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The Journal of Neuroscience, October 15, 1998, 18(20):8417-8422
Reduced Striatal Dopamine Transporter Density in Abstinent
Methamphetamine and Methcathinone Users: Evidence from Positron
Emission Tomography Studies with [11C]WIN-35,428
Una D.
McCann1,
Dean F.
Wong2,
Fuji
Yokoi2,
Victor
Villemagne2,
Robert F.
Dannals2, and
George A.
Ricaurte3
1 Unit on Anxiety Disorders, Biological Psychiatry
Branch, National Institute of Mental Health, Intramural Research
Program, Bethesda, Maryland 20892, and 2 Department of
Radiology, Division of Nuclear Medicine and
3 Department of Neurology, The Johns Hopkins Medical
Institutions, Baltimore, Maryland 21224
 |
ABSTRACT |
Methamphetamine and methcathinone are psychostimulant drugs with
high potential for abuse. In animals, methamphetamine and related drugs
are known to damage brain dopamine (DA) neurons, and this damage has
recently been shown to be detectable in living nonhuman primates by
means of positron emission tomography (PET) with
[11C]WIN-35,428, a DA transporter (DAT) ligand.
The present studies determined whether living humans with a history of
methamphetamine or methcathinone abuse showed evidence of lasting
decrements in brain DAT density. PET studies were performed in 10 control subjects, six abstinent methamphetamine users, four abstinent
methcathinone users, and three patients with Parkinson's disease (PD).
On average, subjects had abstained from amphetamine use for ~3 years.
Before PET studies, all subjects underwent urine and blood toxicology screens to rule out recent drug use. Compared with controls, abstinent methamphetamine and methcathinone users had significant decreases in
DAT density in the caudate nucleus ( 23 and 24%, respectively) and
putamen ( 25 and 16%, respectively). Larger decreases in DAT
density were evident in patients with PD (47 and 68% in caudate and
putamen, respectively). Neither methamphetamine nor methcathinone users
showed clinical signs of parkinsonism. Persistent reductions of DAT
density in methamphetamine and methcathinone users are suggestive of
loss of DAT or loss of DA terminals and raise the possibility that as
these individuals age, they may be at increased risk for the
development of parkinsonism or neuropsychiatric conditions in which
brain DA neurons have been implicated.
Key words:
amphetamines; methamphetamine; dopamine; neurotoxicity; dopamine transporter; parkinsonism
 |
INTRODUCTION |
Recent epidemiological surveys
indicate that the use of psychostimulant drugs of the amphetamine class
is sharply on the rise (Kozel, 1997 ). Two of these psychostimulants,
methamphetamine ("speed", "crystal meth", or "crank") and
methcathinone ("cat"), are easily and inexpensively synthesized
from the legal substance ephedrine (Goldstone, 1993 ; Calkins et al.,
1995 ; Tolliver, 1995 ), prompting some profit-minded individuals to set
up lucrative clandestine portable drug factories for the manufacture of
large quantities of these substances (U.S. Department of Justice,
1994). Outbreaks of methcathinone abuse have occurred during this
decade in Wisconsin and Michigan (Emerson and Cisek, 1993 ; Calkins et
al., 1995 ; Tolliver, 1995 ). Much larger epidemics of methamphetamine
abuse have occurred over the years in the United States (Miller and
Hughes, 1994 ), as well as abroad (Brill and Hirose, 1969 ; Kall, 1997 ;
Suwaki et al., 1997 ). Currently, illicit use of methamphetamine appears to be particularly prevalent in the western United States (Kozel, 1997 ;
Lukas, 1997 ).
Methamphetamine and methcathinone may pose risks to users beyond those
associated with drug abuse and dependence. In particular, both of these
drugs are neurotoxic to brain dopamine (DA) and serotonin (5-HT)
neurons in animals (Seiden and Ricaurte, 1987 ; Gibb et al., 1994 ; Gygi
et al., 1996 ; Sparago et al., 1996 ; Frey et al., 1997 ). After
administration of methamphetamine or methcathinone, animals develop
long-lasting decreases in brain DA and 5-HT axonal markers, including
the neurotransmitters themselves (i.e., DA and 5-HT), their
rate-limiting synthetic enzymes (tyrosine hydroxylase and tryptophan
hydroxylase), and their transporter sites (Seiden et al., 1976 ; Wagner
et al., 1979 , 1980a ,b , 1983 ; Hotchkiss and Gibb, 1980 ; Levine et al.,
1980 ; Steranka and Sanders-Bush, 1980 ; Bakhit et al., 1981 ; Woolverton
et al., 1989 ; Gygi et al., 1996 ; Sparago et al., 1996 ; Frey et al.,
1997 ). In addition, silver-staining methods show evidence of striatal
axon terminal degeneration after the administration of methamphetamine
(Ricaurte et al., 1982 , 1984 ) or methcathinone (Sparago et al., 1996 ).
DA cell body loss has been reported in mice (Sonsalla et al., 1996 ;
Hirata and Cadet, 1997 ) but not in rats (Ricaurte et al., 1982 )
or monkeys (Woolverton et al., 1989 ) previously treated with high doses
of methamphetamine.
In animals, lower doses of amphetamine and methamphetamine produce
neurotoxicity if administered repeatedly at short intervals (e.g., two
to four times at 2 hr intervals) (Sonsalla et al., 1989 ; Melega et al.,
1993 ). Some methamphetamine and methcathinone users ("bingers")
self-administer the drugs repeatedly, typically multiple times daily
and often for several sequential days, during which time they forgo
both food and sleep (Miller and Hughes, 1994 ; Calkins et al., 1995 ). If
one considers differences in body mass and surface area and uses
interspecies scaling methods to calculate equivalent human doses
(Mordenti and Chappell, 1989 ; Chappell and Mordenti, 1991 ), doses known
to be neurotoxic in animals often overlap with those used by humans
(Villemagne et al., 1998 ), raising concern over long-term effects in
humans.
There have been no studies evaluating living humans with a history of
methamphetamine or methcathinone abuse for possible long-term changes
in brain DA neurons, primarily because of difficulties inherent in
evaluating the status of chemically defined populations of neurons in
the living human brain. With the advent of positron emission tomography
(PET) and neuron-specific radioligands, it is now possible to assess
the status of DA neurons in living primates. Indeed, it has been
possible recently to detect methamphetamine-induced DA
neurotoxicity in living baboons by means of PET imaging with [11C]WIN-35,428 (Villemagne et al., 1998 ), a
highly selective DA transporter (DAT) ligand that is also known
as
2 -carbomethoxy-3 -(4-fluorophenyl)-[N-[11C]methyl]tropane
or [11C]CFT (Madras et al., 1989 ; Canfield et al.,
1990 ; Kaufman et al., 1991 ).
The purpose of the present study was to determine whether lasting
decrements in striatal DAT density were evident in abstinent users of
methamphetamine and methcathinone, studied by means of PET imaging with
[11C]WIN-35,428. In particular, it was
hypothesized that methamphetamine and methcathinone users, like
patients with Parkinson's disease (PD), would demonstrate
decreased density of [11C]WIN-35,428 binding,
reflecting possible damage to brain dopaminergic axons and
terminals.
 |
MATERIALS AND METHODS |
Subjects. Ten control subjects, six methamphetamine
users, four methcathinone users, and three patients with early PD
participated in these studies (Table 1).
Methamphetamine subjects were recruited from drug rehabilitation
treatment groups. Methcathinone users were identified through the Drug
Enforcement Administration while they were still incarcerated for
drug-related charges. All methamphetamine and methcathinone users had
used other recreational drugs also (cannabis, lysergic acid
diethylamide, benzodiazepines, cocaine, and alcohol) but listed
methamphetamine or methcathinone as their drug of choice and greatest
use. Control subjects and patients with newly diagnosed PD (Hoehn and
Yahr stage II) were recruited from a university normal volunteer
office and an outpatient neurology clinic, respectively. Subjects were
in good general health (aside from their index condition), as
determined by medical history, physical exam, electrocardiogram, and
blood and urine chemistries, including a complete blood count, liver
and thyroid function tests, hepatitis and human immunodeficiency virus
screens, and routine urinalyses. Detailed neurological exams were
performed by a neurologist experienced with movement disorders,
particularly PD. None of the PD patients had been treated with
anti-parkinsonian medications, because they were newly diagnosed.
Furthermore, none of the subjects were on neuroleptics, Ritalin, or
other therapeutic drugs at the time of PET scanning. Written informed
consent was given by all study participants, who agreed to refrain from
any illicit drug use for at least 2 weeks before study. All subjects
underwent blood and urine drug screens for therapeutic and illicit
drugs before PET scanning.
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Table 1.
Profile of control subjects, abstinent methamphetamine
users, methcathinone users, and Parkinson's disease patients
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Drug use history. Information about drug use was obtained in
several ways: (1) a preliminary telephone interview; (2) a
questionnaire that asked about the number of times methamphetamine or
methcathinone had been used, the typical dose used, the frequency of
use, the last time of use, and the highest dose of methamphetamine or
methcathinone taken; and (3) a standardized drug history questionnaire
(drug history section of the Addiction Severity Index).
Drug screens. Serum and urine samples were screened for
drugs of abuse by Enzyme Multiplied Immunoassay Technique, a
reliable detection method for identifying recent use of amphetamines,
barbiturates, benzodiazepine metabolites, cocaine and metabolites,
opiates, phencyclidine, and tetrahydrocannabinol.
Preparation of [11C]WIN-35,428.
[11C]WIN-35,428 was synthesized as described
previously (Dannals et al., 1993 ). The average specific activity of the
final product calculated at the end of synthesis was >2000 mCi/µmol
and averaged 6,000 mCi/µmol in the present studies.
PET scans. PET studies with
[11C]WIN-35,428 were performed as described
previously (Wong et al., 1993 ), with minor modification. Briefly, ~20
mCi of [11C]WIN-35,428 was administered
intravenously. Thereafter, a series of 50 PET images were acquired. The
scanning image protocol consisted of 50 scan acquisitions, starting
from 15 sec and increasing to 6 min in length over a 90 min period.
Images were acquired on the General Electric
4096Plus whole-body PET scanner and were
preceded by a 10 min attenuation scan using a rotating germanium 68 source. Total protein, albumin, globulin, and protein electrophoresis
were determined for each subject before PET studies. All analyses were
performed on data corrected for radioactive decay. Blood samples for
measurement of [11C]WIN-35,428 metabolites were
obtained from an indwelling arterial line at 5, 15, 30, 60, and 90 min
after injection. Images were reconstructed using a ramped filtered back
projection and were smoothed to a final resolution (5-6 mm in plane
resolution, 6-7 mm z-axis). Regions of interest were
outlined for the caudate, putamen, and cerebellum by an investigator
unaware of the subjects' histories. Adequate anatomical localization
was ensured by using the Register program for magnetic resonance
imaging-PET coregistration (Evans et al., 1991 ). Results were analyzed
by using a three-compartment receptor model (Wong et al., 1993 ),
estimating the four kinetic parameters, and computing a
k3/k4 ratio,
defined as binding potential (BP), to obtain a measure of
[11C]WIN-35,428 binding. In this approach,
k1/k2 obtained in
the cerebellum is used to constrain
k1/k2 in the
striatum (caudate nucleus, putamen), thereby reducing the number of
parameters.
Data analysis. Differences in kinetic parameters of
[11C]WIN-35,428 binding
(k3/k4)
among groups were compared using analysis of covariance (ANCOVA),
followed by Duncan's multiple range post hoc comparisons,
with age as a covariate. Because our sample size was small, the PET
results were also corrected for age before statistical analysis to
guard for possible confounding effects of age-related declines in DAT
(see Table 3 for method of age correction). Age-corrected kinetic
parameters were compared using ANOVA, followed by Duncan's multiple
range post hoc comparisons. Data analysis was done using the
Statistical Program for the Social Sciences (SPSS for Windows, Release
6). All tests were two-tailed, and significance was set at
p < 0.05.
 |
RESULTS |
Demographics
Subjects were well matched with regard to gender. However, as
shown in Table 1, there were significant age differences
(F(3,19) = 5.3; p = 0.008), with
post hoc tests indicating that PD patients were older than
methamphetamine, methcathinone, and control subjects.
Drug use
Characteristics of drug use in methamphetamine and methcathinone
users are summarized in Table 2. Control
subjects and patients with PD had no history of drug abuse or
dependence. All methamphetamine and methcathinone subjects tested
negative for recent drug use and reported having abstained from
amphetamine use for ~3 years (Table 2).
PET imaging with [11C]WIN-35,428
Caudate nucleus
Marked accumulation of [11C]WIN-35,428 was
observed in the caudate nucleus, a brain region with a high density of
DATs (Fig. 1, Table
3). ANCOVA, with age as a covariate,
revealed significant differences in mean
[11C]WIN-35,428 BP in the caudate nuclei of the
four subject groups (F(3,18) = 4.97;
p = 0.039). Post hoc testing indicated that
relative to control subjects, all other subject groups had
significantly lower mean caudate [11C]WIN-35,428
BP values (Table 3). Although patients with early PD had the lowest
[11C]WIN-35,428 BP of all four subject groups
(Table 3), differences between patients with PD and methamphetamine and
methcathinone users did not reach statistical significance. BP values
first adjusted for age (see Table 3 legend for method of age
adjustment) and then compared by ANOVA (without covarying for age)
showed similar differences (Table 3).

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Figure 1.
PET images showing accumulation of
[11C]WIN-35,428 in the striatum in a control
subject, an abstinent methamphetamine subject, an abstinent
methcathinone subject, and a PD patient 70-90 min after injection of
[11C]WIN-35,428.
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Table 3.
Binding potentials of [11C]WIN-35,428 in the
caudate nucleus and putamen of control subjects, abstinent
methamphetamine users, abstinent methcathinone users, and Parkinson's
disease patients
|
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Putamen
As in the caudate nucleus, there was marked accumulation of
[11C]WIN-35,428 in the putamen of control
subjects. ANCOVA revealed significantly lower mean
[11C]WIN-35,428 BP values in the putamen of all
three experimental groups compared with controls
(F(3,18) = 5.53; p = 0.007). In contrast to findings in the caudate nucleus, patients with early PD had
significantly lower mean putamen [11C]WIN-35,428
binding than all other subject groups, differing significantly from
methamphetamine and methcathinone users, as well as control subjects
(Fig. 1, Table 3). The greater reduction in
[11C]WIN-35,428 BP in the putamen compared with
the caudate nucleus is in keeping with previous observations of greater
DA terminal loss in the putamen than in the caudate of patients with PD
(Kish et al., 1988 ; Tedroff et al., 1988 ; Kaufman and Madras, 1991 ; Frost et al., 1993 ). Comparison of age-adjusted BP values using ANOVA
showed similar differences, except that the difference between methcathinone subjects and controls did not achieve statistical significance (Table 3).
 |
DISCUSSION |
The results of the present study are the first to document a
reduced density of striatal
[11C]WIN-35,428-labeled DAT sites in living humans
with a history of methamphetamine and methcathinone abuse. Like
patients with early PD, former methamphetamine and methcathinone users
have decreases in striatal [11C]WIN-35,428
binding, although the decreases in methamphetamine and methcathinone
subjects are not as pronounced as those in PD patients (Fig. 1, Table
3). When considered with results of recent preclinical studies directly
documenting the validity of PET imaging with
[11C]WIN-35,428 for detecting
methamphetamine-induced DA neurotoxicity in the living baboon brain
(Villemagne et al., 1998 ), the present findings suggest that lasting
reductions in DAT density in methamphetamine and methcathinone users
may be related to damage of striatal DA axons and axon terminals.
An important question raised by the present findings is whether the
lasting reduction in striatal DAT density here documented in abstinent
methamphetamine and methcathinone users might not reflect a
neuroadaptive process rather than DA neurotoxicity. Given the large
body of evidence directly documenting the DA neurotoxic potential of
methamphetamine in every animal species thus far examined, including
nonhuman primates (Seiden and Ricaurte, 1987 ; Woolverton et al., 1989 ;
Villemagne et al., 1998 ), we tend to favor the view that DA
neurotoxicity may be involved. This view is also supported by the
observation that similar, although more severe, decreases in
[11C]WIN-35,428 binding are evident in the striata
of patients with PD (Kaufman and Madras, 1991 ; Frost et al., 1993 ;
Table 3), a neurodegenerative disorder in which nigrostriatal DA
neuronal degeneration is well documented (Hornykiewicz, 1966 ; Kish et
al., 1988 ). This support notwithstanding, it must be recognized that decreases in DAT density could be related to a neuroadaptive process, perhaps compensating for a depletion of brain DA not associated with
actual DA nerve terminal degeneration. Indeed, there are several
reports of changes in DAT density after a variety of pharmacological manipulations that do not involve DA neurotoxicity (Cerruti et al.,
1994 ; Koff et al., 1994 ; Tella et al., 1997 ; Malison et al., 1998 ). To
our knowledge, however, none of the reported changes in DAT density are
in the direction or as long-lasting as the reductions herein
documented.
Another important factor to consider is the potential confounding
influence of age on [11C]WIN-35,428 binding. In
particular, subjects with a history of methamphetamine abuse were
somewhat (although not significantly) older than controls, seeming to
parallel losses of DAT binding observed by PET. Although age-related
reductions in the DAT are known to occur (Evans et al., 1991 ; Volkow et
al., 1994 ; van Dyck et al., 1995 ; Frey et al., 1996 ), the reported
age-related decreases are not of the degree observed in the present
study nor do they occur from ages 30 to 37, the mean ages of
methamphetamine and control subjects, respectively. Furthermore, like
abstinent methamphetamine users, abstinent methcathinone users had
decreased [11C]WIN-35,428 binding, yet they were
no different in age from the control subjects. Finally, decrements in
DAT are also evident in age-corrected PET data (Table 3) and are
similar to those in baboons treated with doses and regimens of
methamphetamine comparable to those used by several of the subjects in
the present study (Villemagne et al., 1998 ).
The present results may initially appear to be in conflict with those
of Wilson and colleagues (1996a) , who performed postmortem studies in
chronic methamphetamine users and concluded that no DA neurotoxicity
had occurred, despite a loss of several brain DA neuronal markers,
including the DAT. That conclusion was based primarily on the
observation that levels of dihydroxyphenylalanine decarboxylase (DDC)
and the vesicular monoamine transporter (VMAT) were normal in
methamphetamine users, whereas in PD they were reduced. Although DDC
and VMAT levels can be useful for detecting severe DA cell loss, such
as in PD (Hornykiewicz, 1966 ; Tedroff et al., 1988 ; Wilson et al.,
1996b ), they appear to be less sensitive for detecting milder degrees
of nigrostriatal DA injury, such as that in olivopontocerebellar
atrophy (Zhong et al., 1995 ; Wilson et al., 1996b ). In the
present study, a less profound reduction in DAT density was found in
methamphetamine and methcathinone subjects than in PD patients (Table
3), possibly accounting for the apparently normal DDC and VMAT levels
found by Wilson and colleagues (1996a) in methamphetamine users.
Moreover, baboons treated with dose regimens of methamphetamine
comparable to those used by subjects in the present study have similar
PET findings to those described herein (Villemagne et al., 1998 ).
Because postmortem studies of these animals revealed loss of a variety
of dopaminergic neuronal markers, including VMAT and DAT, it is
possible that differences in drug use patterns (e.g., binge use vs
chronic maintenance drug use) underlie the differences between this
study and that by Wilson and colleagues (1996a) . Additional
neuroimaging studies with radioligands that label other elements of the
DA neuron [e.g., the VMAT, which can be imaged with
[11C]dihydrotetrabenazine (Frey et al., 1996 ;
Gilman et al., 1996 )] should shed further light on this important
issue.
It should be noted that methamphetamine and methcathinone users that
participated in this study had a history of polydrug use, raising the
possibility that other drugs of abuse may have been responsible for
changes seen in PET images. However, none of the other drugs used by
these individuals are known to be DA neurotoxins or to produce lasting
effects on DAT density, mitigating the likelihood of this possibility.
Another potential drawback of the present study is the fact that
previous drug histories were obtained from subjects using retrospective
self-reports. This is an inherent difficulty in studies of individuals
who use illegal substances. Nevertheless, although the accuracy of drug histories (and the purity of the various drugs used) cannot be verified
retrospectively, methcathinone users in this study were members of
methcathinone drug distribution rings. The basis for their arrest and,
in many cases incarceration, was the seizure of large amounts of
methcathinone, as well as the tools necessary for their manufacture.
Thus, although the purity of other drugs used could be questioned, the
purity of methcathinone available to them is certain. Finally, one
could question the use of BP as a measure of DAT density, because
alteration in this parameter could be caused by changes in either
Bmax or Kd. However,
Kd does not change in PD, and experimental
studies indicate that long-term effects of methamphetamine on DA
transporters are related to decreases in Bmax
rather than Kd (Wagner et al., 1980a ; Seiden and
Ricaurte, 1987 ; Frey et al., 1997 ).
In summary, results from the present study are the first to document a
persistent decrease in [11C]WIN-35,428-labeled
brain DA transporters in abstinent human methamphetamine and
methcathinone users. Because similar persistent decreases in
[11C]WIN-35,428 binding are evident in baboons
with known DA neurotoxicity (Villemagne et al., 1998 ), the present
results raise the possibility of brain DA neurotoxicity in human
methamphetamine and methcathinone users, although a neuroadaptive
process is also conceivable. Notably, decrements in
[11C]WIN-35,428 binding in abstinent
methamphetamine and methcathinone users were less severe that those
found in patients with early PD and were not associated with overt
neurological or psychiatric illness. Longitudinal studies are therefore
needed to determine whether individuals with a history of
methamphetamine and methcathinone use are at an increased risk for
developing parkinsonism or other neuropsychiatric conditions in which
brain DA deficiency has been implicated.
 |
FOOTNOTES |
Received July 17, 1998; accepted July 29, 1998.
This work was supported by Public Health Service Grants DA05707,
DA06275 (G.A.R.), and DA09482 (D.F.W.) and by the National Institute of
Mental Health, Intramural Research Program (U.D.M.).
Correspondence should be addressed to Dr. George A. Ricaurte,
Department of Neurology, The Johns Hopkins Medical Institutions, 5501 Bayview Drive, Room 5B71E, Baltimore, MD 21224.
 |
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