Pain is the leading cause of Emergency Department (ED) visits making it one of the primary concerns of the emergency medical field. The experience of pain is subjective and unique to every individual making it difficult to effectively manage. As a result, the subjective nature of pain is also commonly associated with drug-seekers often claiming to have pain simply to receive narcotics to support their addiction. There have been numerous studies completed to determine how to effectively recognize drug-seeking. This integrative literature review will identify the common behaviors that have been seen as indicators of drug-seeking in the ED. The evidence collected from articles published between 2001 and 2011 examined the use of assessment tools, drug screening, and prescription monitoring programs for distinguishing drug-seekers. The evidence did not identify a specific evaluation tool used to recognize drug-seekers; however, the research did suggested that using these techniques can help to identify drug-seeking behavior allowing emergency medical staff to effectively manage pain in the ED.

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Doctor of Philosophy / Department of Psychological Sciences / Mary E. Cain / Drug addiction is a chronic cyclical disease characterized by periods of drug use and abstinence. Drug craving increases as a function of abstinence period, such that longer periods of abstinence result in greater feelings of craving. Longer periods of abstinence may render cues to become more powerful motivators of drug seeking behavior because of the greater craving response. Neurobiological evidence suggests that changes in glutamatergic transmission in the nucleus accumbens (NAc) plays a pivotal role in the incubation of craving and drug seeking motivation. Specifically, the upregulation of Ca²⁺ permeable AMPA receptors may increase drug seeking following the presentation of a drug cue. Environmental housing manipulations also change the expression of metabotropic glutamate receptors (mGlur) and psychostimulant self-administration. In the current experiments, Sprague-Dawley rats were reared in enriched (EC) or isolated (IC) conditions from PND 21-51. Then rats were implanted with indwelling jugular catheters and allowed to self-administer amphetamine (0.1 mg/kg/infusion) or saline paired with a cue light for 16 days for 1h. Then rats went through a forced abstinence period of 1 day and were then tested in a cue-induced seeking test. Immediately after the seeking test, half the rats were sacrificed and the NAc was dissected and prepared for western blot analyses. The other half of rats rested for 40 days and were tested again in the cue-induced seeking test. Immediately following the seeking test, rats were sacrificed and their NAc was dissected. Factorial ANOVA results indicate that rearing in the IC environment increased drug seeking when compared to EC rats after 1 day of abstinence and after 40 days of abstinence, but drug seeking did not increase after 40 days. Rats in the saline groups showed an increase in seeking after 40 days of abstinence, providing evidence of increased responding. Saline responding was significantly lower when compared to rats that responded for amphetamine. When rats self-administered saline, generally IC rats had more responding than EC rats. Western blot analyses indicated that expression of AMPA subunits GluA1, and GluA2, as well as metabotropic glutamate receptors 1 and 5 (mGlur1, and mGlur5) were not different across the experimental groups, suggesting another mechanism could be implicated in drug seeking after short and long abstinence periods. These results suggest that early life experience can have long lasting effects into adulthood and increase the vulnerability of drug abuse. Our results provide mixed results of incubated seeking. Positive early life experiences reduce drug seeking motivation after short and long abstinence periods, providing evidence for further research to examine how early life experience changes the reward seeking and subsequent structures in the mesocorticolimbic pathway.

abstract: The capability of cocaine-associated stimuli in eliciting craving in human addicts, even after extended periods of abstinence, is modeled in animals using cue reinstatement of extinguished cocaine-seeking behavior. This study aimed to examine brain activation in response to cocaine cues in this model apart from activation produced by test novelty using a novel cue control. Rats trained to self-administer cocaine paired with either an oscillating light or tone cue underwent daily extinction training and were then tested for reinstatement of extinguished cocaine-seeking behavior elicited by response-contingent presentations of either their assigned cocaine-paired cue or the alternate, novel cue. Additional controls received saline infusions and cue presentations yoked to a cocaine-trained rat. Brains were harvested for Fos immunohistochemistry immediately after the 90-min reinstatement test. Surprisingly, conditioned and novel cues both reinstated responding to a similar degree; however magnitude of reinstatement did vary by cue modality with the greatest reinstatement to the light cues. In most brain regions, Fos expression was enhanced in rats with a history of cocaine training regardless of cue type with the exception of the Cg1 region of the anterior cingulate cortex, which was sensitive to test cue modality. Also Fos expression within the dorsomedial caudate-putamen was correlated with responding in the novel, but not conditioned, cue groups. In subsequent experiments, we observed a similar pattern of reinstatement in rats trained and tested for sucrose-seeking behavior, whereas rats trained and tested with the cues only reinstated to a novel light and tone, but not a familiar cue. The results suggest that novel cues reinstate responding to a similar extent as conditioned cues regardless of whether animals have a history of operant-delivered drug or a natural reinforcer. Furthermore, similar brain circuits as those involved in cocaine-seeking behavior are activated by novel cues, suggesting converging processes exist to drive conditioned and novel reinforcement seeking. / Dissertation/Thesis / M.A. Psychology 2012

Rationale: Evidence indicates that drug-paired stimuli can evoke drug-craving leading to drug-seeking and repeated relapse periods can influence drug-seeking behaviors. Objectives: The present study examined (1) the effect of an interaction between repeated deprivation cycles and excitatory conditioning stimuli (CS+) on ethanol (EtOH)-seeking; (2) the effects of EtOH-paired cue-exposure in a non-drug-paired environment on subsequent conditioning in a drug-paired environment; and (3) the temporal effects of conditioned cues on subsequent EtOH-seeking. Methods: Adult female alcohol-preferring (P) rats were exposed to three conditioned odor cues; CS+ associated with EtOH self-administration, CS− associated with the absence of EtOH (extinction training), and a neutral stimulus (CS0) presented in a neutral non-drug-paired environment. The rats underwent four deprivation cycles or were non-deprived, following extinction they were maintained in a home cage for an EtOH-free period, and then exposed to no cue, CS+, CS−, or CS0 to assess the effect of the conditioned cues on EtOH-seeking behavior. Results: Repeated deprivations enhanced and prolonged the duration of CS+ effects on EtOH-seeking. Presentation of the CS− in a non-drug-paired environment blocked the ability of a CS+ to enhance EtOH-seeking in a drug-paired environment. Presentation of the CS+ or CS− in a non-drug-paired environment 2 or 4 h earlier significantly altered EtOH-seeking. Conclusion: Results indicated an interaction between repeated deprivation cycles and CS+ resulted in a potentiation of CS+ evoked EtOH-seeking. In addition, a CS− may have therapeutic potential by providing prophylactic protection against relapse behavior in the presence of cues in the drug-using environment.

Estudos apontam a substância cinzenta periaquedutal (PAG) como um sítio crítico para a expressão de vários comportamentos motivados. A porção rostrolateral da PAG (PAGrl), tem um papel chave na regulação da motivação na caça predatória, e modularia mecanismos de recompensa associados ao comportamento alimentar e busca por droga, a partir de projeções para área tegmental ventral e núcleo acumbens; o que dependeria da ligação com neurônios orexinérgicos da área hipotalâmica lateral (LHA). A PAGrl, está mobilizada nos comportamentos de busca por droga assim como na caça predatória. As principais regiões que aferentam a PAGrl são áreas do córtex pré-frontal medial (mPFC) onde a PAGrl integraria tais aferencias e modularia a LHA. Os resultados corroboram com a hipótese, pois lesões no mPFC diminuíram a busca por droga e vimos que neurônios da PAGrl mobilizados no comportamento, que recebem aferências do mPFC, seriam os mesmos que se projetam para LHA e que a PAGrl teria papel crítico na promoção do comportamento de busca por droga no CPP para sulfato de morfina. / Studies show a periaqueductal gray (PAG) as a critical place for an expression of motivated behaviors. The rostrolateral portion of PAG (PAGrl), is a key role in the regulation of motivation in predatory hunting, and modulates, reward mechanisms associated with drug and food seeking, through projections to ventral tegmental area and the nucleus accumbens; what would depend on the connection with orexin neurons of the lateral hypothalamic area (LHA). The PAGrl, is mobilized in predatory hunting as drug seeking. The main region that sends projections to PAGrl is the medial prefrontal cortex (mPFC), where PAGrl integrate such afferent and modulates the LHA. Our results corroborate the hypothesis, because mPFC injuries, decreased drug seeking and we observed that PAGrl neurons mobilized in behavior, and also receive afferents from mPFC, would be the same as projecting to LHA, thus PAGrl had critical role in promotion of drug seeking behavior during the CPP for morphine sulfate.

O córtex pré-frontal (PFC) participa do controle do comportamento de busca por droga e se projeta para a coluna rostrolateral da substância cinzenta periaquedutal (PAGrl) que por sua vez se projeta para o sistema orexinérgico da área hipotalâmica lateral (LHA) que controla comportamentos que oferecem recompensa através de projeções para o sistema dopaminérgico mesolímbico. O objetivo do trabalho é investigar a participação da PAGrl e a sua relação com o PFC e com o sistema orexinérgico da LHA na expressão do comportamento de busca por droga. Submetemos ratos Wistar ao condicionamento de preferência por lugar para sulfato de morfina e notamos que o PFC, a PAGrl e a LHA estão ativados em animais que expressaram tal comportamento. Após, realizamos lesões neuroquímicas bilaterais no PFC e notamos a ausência da busca pela droga nestes animais e da diminuição da ativação da PAGrl e do sistema orexinérgico da LHA. Posteriormente realizarmos lesões neuroquímicas por NMDA na PAGrl e notamos a ausência do comportamento e diminuição de duplas marcações para Fos e orexina na LHA. Os resultados indicam que a PAGrl exerceria um papel crítico para o comportamento de busca por droga, integrando aferências provenientes do PFC para modular os neurônios orexinérgicos da LHA. / The prefrontal cortex (PFC) is involved with planning of the drug seeking behavior and projects itself to the rostrolateral periaqueductal gray (PAGrl) that through projections for the orexin neurons in the lateral hypothalamic area (LHA), participates in the control of behavior that offer rewards. The LHA controls drug reward through projections for the mesolimbic dopaminergic system. This study aims to investigate the relationship between the PFC, PAGrl and orexin neurons in the LHA in drug seeking behavior. We did a morphine conditioned place preference (CPP) procedure in intact, bilateral PAGrl-lesioned and bilateral PFC-lesioned Wistar rats and investigated the pattern of Fos expression. The intact animals displayed such behavior and presented an increase in Fos activation in the PFC, rlPAG and LHA orexinergic neurons. Conversely, PAGrl-lesioned and PFC-lesioned animals did not display this behavior and reduced the activation of orexin neurons in the LHA. PFC-lesioned animals presented a reduction of the Fos activation in the rlPAG. The results suggest a pathway involving the PFC, PAGrl and LHA orexinergic cell group underlying the CCP, where the rlPAG would integrate inputs from the PFC to control the LHA orexinergic cell group.

O córtex pré-frontal (PFC) participa do controle do comportamento de busca por droga e se projeta para a coluna rostrolateral da substância cinzenta periaquedutal (PAGrl) que por sua vez se projeta para o sistema orexinérgico da área hipotalâmica lateral (LHA) que controla comportamentos que oferecem recompensa através de projeções para o sistema dopaminérgico mesolímbico. O objetivo do trabalho é investigar a participação da PAGrl e a sua relação com o PFC e com o sistema orexinérgico da LHA na expressão do comportamento de busca por droga. Submetemos ratos Wistar ao condicionamento de preferência por lugar para sulfato de morfina e notamos que o PFC, a PAGrl e a LHA estão ativados em animais que expressaram tal comportamento. Após, realizamos lesões neuroquímicas bilaterais no PFC e notamos a ausência da busca pela droga nestes animais e da diminuição da ativação da PAGrl e do sistema orexinérgico da LHA. Posteriormente realizarmos lesões neuroquímicas por NMDA na PAGrl e notamos a ausência do comportamento e diminuição de duplas marcações para Fos e orexina na LHA. Os resultados indicam que a PAGrl exerceria um papel crítico para o comportamento de busca por droga, integrando aferências provenientes do PFC para modular os neurônios orexinérgicos da LHA. / The prefrontal cortex (PFC) is involved with planning of the drug seeking behavior and projects itself to the rostrolateral periaqueductal gray (PAGrl) that through projections for the orexin neurons in the lateral hypothalamic area (LHA), participates in the control of behavior that offer rewards. The LHA controls drug reward through projections for the mesolimbic dopaminergic system. This study aims to investigate the relationship between the PFC, PAGrl and orexin neurons in the LHA in drug seeking behavior. We did a morphine conditioned place preference (CPP) procedure in intact, bilateral PAGrl-lesioned and bilateral PFC-lesioned Wistar rats and investigated the pattern of Fos expression. The intact animals displayed such behavior and presented an increase in Fos activation in the PFC, rlPAG and LHA orexinergic neurons. Conversely, PAGrl-lesioned and PFC-lesioned animals did not display this behavior and reduced the activation of orexin neurons in the LHA. PFC-lesioned animals presented a reduction of the Fos activation in the rlPAG. The results suggest a pathway involving the PFC, PAGrl and LHA orexinergic cell group underlying the CCP, where the rlPAG would integrate inputs from the PFC to control the LHA orexinergic cell group.

Estudos apontam a substância cinzenta periaquedutal (PAG) como um sítio crítico para a expressão de vários comportamentos motivados. A porção rostrolateral da PAG (PAGrl), tem um papel chave na regulação da motivação na caça predatória, e modularia mecanismos de recompensa associados ao comportamento alimentar e busca por droga, a partir de projeções para área tegmental ventral e núcleo acumbens; o que dependeria da ligação com neurônios orexinérgicos da área hipotalâmica lateral (LHA). A PAGrl, está mobilizada nos comportamentos de busca por droga assim como na caça predatória. As principais regiões que aferentam a PAGrl são áreas do córtex pré-frontal medial (mPFC) onde a PAGrl integraria tais aferencias e modularia a LHA. Os resultados corroboram com a hipótese, pois lesões no mPFC diminuíram a busca por droga e vimos que neurônios da PAGrl mobilizados no comportamento, que recebem aferências do mPFC, seriam os mesmos que se projetam para LHA e que a PAGrl teria papel crítico na promoção do comportamento de busca por droga no CPP para sulfato de morfina. / Studies show a periaqueductal gray (PAG) as a critical place for an expression of motivated behaviors. The rostrolateral portion of PAG (PAGrl), is a key role in the regulation of motivation in predatory hunting, and modulates, reward mechanisms associated with drug and food seeking, through projections to ventral tegmental area and the nucleus accumbens; what would depend on the connection with orexin neurons of the lateral hypothalamic area (LHA). The PAGrl, is mobilized in predatory hunting as drug seeking. The main region that sends projections to PAGrl is the medial prefrontal cortex (mPFC), where PAGrl integrate such afferent and modulates the LHA. Our results corroborate the hypothesis, because mPFC injuries, decreased drug seeking and we observed that PAGrl neurons mobilized in behavior, and also receive afferents from mPFC, would be the same as projecting to LHA, thus PAGrl had critical role in promotion of drug seeking behavior during the CPP for morphine sulfate.