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324 EPIDEMIOLOGIC TRENDS IN DRUG ABUSE—Panel on Methamphetamine Abuse: NIDA-Supported Research Studies Predicting Relapse in Methamphetamine-Dependent Individuals Martin P. Paulus, M.D. Findings from a study of the use and effectiveness of Functional Magnetic Resonance Imaging (FMRI) in predicting relapse in methamphetamine (MA) dependent individuals show that… • FMRI imagining results can be used to predict whether and when relapse may occur; findings show that FMRI correctly predicted… – 17 of 18 relapses – 20 of 22 nonrelapses • In relapse, there is less activation in insular cortex structures that are critical for decisionmaking; the poor decisionmaking “sets the stage” for relapse. This study, designed to examine the neurobiology of decisionmaking dysfunction in stimulant dependent subjects and the efficacy of using FMRI as a tool to predict relapse, was supported by NIDA [DA 013186 and DA 016663] and conducted by the University of California San Diego and the San Diego Veterans Affairs Health Care System. STUDY SAMPLE AND METHODS The initial sample included 46 males who were diagnosed as MA-dependent using the Structured Clinical Interview for DSM IV diagnosis; 6 were lost for followup, which was conducted in a median of 370 days. All subjects had been sober for a median of 25 days at baseline. All subjects were drawn from the San Diego Veterans Affairs Health Care System Alcohol and Drug Treatment Program under the leadership of Dr. Marc Schuckitt. Of the 40 subjects included in the final analyses, 22 were “nonrelapsers” and 18 were “relapsers.” Some characteristics of the two groups are shown in exhibit 1. Exhibit 1. Characterisitics of the Study Samples Characteristic Nonrelapsers Relapsers Average Age 40.3 41.9 Percent White Percent Divorced/ 73.0 67.0 Separated/ Never 95.0 89.0 Married 1 Average Years of Education Average Years of MA Use 2 12.9 13.5 14.9 17.3 1 Most in this category were either divorced or separated. 2 At baseline, 5 nonrelapsers and 7 relapsers were currently abusing alcohol/marijuana; at follow-up, the respective numbers were 1 and 2 and 1 nonrelapse subject was also abusing cocaine. The FMRI was used to determine changes in blood oxygenation and identify brain areas involved in the behavioral tasks. The Assessment Protocol at baseline included the following: • The two-choice prediction task is used to determine the response characteristics in decisionmaking situations that have an uncertain outcome (for a detailed description, see Paulus 1997). Briefly, on a computer screen a house is presented with a person to the left and right. The subject is told that the task is to predict whether a car will come by on the left or right side to pick up the person on the computer screen. The subject has to make a decision (pressing the left or right button) and is shown the car after pressing the button for 300 milliseconds. If the selected response is “correct,” (i.e., reinforced), the person on the selected side crosses over to the car; otherwise the person moves halfway across the screen and then returns to the center of the screen. The reinforcement schedule is determined apriori, such that 50 percent of the responses will be reinforced, as if they were “correct” predictions. • The two-choice response task is one in which the subject is told that the task is to press the button on the same side that the car is shown on the screen (i.e., left or right). The duration of each trial depends on the time between presentation of the initial situation and the selection of the response. Therefore, the number of trials per experimental block depends on the subject’s average latency to select a response during a trial block. Proceedings of the Community Epidemiology Work Group, Vol. II, January 2005
EPIDEMIOLOGIC TRENDS IN DRUG ABUSE—Panel on Methamphetamine Abuse: NIDA-Supported Research Studies • The key difference between these two tasks is that during the two-choice prediction task, the subject does not know the correct response in advance, and the only information provided that may guide the selection of the current response is the sequence of previous responses and outcomes. In comparison, during the two-choice response task, the subject knows the correct answer before selecting a response, and the current button press does not depend on the previous responses. • Diagnostic––SCID (Structured Clinical Interview for DSM IV Diagnoses), used to obtain DSM IV diagnoses. • Symptoms––BPRS/HDRS (Brief Psychiatric Rating Scale and Hamilton Depression Rating Scale) used to assess general psychiatric and depressive symptoms, and the YMRS (Young Mania Rating Scale), used to assess manic symptoms. • Decisionmaking: see above. • A MRI––Block design using the Two-Choice Prediction Task versus the Two-Choice Response Task. Briefly, both tasks were presented for 30 seconds each and were repeated five times. FINDINGS The FMRI correctly predicted by imaging included 17 of 18 relapses and 20 of 22 nonrelapses, with a high level of sensitivity (94.4 percent) and specificity (86.4 percent). Relapse was predictable by less activation in brain structures that are critical to decisionmaking; these were shown to be in the insular cortex, particularly the anterior insula, the inferior parietal lobule, and the dorsolateral prefrontal cortex. It also appears that poor assessment of the decisionmaking situation and subsequent reliance on habitual behavior involves processes in the inferior parietal lobule. CONCLUSIONS This study has shown that brain patterns can be used to predict whether and when relapse may occur. Questions that need to be more fully addressed in future research are… • What are the specific cognitive processes involved in relapse? • Do interventions have an impact on relapse? • Do such findings apply to other addictions? REFERENCE Paulus, M.P. Long-range interactions in sequences of human behavior. Physical Review E 55: 3249- 3256 (1997). For inquiries concerning this report, please contact Martin P. Paulus, M.D., Associate Professor, Department of Psychiatry, Laboratory of Biological Dynamics and Theoretical Medicine, University of California San Diego, Suite C213, 8950 La Jolla Village Drive, La Jolla CA 92037-0985, Phone: 858-642-3390, Fax: 858-642-1429, E-mail: mpaulus@ucsd.edu. Proceedings of the Community Epidemiology Work Group, Vol. II, January 2005 325
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NATIONAL INSTITUTE ON DRUG ABUSE EP
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Foreword This publication includes
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EPIDEMIOLOGIC TRENDS IN DRUG ABUSE
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2 EPIDEMIOLOGIC TRENDS IN DRUG ABUS
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Epidemiology of Drug Abuse: CEWG Ar
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• The city of Atlanta has become
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In the first 6 months of 2004, trea
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eports (exhibit 2), while African-A
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population) than in 2002 (17.2 per
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16 EPIDEMIOLOGIC TRENDS IN DRUG ABU
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data from the Drug Abuse Warning Ne
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than age 18, compared to 4 percent
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More often than not, marijuana use
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Solomon, L.; Flynn, C.; Muck, K.; e
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• Logan International Airport and
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In 2002, heroin/morphine was indica
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The FY 2004 racial distribution for
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• Emergency department (ED) drug
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monly mentioned secondary drug amon
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Between 2001 and 2003, the Illinois
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In the NIHU Study, 20 percent of pa
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Ecstasy remained available in most
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66 and analyzed by the Division of
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ounce in the Denver metropolitan ar
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18 at the time of admission to trea
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Injecting had been the most common
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alcohol; 651 involved alcohol-in-co
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The economy in Hawai'i, after a dec
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Methamphetamine remains the leading
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methamphetamine, representing 76.5
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Of interest in this chart is the ag
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98 weighted DAWN data released by S
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A total of 5,425 cocaine arrests wa
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data, however, rising from 1.5 perc
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According to NDIC, California and M
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and 15 items were identified as pse
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most frequently reported secondary
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esidents are living with advanced H
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112 EPIDEMIOLOGIC TRENDS IN DRUG AB
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(DAWN) that monitors emergency depa
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Beginning in 2003, SAMHSA’s natio
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65 percent were older than 34. The
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the 1,198 drug abuse ED reports in
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“Crystal” or smokeable methamph
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tion was injection (62.9 percent),
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included reports of ED cases involv
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From November 10 to 16, 2004, 18 me
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NFLIS between October 2003 and Sept
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from 12.2 percent in the first half
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156 2003. Anecdotal information on
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Brownsville, and El Paso. African-A
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ground economy, it was estimated th
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According to street interviews, mos
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that crack sells for about $28,000-
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Benloton, X-man, 911, Lean Back, Se
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DAWN ME mentions for marijuana-invo
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ecstasy. MDMA ED mentions may be st
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the deaths, while Whites constitute
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2000 reported that the average hero
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for this drug, making olanzapine th
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ADHS/DBHS reported that more than o
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Marijuana is widely available in Ar
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212 2004. Data from 2000-2002 DAWN
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purity dropped to 14.4 percent in 2
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No recent GHB incidents or deaths w
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correspond to decreases in total ad
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228 reports in drug-related visits;
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Marijuana Arrests for marijuana-rel
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positivity. UHS staff believe, on t
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236 are not estimates for the repor
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were evident. Excluding missing dat
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The characteristics of other opiate
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June 2004 (exhibit 6c). A minority
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Deaths involving depressants were a
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imipramine) are an older class of m
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The term “lag” refers to the pe
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costs $1,200-$1,500, compared with
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ties. In the DFW area, Mexican mari
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The 2004 secondary school survey re
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nio and two 2-ounce bottles cost $1
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age may be partially due to the fac
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Page 296 and 297: York and Miami (Pach et al. 2002).
Page 298 and 299: In 2003, heroin was the primary sub
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Page 312 and 313: Among GTC patients, marijuana was t
Page 314 and 315: Others (63.8 percent) were using a
Page 323: Panel on Methamphetamine Abuse: NID
Page 333: Appendix A New Drug Abuse Warning N
Page 336 and 337: DAWN LIVE! The new DAWN includes ca
Page 339 and 340: Participant List National Institute
Page 341 and 342: Janie B. Dargan, M.S.W. Policy Anal
Page 343: Martin P. Paulus, M.D. Associate Pr
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