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Methylphenidate Increases Cigarette Smoking in Participants with ADHD

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Methylphenidate Increases Cigarette Smoking in Participants with ADHD Psychopharmacology (2011) 218:381–390 DOI 10.1007/s00213-011-2328-y ORIGINAL INVESTIGATION Methylphenidate increases cigarette smoking in participants with ADHD Andrea R. Vansickel & William W. Stoops & Paul E. A. Glaser & Megan M. Poole & Craig R. Rush Received: 15 March 2011 /Accepted: 22 April 2011 /Published online: 18 May 2011 # Springer-Verlag 2011 Abstract puffs, and carbon monoxide levels. Snacks and decaffeinated Rationale Methylphenidate (Ritalin®) is commonly pre- drinks were available ad libitum; caloric intake during the scribed for behavioral problems associated with attention 4-h smoking session was calculated. deficit/hyperactivity disorder (ADHD). The results of Results Methylphenidate increased the total number of previous studies suggest that methylphenidate increases cigarettes smoked, total number of puffs, and carbon cigarette smoking in participants without psychiatric diag- monoxide levels. Methylphenidate decreased the number noses. Whether methylphenidate increases cigarette smok- of food items consumed and caloric intake. ing in participants diagnosed with ADHD is unknown. Conclusions The results of this experiment suggest that Objective In this within-subjects, repeated measures exper- acutely administered methylphenidate increases cigarette iment, the acute effects of a range of doses of methylphe- smoking in participants with ADHD, which is concordant nidate (10, 20, and 40 mg) and placebo were assessed in with findings from previous studies that tested healthy nine cigarette smokers who were not attempting to quit and young adults. These data indicate that clinicians may need met diagnostic criteria for ADHD but no other Axis I to consider non-stimulant options or counsel their patients psychiatric disorders other than nicotine dependence. before starting methylphenidate when managing ADHD- Methods Each dose of methylphenidate was tested once diagnosed individuals who smoke. while placebo was tested twice. One hour after ingesting drug, participants were allowed to smoke ad libitum for 4 h. Keywords Methylphenidate . Smoking . ADHD . Measures of smoking included total cigarettes smoked, total Subjective effects . Humans A. R. Vansickel : W. W. Stoops : C. R. Rush P. E. A. Glaser Department of Behavioral Science, College of Medicine, Department of Pediatrics, College of Medicine, University of Kentucky, University of Kentucky, Lexington, KY 40536, USA Lexington, KY 40536, USA P. E. A. Glaser : C. R. Rush Department of Psychiatry, College of Medicine, C. R. Rush (*) University of Kentucky, Department of Behavioral Science, Lexington, KY 40536, USA University of Kentucky Medical Center, : : : 140 Medical Behavioral Science Building, A. R. Vansickel W. W. Stoops M. M. Poole C. R. Rush Lexington, KY, USA Department of Psychology, College of Arts and Science, e-mail: [email protected] University of Kentucky, Lexington, KY 40536, USA Present Address: P. E. A. Glaser A. R. Vansickel Department of Anatomy and Neurobiology, College of Medicine, Department of Pharmacology and Toxicology, Virginia University of Kentucky, Commonwealth University, Lexington, KY 40536, USA Richmond, VA 23298, USA 382 Psychopharmacology (2011) 218:381–390 Introduction greater difficulty quitting than people without psychiatric disorders (Pomerleau et al. 1995, 2003; McClernon et al. Methylphenidate is commonly prescribed and effective for 2008; Milberger et al. 1997; Lambert and Hartsough 1998; the treatment of attention deficit/hyperactivity disorder Gray et al. 2010). The reason for the increased prevalence (ADHD) symptoms in children and adults (Brown et al. and severity of smoking and nicotine dependence in 2005; Faraone et al. 2006; Spencer et al. 2005). ADHD is persons with ADHD is unknown. Some researchers have characterized by abnormal levels of impulsivity, inattention, speculated that individuals with ADHD self-medicate by and hyperactivity, the primary cause for which is not fully abusing stimulant-like drugs such as nicotine in order to understood. Results of single-photon emission computed enhance attention or reduce symptoms of ADHD (Gehricke tomography (SPECT) studies suggest that alterations in et al. 2007; Khantzian 1997; Milberger et al. 1997). dopamine transporter (DAT) availability may, in part, Consistent with that notion, the nicotine patch and nicotinic contribute to the pathophysiology of ADHD (Cheon et al. agonists have been shown to ameliorate some ADHD 2003; Dougherty et al. 1999; Krause 2008; Krause et al. symptoms (Gehricke et al. 2006, 2009; Levin et al. 1996; 2000). Methylphenidate is a central nervous system Wilens et al. 1999, 2006). This hypothesis would indicate stimulant that blocks the dopamine transporter, preventing that smoking would be reduced in individuals with ADHD the reuptake of dopamine, resulting in increased extracel- whose symptoms were properly controlled through treat- lular dopamine. It is through the DAT mechanism that ment with psychostimulants such as methylphenidate methylphenidate likely exerts its therapeutic effects in (Winhusen et al. 2010). Other researchers have suggested ADHD-diagnosed individuals (Krause et al. 2000). that treatment with psychostimulants may actually increase Results of previous studies from our laboratory demon- the risk of later tobacco smoking dependence (Lambert and strate that methylphenidate, regardless of formulation type Hartsough 1998; Lambert 2002). (i.e., sustained or immediate-release), increases ad libitum To the best of our knowledge, the direct effects of cigarette smoking in non-ADHD adults (Rush et al. 2005; methylphenidate on cigarette smoking have not been Vansickel et al. 2007, 2009). In those studies, participants examined in adults with ADHD. The purpose of the current were administered sustained or immediate-release methyl- investigation was to determine the acute effects of phenidate and were allowed to smoke ad libitum for 4 h methylphenidate (0, 10, 20, and 40 mg) on cigarette during the peak effects of the medication. Sessions were smoking behavior in ADHD-diagnosed, non-medicated videotaped and scored for various smoking behaviors. In all daily cigarette smokers. Nine otherwise healthy adults studies, at least one dose of methylphenidate increased the participated in this study. Outcome measures included total number of puffs significantly compared to placebo number of cigarettes, total puffs, expired air carbon (Rush et al. 2005; Vansickel et al. 2007, 2009). In another monoxide, caloric intake, cardiovascular indices, and study from our laboratory, methylphenidate was shown to subjective effects. Caloric intake was included as a increase the choice of cigarettes over money (Stoops et al. secondary measure of the effects of methylphenidate on 2011). Participants in that study were administered meth- consumptive behavior and to highlight the specificity of the ylphenidate (0, 10, 20, and 40 mg) and then made a series effect of methylphenidate on cigarette smoking behavior. of choices between half of a cigarette and US $0.25. We hypothesized that acute methylphenidate administration Methylphenidate increased choice of cigarettes over money, would increase smoking and decrease caloric intake in suggesting that methylphenidate increases the reinforcing these non-medicated ADHD-diagnosed participants. efficacy of cigarettes. Results of several other human laboratory studies suggest that d-amphetamine, a psychos- timulant medication also used to treat ADHD, increases Methods cigarette smoking when administered acutely (Cousins et al. 2001; Henningfield and Griffiths 1981; Sigmon et al. Participants 2003; Tidey et al. 2000). Taken together, results of these studies demonstrate a clear relationship between the acute Nine adult cigarette smokers (four males, five females) who effects of stimulant drugs and increased cigarette smoking met diagnostic criteria for ADHD were recruited via behavior in non-ADHD adult cigarette smokers. newspaper ads, flyers, and word-of-mouth to participate in Individuals with ADHD are at increased risk to smoke this experiment. In order to be included, participants had to: relative to individuals without psychiatric disorders (1) report smoking 10–20 cigarettes daily; (2) not be (Lambert and Hartsough 1998; Molina and Pelham 2003; attempting to quit smoking; (3) be diagnosed with adult Milberger et al. 1997: McClave et al. 2010). ADHD- ADHD following a clinical evaluation along with the diagnosed individuals also initiate smoking earlier and have Conners’ Adult ADHD Diagnostic Interview for DSM-IV a greater severity of tobacco abstinence symptoms and (CAADID; Multi-Health Systems 2001), which was com- Psychopharmacology (2011) 218:381–390 383 pleted by a boarded adult and child psychiatrist with Participants generally arrived at the Laboratory of expertise in diagnosing adult ADHD (PEAG); (4) report Human Behavioral Pharmacology at 0800 hours. Partic- not having used physician prescribed psychotropic medi- ipants were instructed to abstain from smoking for at least cations in the past 2 months; (5) have no significant 4 h before arriving at the Laboratory of Human Behavioral medical or psychiatric disorders, other than ADHD, which Pharmacology. Immediately after arriving, participants in the opinion of the study physician would interfere with provided an expired breath sample that was used to participation; (6) have no medical contraindications to determine their carbon monoxide level using a handheld stimulant drugs; and (7) provide serum (at screening) and carbon monoxide meter (Smokerlyzer,
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