Long-acting opioid-agonists in the treatment of heroin addiction: why should we call them "substitution"?

Many studies have documented the safety, efficacy, and effectiveness of long-acting opioids (L-AOs), such as methadone and buprenorphine, in the treatment of heroin addiction. This article reviews the pharmacological differences between L-AO medications and short-acting opioids (heroin) in terms of reinforcing properties, pharmacokinetics, effects on the endocrine and immune systems. Given their specific pharmacological profile, L-AOs contribute to control addictive behavior, reduce craving, and restore the balance of disrupted endocrine function. The use of the term "substitution," referring to the fact that methadone or buprenorphine replace heroin in binding to brain opioid receptors, has been generalized to consider L-AOs as simple replacement of street drugs, thus contributing to the widespread misunderstanding of this treatment approach.

Involvement of coenzyme A esters and two new enzymes, an enoyl-CoA hydratase and a CoA-transferase, in the hydration of crotonobetaine to L-carnitine by Escherichia coli.

Two proteins (CaiB and CaiD) were found to catalyze the reversible biotransformation of crotonobetaine to L-carnitine in Escherichia coli in the presence of a cosubstrate (e.g., gamma-butyrobetainyl-CoA or crotonobetainyl-CoA). CaiB (45 kDa) and CaiD (27 kDa) were purified in two steps to electrophoretic homogeneity from overexpression strains. CaiB was identified as crotonobetainyl-CoA:carnitine CoA-transferase by MALDI-TOF mass spectrometry and enzymatic assays. The enzyme exhibits high cosubstrate specificity to CoA derivatives of trimethylammonium compounds. In particular, the N-terminus of CaiB shows significant identity with other CoA-transferases (e.g., FldA from Clostridium sporogenes, Frc from Oxalobacter formigenes, and BbsE from Thauera aromatica) and CoA-hydrolases (e.g., BaiF from Eubacterium sp.). CaiD was shown to be a crotonobetainyl-CoA hydratase using MALDI-TOF mass spectrometry and enzymatic assays. Besides crotonobetainyl-CoA CaiD is also able to hydrate crotonyl-CoA with a significantly lower Vmax (factor of 10(3)) but not crotonobetaine. The substrate specificity of CaiD and its homology to the crotonase confirm this enzyme as a new member of the crotonase superfamily. Concluding these results, it was verified that hydration of crotonobetaine to L-carnitine proceeds at the CoA level in two steps: the CaiD catalyzed hydration of crotonobetainyl-CoA to L-carnitinyl-CoA, followed by a CoA transfer from L-carnitinyl-CoA to crotonobetaine, catalyzed by CaiB. When gamma-butyrobetainyl-CoA was used as a cosubstrate (CoA donor), the first reaction is the CoA transfer. The optimal ratios of CaiB and CaiD during this hydration reaction, determined to be 4:1 when crotonobetainyl-CoA was used as cosubstrate and 5:1 when gamma-butyrobetainyl-CoA was used as cosubstrate, are different from that found for in vivo conditions (1:3).

The NMDA antagonist memantine attenuates the expression of opioid physical dependence in humans.

RATIONALE: Preclinical observations suggest that NMDA receptor-mediated glutamatergic neurotransmission is involved in the expression and maintenance of opioid dependence. OBJECTIVE: The present study evaluated whether memantine, the clinically available non-competitive NMDA receptor antagonist, decreases naloxone-precipitated withdrawal in morphine-dependent humans. METHODS: Eight heroin-dependent, non-treatment seeking, inpatient participants were stabilized on a fixed dose of morphine (30 mg PO qid). Subsequently, they received a series of challenges with naloxone (0.4 mg, IM) and the severity of opioid withdrawal was monitored. Either placebo or memantine (60 mg PO) was given 6 h before each naloxone challenge. A modified multiple baseline, across-participants design was used to evaluate the effects of memantine on the severity of naloxone-precipitated opioid withdrawal. RESULTS: Naloxone increased ratings and produced physical changes consistent with opioid withdrawal. Memantine attenuated the severity of opioid withdrawal as assessed with the Clinical Institute for Narcotic Withdrawal Scale scale. Withdrawal was significantly reduced when naloxone was administered at 6 and 52 h after memantine, but not when administered 126 h (5 days) after memantine. Medication effects, assessed 5 h after memantine administration and before naloxone administration, included significant increases in ratings of "strong" and "good" drug effect, and "I feel sedated", "mellow", and "high". CONCLUSIONS: Memantine attenuated the expression of opioid physical dependence in humans, indicating that glutamatergic neurotransmission at the NMDA receptor site contributes to the maintenance of opioid dependence. This finding suggests that memantine may be a useful adjunct in the treatment of opioid dependence.

Biotransformation of crotonobetaine to L(-)-carnitine in Proteus sp.

Two proteins, component I (CI) and component II (CII), catalyze the biotransformation of crotonobetaine to L(-)-carnitine in Proteus sp. CI was purified to electrophoretic homogeneity from cell-free extracts of Proteus sp. The N-terminal amino acid sequence of CI showed high similarity (80%) to the caiB gene product from Escherichia coli O44K74, which encodes the L(-)-carnitine dehydratase. CI alone was unable to convert crotonobetaine into L(-)-carnitine even in the presence of the cosubstrates crotonobetainyl-CoA or gamma-butyrobetainyl-CoA, which are essential for this biotransformation. The relative molecular mass of CI was determined to be 91.1 kDa. CI is composed of two identical subunits of molecular mass 43.6 kDa. The isoelectric point is 5.0. CII was purified to electrophoretic homogeneity from cell-free extracts of Proteus sp. and its N-terminal amino acid sequence showed high similarity (75%) to the caiD gene product of E. coli O44K74. The relative molecular mass of CII was shown to be 88.0 kDa, and CII is composed of three identical subunits of molecular mass 30.1 kDa. The isoelectric point of CII is 4.9. For the biotransformation of crotonobetaine to L(-)-carnitine, the presence of CI, CII, and a cosubstrate (crotonobetainyl-CoA or gamma-butyrobetainyl-CoA) were shown to be essential.

Epigenetic regulation of carnitine metabolising enzymes in Proteus sp. under aerobic conditions.

Proteus sp. is able to catalyse the reversible transformation of crotonobetaine into L(-)-carnitine during aerobic growth. Contrary to other Enterobacteriaceae no reduction of crotonobetaine into gamma-butyrobetaine could be detected in the culture supernatants. Activities of L(-)-carnitine dehydratase, carnitine racemasing system and crotonobetaine reductase could be determined enzymatically in cell-free extracts of Proteus sp. Small amounts of gamma-butyrobetaine were found in cell-free extracts, indicating that it accumulates in the cell and inhibits the crotonobetaine reductase. Crotonobetaine and L(-)-carnitine were able to induce enzymes of carnitine metabolism. gamma-Butyrobetaine and glucose repress carnitine metabolism in Proteus sp. Other betaines are neither inducers nor repressors. Monoclonal antibodies against purified CaiA from Escherichia coli O44K74 recognise an analogous protein in cell-free extract of Proteus sp. No cross-reactivity could be detected with monoclonal antibodies against purified CaiB and CaiD from E. coli O44K74.

The economic costs of heroin addiction in the United States.

This study documents the costs of heroin addiction in the United States, both to the addict and society at large. Using a cost-of-illness approach, costs were estimated in four broad areas: medical care, lost productivity, crime, and social welfare. We estimate that the cost of heroin addiction in the United States was US$21.9 billion in 1996. Of these costs, productivity losses accounted for approximately US$11.5 billion (53%), criminal activities US$5.2 billion (24%), medical care US$5.0 billion (23%), and social welfare US$0.1 billion (0.5%). The large economic burden resulting from heroin addiction highlights the importance of investment in prevention and treatment.

The co-occurrence of smoking and binge drinking in adolescence.

The present work sought to determine adolescent rates of smoking and binge-drinking co-occurrence. Secondary analyses were conducted on the interview responses of more than 4,000 adolescents between the ages of 13 and 18 who took part in the 1995 National Household Survey on Drug Abuse. Results revealed that not only are adolescent smokers likely to be binge drinkers, but adolescent binge drinkers are also likely to be smokers. Conversely, those who abstain from involvement with one of these substances generally abstain from the other as well. The discussion highlighted race/ethnic and gender differences in co-occurrence rates as well as prevention and intervention implications.

Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation.

The effects of drug dependence on social systems has helped shape the generally held view that drug dependence is primarily a social problem, not a health problem. In turn, medical approaches to prevention and treatment are lacking. We examined evidence that drug (including alcohol) dependence is a chronic medical illness. A literature review compared the diagnoses, heritability, etiology (genetic and environmental factors), pathophysiology, and response to treatments (adherence and relapse) of drug dependence vs type 2 diabetes mellitus, hypertension, and asthma. Genetic heritability, personal choice, and environmental factors are comparably involved in the etiology and course of all of these disorders. Drug dependence produces significant and lasting changes in brain chemistry and function. Effective medications are available for treating nicotine, alcohol, and opiate dependence but not stimulant or marijuana dependence. Medication adherence and relapse rates are similar across these illnesses. Drug dependence generally has been treated as if it were an acute illness. Review results suggest that long-term care strategies of medication management and continued monitoring produce lasting benefits. Drug dependence should be insured, treated, and evaluated like other chronic illnesses. JAMA. 2000;284:1689-1695.

Isolation, identification, and synthesis of gamma-butyrobetainyl-CoA and crotonobetainyl-CoA, compounds involved in carnitine metabolism of E. coli.

A still unknown low-molecular-mass cofactor essential for the activity of carnitine-metabolizing enzymes (e.g., L-carnitine dehydratase, crotonobetaine reductase) from E. coli has been purified to homogeneity from a cell-free extract of E. coli O44K74. The purity of the cofactor was confirmed by HPLC analysis. Biosynthesis of the unknown compound was only observed when bacteria were cultivated anaerobically in the presence of L-carnitine or crotonobetaine. The determined properties, together with results obtained from UV-visible, (1)H NMR, and mass spectrometry, indicate that the compound in question is a new CoA derivative. The esterified compound was suggested to be gamma-butyrobetaine-a metabolite of carnitine metabolism of E. coli. Proof of structure was performed by chemical synthesis. Besides gamma-butyrobetainyl-CoA, a second new CoA derivative, crotonobetainyl-CoA, was also chemically synthesized. Both CoA derivatives were purified and their structures confirmed using NMR and mass spectrometry. Comparisons of structural data and of the chemical properties of gamma-butyrobetainyl-CoA, crotonobetainyl-CoA, and the isolated cofactor verified that the unknown compound is gamma-butyrobetainyl-CoA. The physical and chemical properties of gamma-butyrobetainyl-CoA and crotonobetainyl-CoA are similar to known CoA derivatives.

The relationship between adolescent smoking and drinking and likelihood estimates of illicit drug use.

Using data from a recent national survey of adolescent substance use, the present work examined whether adolescents with different patterns of alcohol and cigarette use differed in their estimates of the likelihood they would use an illegal drug in the future. While nonusers of either substance were the most likely to indicate that they would never use drugs in the future, users of both substances were the most likely to indicate that they would use drugs. In addition, while users of both were most likely to indicate that they were likely to use illegal substances, only-smokers were more likely than only-drinkers to indicate that they were likely to use such substances in the future. Results are discussed in terms of the gateway theory of drug sequencing and cognitive precursors of experimentation with illegal substances.

Age-related differences in adolescent smokers' and nonsmokers' assessments of the relative addictiveness and health harmfulness of cigarettes, alcohol, and marijuana.

The present work was undertaken to determine how general beliefs about various substances and substance use behaviors change during adolescence. Secondary analyses were carried out on the telephone interview responses of 1,200 adolescent smokers and nonsmokers between the ages of 12 and 17. The specific beliefs regarding which substances were hardest to stop using and which were the most harmful to one's health by smoking status and age were compared using Chi-squared analyses for univariate comparisons, and polytomous logistic regression for multivariate analyses. Results revealed that the youngest cohort believed that marijuana was the substance most difficult to stop using while the oldest cohort believed that cigarettes were the hardest to stop using. A similar pattern was observed regarding which substance was the most harmful to one's health. While smokers believed that cigarettes were both the hardest to stop using and the most harmful, nonsmokers were divided between cigarettes and marijuana as the hardest to stop using, and indicated that marijuana, rather than cigarettes, were most harmful. Results are discussed in terms of their implications for substance abuse prevention and the development of relative risk assessments.

Cigarettes, alcohol, marijuana, other risk behaviors, and American youth.

Increases in adolescent marijuana and other drug use have created widespread concern. One theory argues that increased use of cigarettes and alcohol among younger adolescents leads to greater use of marijuana which, in turn, leads to subsequent use of other drugs (e.g. cocaine, heroin, hallucinogens). Detractors of this theory claim that use of these substances is a symptom of a larger set of destructive behaviors (e.g. violence, suicide, promiscuous sex), and marijuana has no independent effect on the use of other more serious drugs. The authors examined whether, for high school seniors, early use of cigarettes, alcohol and marijuana has an independent effect on more serious drug use even when other behaviors are considered. Using the 1995 Youth Risk Behavior Survey (n = 2871) and logistic analysis, after accounting for selected other behaviors, seniors using cigarettes before age 13 were 3.3 (95% C.I. 2.3,4.6) times likelier to have used marijuana than ones who never smoked; for alcohol, the odds ratio was 4.5 (2.6,7.7). Seniors using marijuana before the age of 14 were 7.4 times (4.0,13.6) likelier to have used other drugs. Though no causal effect is demonstrated, cigarette and alcohol use was associated with the likelihood of marijuana use; marijuana use was associated with the likelihood of other drug use, even after selected other risk and protective behaviors were considered.

Purification and characterization of the soluble methane monooxygenase of the type II methanotrophic bacterium Methylocystis sp. strain WI 14.

Methane monooxygenase (MMO) catalyzes the oxidation of methane to methanol as the first step of methane degradation. A soluble NAD(P)H-dependent methane monooxygenase (sMMO) from the type II methanotrophic bacterium WI 14 was purified to homogeneity. Sequencing of the 16S rDNA and comparison with that of other known methanotrophic bacteria confirmed that strain WI 14 is very close to the genus Methylocystis. The sMMO is expressed only during growth under copper limitation (<0.1 microM) and with ammonium or nitrate ions as the nitrogen source. The enzyme exhibits a low substrate specificity and is able to oxidize several alkanes and alkenes, cyclic hydrocarbons, aromatics, and halogenic aromatics. It has three components, hydroxylase, reductase and protein B, which is involved in enzyme regulation and increases sMMO activity about 10-fold. The relative molecular masses of the native components were estimated to be 229, 41, and 18 kDa, respectively. The hydroxylase contains three subunits with relative molecular masses of 57, 43, and 23 kDa, which are present in stoichiometric amounts, suggesting that the native protein has an alpha(2)beta(2)gamma(2) structure. We detected 3.6 mol of iron per mol of hydroxylase by atomic absorption spectrometry. sMMO is strongly inhibited by Hg(2+) ions (with a total loss of enzyme activity at 0.01 mM Hg(2+)) and Cu(2+), Zn(2+), and Ni(2+) ions (95, 80, and 40% loss of activity at 1 mM ions). The complete sMMO gene sequence has been determined. sMMO genes from strain WI 14 are clustered on the chromosome and show a high degree of homology (at both the nucleotide and amino acid levels) to the corresponding genes from Methylosinus trichosporium OB3b, Methylocystis sp. strain M, and Methylococcus capsulatus (Bath).

Developing a national addiction treatment information system. An introduction to the Drug Evaluation Network System.

The purpose of this article is to test the applicability and utility of the Drug Evaluation Network Study (DENS), a timely electronic information system that tracks trends in substance abuse treatment. This article examines existing large-scale data collection efforts, discusses the rationale and design of the DENS system, and presents results of the DENS pilot phase. Clinical staff from more than 40 service delivery units in five cities were trained to conduct intake assessments on laptop computers with the computerized Addiction Severity Index (ASI). The DENS computer system also included an automatic data transfer protocol to allow regular transmission of ASIs and other data to a central server at Treatment Research Institute. Descriptive information and discharge status were also collected. Several problems were encountered during the early stages of the pilot phase, including obtaining consecutive cases from treatment programs, computerization and software application, treatment staff turnover, and assuring quality of data. Data is presented on 4,300 adults entering drug and/or alcohol treatment at the nonrandomly selected DENS pilot programs between June 1996, and April 6, 1998. Various examples of how DENS data can be used are presented.

High-density Escherichia coli cultures for continuous L(-)-carnitine production.

The use of a biological procedure for L-carnitine production as an alternative to chemical methods must be accompanied by an efficient and highly productive reaction system. Continuous L-carnitine production from crotonobetaine was studied in a cell-recycle reactor with Escherichia coli O44 K74 as biocatalyst. This bioreactor, running under the optimum medium composition (25 mM fumarate, 5 g/l peptone), was able to reach a high cell density (26 g dry weight/l) and therefore to obtain high productivity values (6.2 g L-carnitine l-1 h-1). This process showed its feasibility for industrial L-carnitine production. In addition, resting cells maintained in continuous operation, with crotonobetaine as the only medium component, kept their biocatalytic capacity for 4 days, but the biotransformation capacity decreased progressively when this particular method of cultivation was used.

Metabolism of L(-)-carnitine by Enterobacteriaceae under aerobic conditions.

Different Enterobacteriaceae, such as Escherichia coli, Proteus vulgaris and Proteus mirabilis, are able to convert L(-)-carnitine, via crotonobetaine, into gamma-butyrobetaine in the presence of carbon and nitrogen sources under aerobic conditions. Intermediates of L(-)-carnitine metabolism (crotonobetaine, gamma-butyrobetaine) could be detected by thin-layer chromatography. In parallel, L(-)-carnitine dehydratase, carnitine racemasing system and crotonobetaine reductase activities were determined enzymatically. Monoclonal antibodies against purified CaiB and CaiA from E. coli O44K74 were used to screen cell-free extracts of different Enterobacteriaceae (E. coli ATCC 25922, P. vulgaris, P. mirabilis, Citrobacter freundii, Enterobacter cloacae and Klebsiella pneumoniae) grown under aerobic conditions in the presence of L(-)-carnitine.

Making sense of medical marijuana.

The case for marijuana's medical use is primarily from anecdotal clinical reports, human studies of delta-9-tetrahydrocannabinol, and animal studies on constituent compounds. The authors believe that while a key policy issue is to keep marijuana out of the hands of children, its use for medicinal purposes should be resolved by scientific research and Food and Drug Administration (FDA) review. Weighed against possible benefits are increased risks such as cancer, pulmonary problems, damage to the immune system, and unacceptable psychological effects. More study is needed to determine the efficacy of marijuana as an antiemetic for cancer patients, as an appetite stimulant for AIDS and cancer patients, as a treatment for neuropathic pain, and as an antispasmodic for multiple sclerosis patients. If this new research shows marijuana to have important medical uses, FDA approval could be sought. However, the better response is accelerated development of delivery systems other than smoking for key ingredients, as well as the identification of targeted molecules that deliver beneficial effects without intoxicating effects. If the National Institutes of Health conducts research on marijuana, we would propose parallel trials on those indications under careful controls making marijuana available to appropriate patients who fail to benefit from standard existing treatments. This effort would begin after efficacy trials and sunset no later than 5 years. If this open-trial mechanism is adopted, the compassion that Americans feel for seriously ill individuals would have an appropriate medical/scientific outlet and not need to rely on referenda that can confuse adolescents by disseminating misleading information about marijuana effects.