schramm Y, Dieu LH, Huwyler J, Chaboz S, Hoener MC, Liechti ME.Pharmacological characterization of designer cathinones in vitro. Br J Pharmacol. 2012 Aug 17. doi: 10.1111/j.1476-5381.2012.02145.x.

report very similar findings for MDPV, the cathinone that appears most frequently in US newspaper reports.

As a very general rule, the amphetamine class stimulants do a couple of things to enhance the neuron-to-neuron chemical communication that occurs in the brain. The most common and significant effects tend to involve the transporter mechanisms that remove dopamine, norepinephrine and / or serotonin from the synapse, the gap between two neurons. These transporter molecules are an integral part of terminating a signalling event which has been caused by the release of one of these three monoamines from one of the neurons in question. Interfere with the operation of these transporters and a drug can potentiate the magnitude or duration of a given signalling event (i.e., release of one of the dopamine (DA), norepinephrine (NE) or serotonin neurotransmitters).

The amphetamine class stimulants have these properties. As does cocaine. As do therapeutic drugs such as methylphenidate (Ritalin) and Prozac. The term selective serotonin re-uptake inhibitor, SSRI, for Prozac-class antidepressant drugs refers to the transporter, obviously, and also indicates a key thing with the term "selective". Drugs which have the ability to interact with one of the monoamine transporters tend to interact with the other ones as well. Substantial differences in effect can be associated with differences in the relative ability a specific molecule has to attach to the DAT versus the NET versus the SERotonin transporter (SERT). As one clear example, methamphetamine and MDMA differ in their relative ability to inhibit the SERT....this property of MDMA is associated with many of it's stimulant-atypical properties relative to other amphetamine-class drugs.

The new studies both show that MDPV blocks all three transporters with much more potent effects at the DAT and NET relative to SERT. As Baumann and colleagues note, MDPV is 50 and 10 times more potent than cocaine (not an amphetamine, we'll come to this) at DAT and NET respectively. Simmler and colleagues similarly indicate that MDPV is much more potent at DAT than cocaine or methamphetamine which did not qualitatively differ from each other.

So to this point, MDPV looks like a high-potency traditional stimulant. Most effective at the DAT, fairly effective at the NET and with less ability to block the SERT.

Cocaine and the amphetamines diverge at this point because the amphetamines act as a substrate at the transporters. Instead of only interfering and blocking them from doing anything, the amphetamines actually substitute for the neurotransmitter in question and are taken up into the cell. In so doing, they also cause an exchange to happen whereby the transporter moves some neurotransmitter from inside the cell back into the synapse. This transporter mediated efflux contributes to any "regular" release of neurotransmitter mediated through the merging of intracellular sacs (called vesicles) with the cell membrane.

The two papers agree in finding that MDPV has no ability to cause transporter-mediated efflux of dopamine and is therefore best categorized neuropharmacologically as a "pure" blocker (like cocaine) rather than an amphetamine-like transporter substrate.

The Simmler paper adds an in vitro model of blood/brain barrier penetration...in very simple terms the degree to which a molecule is fat-liking versus water-liking can alter the speed at which it can cross cell membranes and get into the brain. This paper used an in vitro preparation of human capillary endothelial cells (that form the blood-brain barrier) to show that MDPV is likely to cross the blood-brain barrier very rapidly, consistent with high lipophilicity predicted from its structure.

The upshot of the two papers is that MDPV shows pharmacological properties consistent with classical stimulants. It shows relatively high selectivity for DAT over SERT and high potency relative to drugs such as methamphetamine or cocaine. In vivo neurochemistry in the Baumann paper confirm that MDPV has potent effects on dopamine levels in the nucleus accumbens, a hallmark of drugs (beyond the stimulants even) which have substantial risk for compulsive use. The only somewhat discordant note for the structure-activity nerds is that MDPV looks so much like the rest of the amphetamines and cathinones that it will be interesting to discover why it doesn't act as a transporter substrate (Simmler et al included a number of other cathinones and showed that many of them do act as transporter substrates.)

Together these papers suggest that MDPV has high abuse liability with a use pattern characterized by frequent re-dosing much like one sees with cocaine. This is consistent with many self-reports that are emerging from people who use MDPV and therefore, despite the relatively brief time on the "market", we can predict a cocaine-like dependence problem to emerge for MDPV in the near future.

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Estimating the populations at risk for dependence on marijuana versus cocaine

Oct 08 2012 Published by under Cannabis, Cocaine, Drug Abuse Science

The recent fax (yes, they still call it this despite it arriving via email attachment) from CESAR (Vol 21, Issue 40; October 09, 2012) puts us back on an occasional theme of this blog.
They have adapted data from the latest update from SAMHSA's National Household Survey on Drug Abuse. This figure shows the number of past year users of selected illicit/recreational drugs.
Interestingly, marijuana use continues to trend up from the approximate plateau of 2002-2007, while use of cocaine is trending downward. Even the nonmedical use of prescription drugs (which has been a big problem overdose-wise) is relatively flat. Rounding slightly, we're looking at some 30 million past year users of marijuana compared with 4 million past year users of cocaine.

So why is this interesting? Well, as we've covered in the past the notion of conditional probability of dependence is a key issue for parents and policy makers and yet we have really poor estimates on that. Direct studies are usually limited in scope and the big-scale epidemiological stuff is too imprecise- i.e., rarely are there good diagnostics of dependence. So we sometimes have to infer things based on, e.g., daily use rates versus annual rates. Something like that. Fortunately the more precise studies and the broader interpretive efforts tend to agree.

Roughly speaking the conditional probability of alcohol dependence is on the order of 4%, for cannabis on the order of 8-10% and for stimulants, including cocaine, on the order of 15%.

So, applying these rough estimates to the past-year data above, we end up with something on the order of 600,000 dependent on cocaine and 2,400,000 dependent on marijuana. If you dropped the estimate of conditional probability for marijuana to the 4% of alcohol, you still end up with 1.2M people dependent on marijuana.

My point, as always, is that the definition and scope of a "drug dependence problem" is going to depend on frame of reference. One important frame of reference in my view is the number of people who are affected. This, btw, is why we think of alcohol dependence as such a huge problem even though just about every estimate suggests the conditional probability of dependence is one of the lowest. Because the percentage of the entire population exposed to alcohol on a regular basis is so large, the number of people who are dependent is relatively large.

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More cannabis hyperemesis Cases emerge

Aug 15 2012 Published by under Cannabis, Drug Abuse Science

Just as our most fervent defender of pot posted the most scientifically offensive clause in the legalization initiative defeated by California voters:

5. Cannabis has fewer harmful effects than either alcohol or cigarettes, which are both legal for adult consumption. Cannabis is not physically addictive, does not have long term toxic effects on the body, and does not cause its consumers to become violent.[DM- policy statement, false, false, distraction]

a comment on an older post returned our attention to the cannabis hyperemesis syndrome.

The past year I started smoking a lot more than ever before.
I'm 21, and every single morning I wake up with the worst upset stomach. It gets all the way to the point where I'm running to the bathroom to throw up and nothing ever comes out. The doctors think its in my head. Awesome. When this first began happening I would just make myself throw up but once I began it wouldn't stop for hours and I had to be taken to the emergency room. I feel like I'm dying!! But of course I feel completely better when I go smoke. It's insane!

So I trotted over to PubMed to see what is new, if anything, with cannabis hyperemesis. I found three new CaseReport publications that I had not seen before including:

Nicolson SE, Denysenko L, Mulcare JL, Vito JP, Chabon B. Cannabinoid hyperemesis syndrome: a case series and review of previous reports. Psychosomatics. 2012 May;53(3):212-9. Epub 2012 Apr 4. PubMed

Luther V, Yap L.A hot bath to calm what ails you: the Cannabis Hyperemesis Syndrome. Acute Med. 2012;11(1):23-4. PubMed

Bagdure S, Smalligan RD, Sharifi H, Khandheria B. Waning effect of compulsive bathing in cannabinoid hyperemesis.Am J Addict. 2012 Mar-Apr;21(2):184-5. doi: 10.1111/j.1521-0391.2011.00209.x. Epub 2012 Feb 7. PubMed

There are a total of 6 individuals reported (20-27 yrs of age, 2 female), all of whom presented to medical services (New York, 4; London, 1; Amarillo, TX, 1) with repeated and severe vomiting. All Cases had been smoking marijuana for many years with at least daily smoking in recent months to years. Five of the cases identify multiple uses per day, the sixth just indicates daily smoking.

Medical workups for all six indicated no other detectable gastrointestinal causes. All six Cases include multiple episodes of repeated vomiting in the past which had resulted in emergency department visits or hospitalizations for that patient.

All six had been using hot showers to control their symptoms, selected quotes from different Cases are illustrative:

he persistently demanded to use our showering facilities...He continued to demand to use the showering facilities, and oddly seemed more settled after bathing.

Several times during the interview, he went to the bathroom to put his head under the hot shower, which he said improved his

Ms. B complained that the hospital showers were not warm enough because the best way to relieve her symptoms was to take extremely hot, hour-long showers four times daily.

Three of the cases have evidence that ceasing marijuana smoking prevented further episodes of cyclical vomiting. Three show evidence that returning to marijuana smoking after abstinence led to recurrence of symptoms. Two cases had no followup evidence.

As this evidence starts to accumulate, we need to remember one thing about the Case Reports which is that there is a severe publication/selection bias in this sort of thing. Physicians' motivations to publish are not like ours and what strikes one group of physicians to bother to publish a Report is entirely opaque to me. It is, however, likely only the tip of the iceberg. As a second caution, it may also be the case that their is a bias for the publication of "clean" Cases. For only bothering when the individual Case seems to fit this growing profile to a T. Thus, it may make things about this syndrome appear more clear cut, more severe, etc. This goes both ways but one thing I would be concerned about are those Cases that are indeed caused by chronic cannabis use but are not diagnosed because they don't seem to fit the Case Report literature.

Perhaps hot bathing/showers are not always involved? Perhaps the use history is not as severe as it was for this most recent set of six cases? Perhaps there are some cases in which marginal gastro-intestinal concerns have interacted with a lesser degree of chronic cannabis smoking to push an individual over the threshold to cyclic vomiting symptoms?

There is always the unknown factor. People have proposed unknown toxins in the past...contamination of the cannabis being used. Still not impossible, especially given the apparent rarity of the syndrome. But, I would argue, as the cases occur across time and geography this becomes less likely. You would think that contamination might surround particular drug supplies (in time and space) in a way that might turn up as a geographic patient cluster.

For now, however, the evidence is reasonably strong and it is most certainly growing. Obviously, I think it is well past time for scientists with models that are relevant to emesis to get cranking and start up some studies. Unfortunately rats don't vomit so it is going to require some specialized animal models, perhaps the ferret.

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Self-portraits.....on DRUGS!

Aug 09 2012 Published by under Art, Drug Abuse Science

This is pretty interesting. An artist decided to draw a series of self-portraits after consuming different psychoactive compounds.
There are 45 of them so click on over. I gotta say, I'd really like to have seen him do his study project blinded to drug identity. Perhaps even more interestingly, he's been doing one self-portrait per day and is up in the 8,000s.

Naturally I picked this particular one to highlight because it is pretty much my mental image of a certain ex-co-blogger.

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