Rajita Sinha - US grants

DESCRIPTION: (Applicant's Abstract) Although craving for cocaine is identified as the key motivating factor perpetuating cocaine use and relapse, there is little understanding of the mechanisms underlying cocaine craving and the possible gender differences in cocaine craving responses. Drug abusers cite environmental stressors and psychological distress as among the most common triggers for relapse to drug use. While several animal studies have shown that acute stress increases self-administration of drugs, human laboratory studies demonstrating an association between acute stress and cocaine craving or cocaine relapse have been lacking. We have developed an effective personalized stress and drug cue imagery paradigm that reliably increases cocaine craving. In 60 cocaine abusing men and women we will test whether stress and drug cue imagery increase cocaine craving as compared to neutral imagery. Neurobiological correlates of stress-induced and drug-induced craving will be studied, and potential gender differences in these responses will be examined. We hypothesize the following: (1) Cocaine craving will increase with stress and drug cue imagery, and not during neutral imagery, (2) In contrast to neutral imagery, stress and drug cues will activate: (i) sympathetic responses as measured by increases in heart rate, skin conductance, finger temperature and blood pressure; (ii) the hypothalamic-pituitary-adrenal axis (HPA), as measured by plasma adrenocorticotrophic hormone (ACTH), cortisol and prolactin, and (iii) the dopaminergic system, as measured by homovanillic acid (HVA), (3) Women will exhibit greater stress-induced cocaine craving and stress reactivity than men, and (4) Increases in cortisol and HVA during stress imagery and drug cues imagery will be associated with stress-induced and drug cue-induced cocaine craving respectively. If our hypotheses are confirmed, the findings will provide (a) greater understanding of the mechanisms by which craving for cocaine is elicited, (b) new leads for the development of pharmacological interventions for cocaine abuse, and(c) modifications in state-of-the-art behavioral therapies for cocaine abuse.

DESCRIPTION (provided by applicant): Cocaine addiction is a chronic relapsing disorder with devastating psychosocial, health and societal consequences. Emerging data clearly indicate the importance of studying sex-specific effects in cocaine dependence - a growing problem for women in this country. Stress has been identified as one of the key factors in increasing the vulnerability to develop cocaine dependence in women. Women also report stress and negative mood as playing a pivotal role in the continued drug use and relapse cycle. While there have been attempts to understand the mechanisms underlying the association between stress and cocaine addiction, systematic research on sex-specific factors that contribute to this association has been rare. The goal of this Center is to use interdisciplinary approaches of examination: (A) to assess the effects of early life stress, sex hormones and stress hormones on cocaine reinforcement and the risk of developing cocaine dependence; and (B) to understand the contribution of sex-based factors in the association between stress and cocaine relapse. These goals will be achieved using multidisciplinary laboratory and clinical research conducted in animals and in humans. A greater understanding of the interactions between sex, stress and cocaine dependence will be significant in the development of sex-specific prevention and treatment approaches that will specifically affect the health of women with cocaine dependence. The following specific aims will be achieved by the SCOR: (1) To establish a collaborative multidisciplinary research Center that will address the study of sex-specific factors in the relationship between stress and cocaine addiction. (2) To conduct a series of programmatic animal and human research studies aimed at understanding sex-specific factors in the relationship between stress and cocaine addiction. (3) To develop a collaborative research program that will utilize SCOR core resources to facilitate the investigation of sex-specific factors in ongoing independently-funded research at Yale relating to the etiology, neurobiology and treatment of cocaine addiction. (4) To assist a range of young investigators from different disciplines in conducting sex-specific research on stress and cocaine addiction through mentorship activities of Center staff.

DESCRIPTION (provided by applicant): Chronic Alcohol and Brain Stress Circuit Response Alcoholism is a chronic relapsing illness in which alcohol-related neuroadaptations in brain stress and reward pathways are known to promote persistent craving or compulsive alcohol seeking, a hallmark symptom in both the development of alcoholism and in alcohol relapse susceptibility. In the first funding period of this project, we found that chronic alcohol abuse is associated with a series of stress-related alterations that accompany the compulsive alcohol seeking state, and these changes contribute to high relapse susceptibility in alcoholics completing inpatient treatment. Furthermore, preliminary results comparing moderate (MD), moderate bingeing (MB) and heavy (HD) non-dependent drinkers studied in the current period suggested a progressive increase in sensitivity to stress-induced and cue-induced alcohol craving and associated physiological and biochemical alterations associated with heavy drinking and/or binge drinking. These findings suggest that alcohol-related alterations in stress responses and stress and cue-induced craving may contribute to the development of compulsive alcohol seeking. Therefore, in this competing renewal application, we extend and expand the findings from the current period to examine the role of stress in the development of compulsive alcohol seeking and in increased stress and cue-related alcohol consumption in non-dependent heavy and binge drinkers. A 5-year project with a cross-sectional design is proposed that will study demographically-matched samples of 50 MD, 50 MB and 50 HD drinkers, to address the following specific aims: (1) To examine whether exposure to stress and to alcohol cues increases alcohol craving, negative emotions, behavioral distress responses and alters physiological and biochemical responses differentially across the three drinking groups. (2) To examine whether exposure to stress and to alcohol cues vs. neutral cues increases alcohol consumption in the alcohol taste test, and if amount consumed vary as a function of drinking group. (3) To examine whether subjective, physiological and biochemical markers of distress and compulsive seeking is predictive of amounts of alcohol consumed in each condition. (4) To examine the influence of demographic and individual differences variables, such as gender, race, family history of alcoholism (FH), co-morbid use of nicotine and poor cognitive/impulse control in stress and cue-related responses and level of alcohol consumption. Addressing these questions will increase an understanding of the mechanisms by which alcohol consumption and stress responses interact to influence development of compulsive alcohol seeking and vulnerability to loss of control drinking, and the results will have significant implications for the development of new prevention and treatment interventions for alcoholism. Alcoholism is among the top three causes of preventable death and disease in the US (Mokdad et al., 2004;Room et al., 2005). Stress plays an important role in the development of alcoholism and in high vulnerability to alcohol relapse. The proposed study will provide a greater understanding of the mechanism by which stress and alcohol consumption interacts to influence development of compulsive alcohol seeking and vulnerability to stress-induced drinking, and the results will have significant implications for the development of new prevention and treatment interventions for alcoholism.

DESCRIPTION (provided by applicant): This K02 application seeks support which is essential for my continued career development as a newly independent clinical researcher. Funded by a joint NIH Office of Research on Women's Health (ORWH) and NIDA institutional training grant (K12-DA14038; PI: Carolyn Mazure, Program Director: Bruce Rounsaville), I have attained substantial experience in examining sex differences in the association between stress and drug abuse over the past 3 years. I have demonstrated considerable research productivity as evidenced by my peer-reviewed publications, my scientific directorship of a Women's Health Specialized Center of Research (SCOR) on sex, stress and cocaine addiction (P50-DA16556, PI: Sinha), my principal and co-principal investigatorships on two center sections, a previous NIDA funded R01 (R01-DA11077, PI: Sinha) and a recently awarded R01 (AA13892, PI: Sinha). However, this source of salary support (75%) will expire by 12/31/03, leading me to seek an alternative mechanism of funding. Therefore, this K02 award is vital for sustaining my current full-time research focus and for facilitating my development into a fully independent investigator. Justification for the award is provided by a comprehensive 5-year Career Development Plan that fills important gaps in my current expertise in sex-specific factors in the neurobiology of stress and drug relapse. Specifically, I will acquire specialized skills in several additional multidisciplinary areas: (a) basic sex-specific neurobiology of stress and drug addiction; (b) pharmacological and psychological methods to study stress and drug craving states; and (c) advanced bio-statistical tools such as mixed linear models and random effects models. Intensive training is provided by an integrated curriculum of intramural coursework, extramural didactics, individualized preceptorships, interactive symposia, and research-related organizational meetings on drug abuse and women's health. A representative research project (P50-DA16556, Center Project PI: R. Sinha) is included, which will examine, (1) sex differences in the subjective, autonomic and HPA response to stress and to drug cues as compared to neutral cues in cocaine dependent men and women, and (2) sex differences in the association between early trauma, stressful life events, acute psychobiological responses to stress and to drug cues and cocaine relapse. This research project along with additional lines of research that I am conducting illustrates the significant impact this career award will have in furthering not only my scientific career, but also our fundamental understanding of how stress increases the risk of drug relapse differentially in men and women. Such an understanding will have important implications for the development of gender-specific treatments for cocaine dependence that will ultimately improve the health of cocaine-addicted women and their families.

substance abuse related behavior; cocaine; stress; gender difference; cues; behavioral /social science research tag; human subject; clinical research;

DESCRIPTION (provided by applicant): This application proposes to conduct a phase II randomized, double blind, placebo-controlled trial of Iofexidine to prevent stress related opiate relapse in naltrexone treated opioid addicted individuals. Stress is known to increase drug craving and risk of relapse to drugs. Lofexidine, an alpha-2-adrenergic agonist, has been shown to attenuate stress-induced reinstatement of opiate seeking behavior in heroin dependent laboratory animals. In a recently completed 8-week pilot safety and efficacy study with 25 opioid dependent individuals seeking naltrexone (Ntx), we found the combination of Iofexidine (Lof) and naltrexone (Ntx) to be well tolerated. Individuals receiving naltrexone-lofexidine (Lof/Ntx) were significantly more likely to stay abstinent from opiates and were significantly more compliant with naltrexone treatment as compared to naltrexone-placebo (Pla/Ntx) subjects. In light of these promising preliminary data, we propose a 4-year clinical trial that will recruit 120 opioid dependent individuals immediately following opioid detoxification to participate in a randomized, double blind, placebo-controlled 12-week treatment study. The following specific aims will be addressed: (1) To evaluate the safety of Iofexidine in combination with naltrexone treatment in opioid dependent individuals. ) To evaluate the efficacy of Iofexidine in enhancing naltrexone treatment in opioid dependent individuals on measures of (a) protracted opioid withdrawal symptoms; (b) opiate abstinence, and (c) naltrexone treatment adherence. (3) To assess naltrexone treatment outcomes at 1- and 3-month follow-up after 12-week Iofexidine/placebo treatment. 4) To examine whether individual differences in perceived stress and frequency and magnitude of stressful life events predicts Iofexidine treatment response and vulnerability to opiate relapse. Findings from this study will provide important information on whether pharmacologically targeting stress enhances naltrexone treatment, and whether the combination provides an efficacious opiate relapse prevention intervention.

NIH Roadmap Initiative tag; medical outreach /case finding; statistical service /center

DESCRIPTION (provided by applicant): Tobacco smoking, alcohol consumption and overconsumption of rich and high fat 'comfort'foods are the top three causes of preventable death and disease in the US today. The persistent and compulsive engagement in these addictions despite serious health, social and legal consequences is a common feature. Emerging data indicate that self control mechanisms are critical in perpetuating this compulsive engagement in addictive behaviors. Stress, which plays a key role in addiction, other psychiatric illnesses and in many chronic diseases, also facilitates lapses in self control. Although research on the links between stress and addiction, stress and psychiatric disorders and stress and chronic diseases exists, systematic research on the interactions between stress, self control and addiction have been rare. This three-way interplay between stress, self control and addiction is complex, and requires an interdisciplinary (ID) conceptual framework with collaborative team-based approaches of study that include the multiple brain, body, behavioral and social systems. We therefore propose an interdisciplinary research consortium on stress, self control and addiction (IRCSSA) that brings together over 50 leading scientists who conduct research relevant to a number of NIH Institutes (NIMH, NIA, NIDA, NIAAA, NHLBI, NCI, NICHD, NIDDK, NIEHS, NINDS, NIDCD). These experts representing 20 disciplines that span 5 schools (Medicine, Arts and Sciences, Management, Nursing and Public Health) and three academic Institutions will collaborate as a team to: (A) identify mechanisms underlying the development of stress-related effects on self-control in the addictive behaviors of smoking, drinking and overeating;(B) evaluate self-control mechanisms in the pathophysiology of chronic stress and addiction, and (C) develop social, behavioral and pharmacological strategies to increase self-control and decrease these addictive behaviors. These goals will be accomplished using animal models (non-human primate and rodents) and human studies that include children and adults. Achieving these goals will have a direct impact in reducing morbidity and mortality resulting from each of these disorders. The goals will be achieved by addressing the following specific aims: (1) To establish an interdisciplinary research consortium by bringing together leading biological, behavioral and social scientists to examine the mechanisms underlying stress, self-control and addictive behaviors;(2) To conduct programmatic, team-based collaborative research to understand the processes underlying stress and self control that promote and maintain compulsive smoking, drinking and overeating;(3) To develop new social, behavioral and pharmacological prevention and treatment strategies to decrease stress, increase self-control and prevent and decrease addictive behaviors;(4) To foster career development and mentoring of interested students and scientists from varied disciplines in collaborative, interdisciplinary research on stress, self control, addiction and related chronic diseases;and (5) To disseminate research findings to professional audiences and the public, including partnering with the community to collaboratively address emerging social, health policy and bioethical issues raised by studies of stress, self-control and addictive behaviors.

Adolescence is a critical period in the maturation of a subcortical-prefrental neural system central to stress regulation and the regulation of hedonically-driven behaviors such as drug use and abuse. Emerging preclinical data support the observation that prenatal and early life stressors constitute an important vulnerability factor associated with dysregulated stress response mechanisms in adolescence and young adulthood. That is, a key mechanism for the initiation of drug use and abuse in adolescence may be a dysregulated balance between reward and stress response systems. Further, there is evidence of a significant association between early trauma history before age 18, recent adverse life events, laboratory- induced acute stress/drug cue reactivity and drug use relapse in addicted women, as compared to men. These findings suggest that the proposed dysfunctional stress-regulation system as one mechanism for initiation of drug use and then abuse in adolescence may be differentially more active in girls compared to boys. We propose to study adolescent response to stressors and gender differences in that response in a well- characterized cohort of adolescent males and females beginning at age 14 who have been studied since birth and who were exposed or non-exposed to cocaine and other drugs prenatally. Both exposed and non- exposed adolescents have grown up in psychosocial adversity with one group also exposed to the early stressors of a drug-using environment. This cohort provides a unique opportunity to examine the relation between early experience and functioning assessed prospective^ and stress response and drug use in adolescence. Two hundred adolescent girls and boys will participate in laboratory based stress-induction sessions with detailed assessments of their behavioral and physiological response. Adolescents will then be followed with biyearly assessments of drug use and other risk taking behaviors. Specifically we aim to examine sex differences in adolescents as well as the impact of early life stressors, especially prenatal exposure to drugs of abuse, in measures of emotion state, HPA activation, physiological arousal and urinary catecholamine response to both a social stress and to stress, appetitive and neutral imagery;to examine the interaction between early life stressors and current adverse life events on adolescent response to social stress and stress imagery and to examine the relation between stress response as measured physiologically and behaviorally and initiation of drug use in a one to four year follow-up period. Understanding possible mechanisms for the initiation of drug use and early abuse, and how these mechanisms work differentially in females and males will inform the development of more effective and targeted interventions in adolescents at risk.

Addictions constitute the most costly medical illnesses in society today. Onset of drug addiction often begins in adolescence and an improved understanding of the neural correlates of addiction vulnerability within this developmental period has significant implications for prevention and treatment interventions. Few prior investigations have followed at-risk cohorts from birth through adolescence, and many have focused on boys, generating a relative deficiency in our understanding of these processes in girls and in how boys and girls differ. No longitudinal studies to date have used brain imaging to identify how boys and girls at risk for addiction differ in brain function. Furthermore, although cocaine and other drug exposure in utero remains a significant public health problem, no studies to date have examined the influence of such exposure upon human adolescent brain function or addiction vulnerability. We propose examining 120 adolescent girls and boys 13-15 years of age who have been followed since birth, and were either prenatally cocaine-exposed to (PCE) or non-drug exposed in utero (NDE) and are matched on important sociodemographic features that categorize them as particularly vulnerable to the development of addiction. We propose using fMRI to investigate gender differences in the neural correlates of stress-responsiveness using an fMRI paradigm that our group has developed and used in prior SCOR-supported research. Our prior SCOR research found that adult men and women differed in the neural responses to individualized stress, appetitive and neutral scripts within limbic or "emotion-related" brain regions including caudate, amygdala, hippocampus and anterior cingulate, and that these differences in activations were largely observed during the stress scripts. Furthermore, these responses were differentially altered by chronic cocaine abuse in men and women. We propose using this paradigm to examine: 1) sex differences in the neural correlates of stress-responses in these younger individuals at increased risk for addiction;2) sex differences in neural activations related to in- utero cocaine exposure;and, 3) the stress-related brain activity that is predictive of subsequent substance use behaviors in girls and boys and how they differ across sex group. Findings from this study will provide critical gender-specific data on brain correlates of stress responses in adolescent girls and boys and provide insights into the risk related neural pathways in adolescent addiction.

Scientific and Administrative Core A The Scientific and Administrative Core will be the central organizing force for this research SCOR. It will provide scientific and administrative support to conduct translational and interdisciplinary studies to address the following three scientific goals: (1) to examine sex differences in the neural and psychobiological effects of prenatal cocaine exposure (PCE) on stress-related factors increasing risk of developing drug abuse;(2) to evaluate the effects of sex-specific factors in the association between stress, drug seeking and vulnerability to cocaine relapse;and (3) to build scientific collaborations through consultation and research support so as to increase the study of sex-specific effects on stress and drug abuse among investigators locally, regionally and nationally. It will provide Core resources and support to basic science and clinical studies conducted in animals and in humans across the lifespan. The aims of this Core will be the following: (1) To provide scientific planning, integration, synthesis and oversight of Center goals by the Principal Investigator, Co- Director and the Executive Committee, with consultation from the Scientific Advisory Board;(2) To provide fiscal and administrative oversight to the SCOR, its component and affiliated projects;(3) To provide scientific consultation and support to SCOR research collaborations with junior and senior investigators at Yale and at other research institutions to examine sex-specific hypotheses pertaining to stress and SUDs in the proposed specific aims of their respective research;(4) To coordinate human subject recruitment across SCOR projects by facilitating recruitment of subjects, especially women and minorities, to achieve the goals of the Center and its component and affiliated projects;(5) To assist component and affiliated projects through coordinated data collection, data management and statistical analysis approaches and in core laboratory resources for processing sex and stress hormones;(6) To maximize the yield across individual studies by utilizing a core battery of methods and assessments and coordinating the training of assessments and methods centrally;and (7) To facilitate inter-SCOR collaborations on common stress mechanisms in order to study similarities and differences in biological and social factors affecting stress-related disorders in women's health.

[unreadable] DESCRIPTION (provided by applicant): Competitive Renewal of the Yale SCOR on Women Health: Sex, Stress and Substance Abuse Substance use disorders (SUDs) are chronic relapsing illnesses with devastating psychosocial, health and societal consequences. Differential susceptibility to SUDs in men and women is well known. Historically, prevalence of disorders such as cocaine abuse is higher in men than women, but emerging evidence indicates that adolescent girls are as likely or slightly more likely to use and abuse substances, such as cocaine, than adolescent boys. Stress is a major factor increasing the vulnerability to develop SUDs in girls and in women. Our current SCOR findings indicate that females are more vulnerable to the addictive properties of abusive drugs and that stress markers such as early trauma and altered stress neurobiology plays a pivotal role in the continued drug use and relapse cycle in women. In this SCOR competitive renewal, we propose translational research that will systematically examine mechanisms of such increased vulnerability in girls and in women. Continued support is requested to conduct interdisciplinary studies to address the following three scientific goals: (1) to examine sex differences in the neural and psychobiological effects of prenatal cocaine exposure (PCE) on stress responses affecting risk of developing SUDs; (2) to evaluate the effects of sex-specific factors in the association between stress, drug seeking and vulnerability to cocaine relapse; and (3) to build scientific collaborations through consultation and research support so as to increase the study of sex-specific effects on stress and drug abuse among investigators locally, regionally and nationally. These goals will be accomplished by means of basic science and clinical studies conducted in animals and in humans. A greater understanding of these interactions will directly affect the development of sex-specific prevention and treatment approaches that will enhance the health of addicted women and their families. The following specific aims will be achieved by the SCOR: (1) To conduct a series of translational research projects on the interdisciplinary study of sex-specific effects in the association between stress and SUDs across the lifespan; (2) To extend the SCOR collaborative research program utilizing SCOR core scientific resources to facilitate the investigation of sex-specific factors in ongoing independently-funded research relating to the etiology, neurobiology and treatment of SUDs that includes faculty and research at other institutions; (3) To assist a range of young investigators from different disciplines both at Yale and at other institutions in conducting sex-specific research on stress and drug abuse through mentorship, research support and scientific consultation; (4) To establish inter-SCOR collaborations on common stress mechanisms to study similarities and differences in biological and social factors that contribute to stress-related disorders affecting women's health. [unreadable] [unreadable] [unreadable] [unreadable]

The conduct of interdisciplinary and translational clinical research is complex and can be optimized through coordination of specialized resources across projects. This P30 will provide core Human Subjects resources for coordinated and efficient data collection and statistical analysis across the clinical studies and pilot projects included in this consortium. Among the overall goals of the IRCSSA, is the need to study well characterized clinical and non-clinical participants in all human projects so as to achieve both economics of scale and more importantly to synthesize findings on stress, self control and addiction across multiple response systems. This may be achieved by a coordinated and centralized participant recruitment process and by the use of analogous measures to understand the key concepts of stress, self control and addiction across research projects. Furthermore, as multi-system assessments (e.g., genetics, neurochemical, physiological, behavioral, social factors) are being conducted across studies, we plan to create large datasets of common measures across clinical and non-clinical participant groups so as to evaluate the key constructs from multiple perspectives. In this way a Human Subjects P30 that incorporates these services will enhance the synergy between human projects in the IRCSSA. Therefore, the overall aims of this Core are the following: (1) To provide centralized coordination of subject recruitment for clinical studies;(2) To provide a central assessment resource on stress, self control, physical health screening measures and for specific addictive behaviors of smoking, drinking, overeating;(3) To provide central data collection and management resources;(4) To provide centralized and coordinated data analysis and statistics expertise; and (5) To provide scientific support and consultation to ongoing and pilot study investigators. Through these aims the P30 will provide critical support to the human studies and facilitate integration of data across projects in the IRCSSA. Such integration will permit pooled analysis across studies that will lead to a more comprehensive understanding of the stress mechanisms that affect self control processes in addiction.

DESCRIPTION (provided by applicant): This preliminary study, which will be of 2 years duration, will assess the relationship between changes in gene-expression induced by treatment with progesterone and laboratory measures of stress-induced craving, negative emotion, and physiology previously shown to predict risk for early relapse in cocaine addicted subjects. The long-term goal of this project is to develop novel molecular tools that can be used to predict and monitor the response to specific treatments for cocaine dependence. Preliminary studies have shown that men and women differ in their subjective and physiological responses to cocaine, as well as stress or drug-cue related stimuli associated with risk for relapse. Men and women also differ in their clinical response to various proposed pharmacological treatments for cocaine addiction. Differences in the level of gonadal steroids may underlie some or all of these differences. Recently, a number of small scale laboratory investigations and clinical trials have investigated progesterone as a possible treatment for cocaine addiction. Studies in animal models have shown that progesterone receptors are widely expressed in the brain and regulate the expression of a large number of genes in the brains of both female and male animals. In addition, progesterone has been shown to activate both the ERK/CREB/bcl-2 and Akt second messenger signaling pathways in neurons. These effects have been proposed to underlie the neuroprotective actions of progesterone in several experimental models. Activation of these pathways may oppose the actions of stress-induced patterns of gene expression, which could mediate increased risk for relapse in cocaine dependent individuals. In this study, we will recruit (n=60;30 male and 30 female) treatment-seeking cocaine-dependent subjects who are currently being recruited to take part in a NIDA-funded study of progesterone effects on stress and cue- induced cocaine craving and relapse susceptibility. In that study, subjects are randomly assigned to receive either progesterone (400mg/day) or placebo for a period of five days and undergo brief guided imagery sessions involving personalized stressful, drug-cue or neutral-relaxing situations (one imagery condition per session). In the proposed study, we will isolate RNA from blood collected prior to treatment and on day 5 of treatment with either progesterone or placebo. Gene-expression levels will be assessed by microarray hybridization using Illumina Sentrix Beadchip (Human-6v2) arrays (the same platform used in our preliminary studies). Gene-expression levels will be correlated with drug craving, anxiety and emotion ratings, as well as behavioral distress responses, heart rate, blood pressure, and salivary cortisol measures assessed during each session. Differential expression of selected genes of interested will be confirmed using Quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR). Specific aims include: (1) comparing progesterone-induced changes in peripheral blood gene-expression in cocaine-dependent men and women;and (2) identifying specific progesterone-regulated transcripts whose expression is correlated with the subjective response to stress or drug-cue related stimuli. PUBLIC HEALTH RELEVANCE: These studies will allow us to better understand the molecular basis for individual differences in the response to progesterone in cocaine dependent men and women. Better understanding of these differences will allow us to identify those individuals (both men and women) most likely to benefit from treatment with progesterone. In addition, better understanding of the mechanism of action of progesterone at the genomic level may help to guide the development of novel hormonally based pharmacotherapies for the treatment of cocaine dependence.

DESCRIPTION (provided by applicant): This application proposes to conduct a randomized, double blind, placebo-controlled laboratory study to examine whether guanfacine (GUA) decreases cocaine and nicotine craving, anxiety and stress related arousal in cocaine dependent, nicotine smoking (CD) individuals. In previous research we've shown that laboratory exposure to stress and drug cues increases drug craving and stress related arousal and both measures predict cocaine relapse outcomes. Alpha-2-adrenergic agonists such as lofexidine and guanfacine attenuate stress-induced reinstatement of cocaine-seeking behavior in cocaine experienced laboratory animals. In previous pilot studies, we've shown that lofexidine decreases stress and cue-induced opiate and cocaine craving and reduces negative affect and physiological arousal in opiate dependent individuals treated with naltrexone. It was also found to improve opiate abstinence rates and compliance with daily naltrexone regimen. Preliminary work with GUA 2 mg and 3 mg daily dosing versus placebo (PLA) showed positive results with respect to drug cue-induced and stress- induced drug craving, anxiety and stress-related arousal. Thus, in light of previous preclinical research and our clinical findings, we propose a 3-year study that will recruit 60 CD individuals to participate in a randomized, double blind, placebo-controlled 4-week inpatient laboratory study. The following specific aims will be addressed: (1) to evaluate the safety/tolerability of 2mg and 3mg daily of guanfacine in CD individuals;(2) to determine the dose-dependent effects of guanfacine on basal cocaine and nicotine craving, depressive symptoms and perceived stress scores in weekly assessments during the inpatient stay;(3) To determine the dose-dependent effects of guanfacine on cocaine craving, nicotine craving and mood following guided imagery exposure to stress, drug cue and combined stress+drug cue scenarios;and (4) to determine the dose-dependent effects of guanfacine on cardiovascular and catecholamine (norepinephrine and epinephrine) response following exposure to stress, drug cue and combined stress+drug cue scenarios. Findings from this study will provide important information on whether alpha-2adrenergic compounds such as guanfacine show promise in decreasing drug craving, anxiety and stress, factors shown to predict high cocaine relapse outcomes. If the proposed hypotheses are supported, it will also provide evidence for further development of guanfacine as a medication for cocaine relapse prevention. PUBLIC HEALTH RELEVANCE: Drug craving and associated high cocaine relapse rates are major clinical challenges in the treatment of cocaine dependence, and drug craving, anxiety and stress-related arousal are significant factors that increase cocaine relapse risk. The proposed study will test guanfacine as a potential therapeutic strategy to decrease these symptoms of drug craving, anxiety and distress and cocaine relapse risk and the results will have significant clinical implications for the development of new medications to decrease cocaine craving and prevent relapse in cocaine dependence.

DESCRIPTION (provided by applicant): We propose to investigate how peripheral immune system cytokines contribute to stress-related alcohol craving and relapse risk in alcohol dependent (AD) individuals with and without high levels of depressive symptomatology. Stress-induced craving in alcoholics is a persistent distress state characterized by elevated negative mood, up-regulated basal adrenal sensitivity and a subsequent dampened arousal response to stress. Notably, this dysregulation is associated with a high susceptibility for relapse, and may be exacerbated in AD individuals with co-morbid depressive and affective symptomology. As chronic stress and alcohol consumption has robust and reciprocal effects on immune system cytokines, we postulate that adaptations in both pro- and anti-inflammatory cytokine levels may contribute to the stress system dysregulation underlying alcohol craving and relapse. Furthermore, that alcohol-related cytokine changes may contribute differentially to the craving state in non-depressed AD individuals compared to those with high co-morbid depressive symptomatology. Our preliminary pilot data shows an increased inflammatory response (high pro-inflammatory cytokines and low anti-inflammatory cytokines) in AD individuals compared with social drinkers (SDs); both at baseline and in response to stress. Moreover, this inflammatory immune system response was shown to be associated with increased stress-induced alcohol craving, negative affect and relapse and was also shown to vary between AD individuals with and without high co-morbid depressive symptomatology. Therefore, our objectives are to investigate the role of pro- and anti- inflammatory cytokine biomarkers in relation to the negative reinforcement processes integral to relapse risk in both non-depressed AD individuals as well as AD individuals with high co-morbid depressive symptomatology (AD+dep VS AD-dep). A 5-year project with a cross-sectional design and a prospective follow-up relapse assessment phase is proposed to study demographically-matched samples of 60 AD (30 +dep / 30 -dep) and 60 SDs (30 +dep / 30 -dep) to address the following specific aims: (1) to examine whether AD subjects and SDs differ with regard to cytokine basal levels and cytokine reactivity following exposure to stress-related imagery. (2) to examine whether AD and SD individuals with and without depressive symptomology will differ with regard to cytokine basal levels and cytokine reactivity following exposure to stress-related imagery. (3) to examine the relationship between stress- induced cytokine adaptations and craving as well as relapse at 14, 30 and 90 days following discharge from inpatient treatment. (4) to explore potential moderators of change in basal and response cytokine levels, including sex and severity of chronic alcohol abuse. As high co-morbid depressive symptomatology is one of the most prevalent psychiatric disorders associated with alcoholism, the identification of new molecular targets for the treatment of alcoholism in both non-depressed individuals as well as those with high depressive symptomatology will be integral to the development of new immune-related, individualized medications for alcohol treatment.

ABSTRACT This revised application proposes to conduct a randomized, double blind, placebo-controlled combined laboratory and clinical outcome study to test the efficacy of Prazosin (PZ) in decreasing alcohol craving, anxiety, stress dysregulation and alcohol use outcomes in treatment seeking alcohol dependent (AD) individuals with and without current anxiety disorders (+Anx/-Anx). In previous research we've shown that laboratory exposure to stress and alcohol cues increases alcohol craving, anxiety and stress dysregulation, which in turn, are predictive of subsequent alcohol relapse outcomes. Prazosin, an alpha-1 adrenergic antagonist, known to decrease central norepinephrine and CRF upregulation, decreases stress-induced alcohol reinstatement and alcohol consumption in both dependent rats and in a preliminary study with alcoholic patients. However, the specific mechanisms by which PZ may be decreasing alcohol consumption in humans is not understood. Our preliminary data show that PZ relative to Placebo (PL) decreases stress and cue- induced alcohol craving, anxiety and stress dysregulation in AD individuals, and that such decreases are more pronounced in AD individuals with current anxiety disorders than those without such comorbidity. Thus, in light of previous research and our preliminary findings, we propose a 5-year study that will recruit 150 AD individuals (evenly split by those with and without any current anxiety disorders) to participate in a randomized, double blind, placebo-controlled 12-week clinical laboratory and outcome study. The following specific aims will be addressed: 1) To evaluate the effects of PZ (16 mg, tid) on stress and cue-induced alcohol craving and anxiety, stress dysregulation in the laboratory in AD patients with and without current anxiety disorders; (2)To evaluate the effects of 16mg PZ on alcohol craving, anxiety and stress dysregulation in AD patients with current anxiety disorders as compared to those without anxiety disorders; (3) To determine the efficacy of 12- week PZ treatment on primary alcohol use outcomes, and secondary outcomes including alcohol craving, negative mood symptoms, smoking and sleep; (4) To assess the efficacy of 12-week PZ versus PL treatment on primary alcohol use and secondary outcomes in alcoholics with/without any current anxiety disorders. (5) To examine one-month post-treatment follow-up alcohol use outcomes for enduring short term treatment effects. The role of patient characteristics and laboratory-based craving and stress dysregulation in predicting alcohol treatment outcome will also be explored. If the proposed hypotheses are supported, it will provide evidence for efficacy of Prazosin as a medication for alcoholism, particularly for those with co-morbid anxiety disorders.

DESCRIPTION (provided by applicant): Childhood obesity is a serious public health problem. Childhood obesity is associated with obesity in adulthood and increased risk for diabetes, heart disease, and some cancers. Notably, obesity is particularly common in low-income ethnic minority children and children of obese parents. Preschool-aged children (aged 2-5 years) are just beginning to form patterns of eating and physical activity (PA) preferences and so this is an ideal age to target in prevention programs, particularly family-based programs which can improve food and activity choices offered to young children at home. Significant basic research indicates parent stress as a risk factor for child obesity. This risk may be exacerbated in low-income families who face multiple chronic stressors. Mindfulness-based stress reduction (MBSR) is an empirically-supported treatment that reduces stress in adults. However, the potential effects of MBSR on parent stress and child obesity have not been tested. The goal of the proposed study is to test initial feasibility and obtain effect sizes for a parenting-focused version of MBSR plus nutrition and physical activity counseling to reduce parent stress and prevent obesity in at-risk 2-5 year olds from low-income urban families. We hypothesize that MBSR plus nutrition and PA counseling (MBSR+N) for parents will decrease parent stress, improve parenting, increase healthy eating and PA, and prevent obesity in children of highly stressed low-income obese parents. The proposed study brings together a multidisciplinary team of experts in child development, behavioral interventions for obesity, pediatric endocrinology, nutrition, and exercise physiology to pilot test the feasibility and initial efficac of MBSR+N in an urban community-based clinic. 60 overweight parents of 2-5 year olds reporting high stress levels will be recruited from a child guidance clinic serving a low-income urban community. Parents will be randomly assigned to receive either an 8 week MBSR+N intervention (based on the MBSR plus nutrition and PA intervention for adults developed by Dr. Sinha, co-PI) or to a contact control+N group. At pre- and post-intervention and at a 6 month and 1 year follow-up, we will collect questionnaire, clinical interview, and biological measures of parent and child stress (including cortisol response to a laboratory stressor), parenting, parent and child eating behavior and PA, and child BMI percentile scores. We will also collect data on parent BMI and metabolic variables (e.g., glucose). We will assess feasibility and acceptability of MBSR+N and will test initial intervention effects and determine effect sizes to plan for an adequately- powered long-term efficacy trial of MBSR+N. The study will provide: 1. Initial efficacy data for MBSR+N, 2. Pilot data for a R01 proposal to conduct a large long-term trial of MBSR+N, 3. Evidence of acceptability of MBSR+N in a real-world community clinic setting, and 4. Longitudinal data on the development of obesity in at-risk children. If effective, MBSR+N could be a novel strategy to reduce stress and obesity in high risk adults and simultaneously prevent overweight/obesity in their young children.

DESCRIPTION (provided by applicant): Obesity is a global epidemic that greatly increases chronic disease burden. Overeating of highly palatable (HP) foods, especially in the ubiquitous food cue environment and in the context of stressful life events, are known to promote HP food craving, intake and weight gain, but the differential biobehavioral mechanisms underlying these effects is unclear. Using a novel experimental paradigm, promising preliminary results indicated that brief exposure to food cue and to emotional stress increases motivation for and intake of HP snack foods in the laboratory, more so in overweight (OW/OB) than in lean (LN) individuals. Furthermore, OW/OB individuals show altered biological stress and metabolic states with different biobehavioral responses during food cue and stress exposures which predict HP food craving and intake. On the basis of these results, we propose a 5-year experimental study with a prospective 2-year longitudinal follow-up in healthy men and women categorized on the basis of lean (body mass index: BMI<25), overweight (BMI=25-29.9) and obese Class I (BMI=30-35) groups to test the hypothesis that food cue and stress will increase HP food craving and intake, and higher BMI-related metabolic and stress system adaptations will predict HP food motivation and intake, which in turn, will promote future weight gain and obesity. The specific aims are: (1) to examine if exposure to food cue and to stress vs. neutral relaxing cues differentially increase HP food craving, eating topography, emotion, hunger and alters physiological and biochemical responses, and if changes vary across BMI groups; (2) to assess differential increases in HP food intake in each condition and whether it varies as a function of BMI group; (3) to identify whether HP food craving, emotion, hunger, physiological and metabolic responses is predictive of eating topography measures, calories and weight of HP food intake in each condition; (4) to assess whether stress- and food cue-induced HP food craving, intake and laboratory responses are predictive of food motivation, dietary intake and weight gain over the 2-year follow-up period; and (5) to explore the influence of key individual differences variables of cumulative stress, eating patterns, and physical activity on stress and cue-related responses and food intake in the laboratory and on motivation for HP food intake in the two-year follow-up period. Successful completion of the project will lead to an innovative and valid method to model of HP food craving and intake in the laboratory, which may be utilized for testing novel intervention strategies to decrease high levels of food motivation, overeating and obesity risk.

DESCRIPTION (provided by applicant): NISTP: NEUROIMAGING SCIENCES TRAINING PROGRAM This institutional grant requests funds for four postdoctoral positions for interdisciplinary training and research in neuroimaging. Two general classes of neuroimaging will be emphasized: radiotracer and nuclear magnetic resonance. The specific imaging methods are described by the following acronyms: PET (positron emission tomography, MRI (magnetic resonance imaging), including fMRI (functional magnetic resonance imaging) and DTI (diffusion tensor imaging), and MRS (magnetic resonance spectroscopy). These imaging methodologies offer real promise for the expanded clinical utility of neuroimaging in the diagnosis, treatment, and understanding of the pathophysiology of substance abuse and dependence. However, these new methodologies typically derive from complex, multidisciplinary sciences, which thereby create a challenging information barrier to their further development and application in medical practice. The purposes of the proposed program are the following: - Provide formal course training to postdoctoral fellows, with an emphasis on imaging and clinical research methodology, and instruction in their underlying multidisciplinary sciences. - Provide mentored training for fellows to apply these new methods to the interdisciplinary advance of our understanding of the function of the brain in health, substance abuse, and other psychiatric diseases. - Provide an integrated research experience for the fellows both in imaging applications and in methodology. All postdoctoral fellows will be expected to complete at least one research project with an applications mentor and one with a methodology mentor during their training period. The integration of training in methodology and imaging applications will be enhanced by the organization of this program as two interactive tracks of approximately equal size: Methodology and Application. We expect that the majority of postdoctoral fellows in the Methodology track will have Ph.D. degrees, and those in the Application track, primarily M.D. degrees or Ph.D. in neurosciences or behavioral sciences. Each fellow will have a primary and secondary faculty mentor to represent the two tracks.

This Yale TL1 application has been developed to provide outstanding mentoring, educational training and support for career development to exceptional trainees in the Yale Schools of Medicine, Nursing, Public Health, and Biomedical Engineering to help them successfully pursue careers in clinical and translational research focused on improving human health. In recognition of the critical need for fostering successful career paths in all aspects of clinical and translational research for biomedical trainees at multiple points during training, we have established three programs that span both pre- and post-doctoral training for the TL1. These include: 1) The National Clinician Scholars Program that provides two years of outstanding training for postdoctoral fellows in either nursing or medicine who are focused on careers in T3-T4 translational research to improve health and healthcare policy for communities and populations; 2) The Investigative Medicine PhD Program that provides 3-5 years of rigorous PhD training for physicians who have completed their clinical training and haven chosen to pursue careers in translational (T1-T4) research; and 3) The Multidisciplinary Pre-Doctoral Training Program in Translational Research that provides predoctoral trainees in the Schools of Medicine, Nursing, Public Health and Biomedical engineering with a full year devoted to training across the full span (T1-T4) of clinical and translational research. These programs each have a rich history of successfully preparing trainees for careers in translational research. The goals of this TL1 application are to identify and to support a representative and diverse group of outstanding trainees in each of the four programs who specifically want to pursue careers in clinical and translational research; to train them in the use of state-of-the-art research tools; to facilitate their abilities to work collaboratively in complex multidisciplinary research teams; to provide outstanding mentoring (including concordant mentoring) by experienced and diverse faculty that supports long-term professional development. To facilitate these goals, we have established an educational leadership team with diverse backgrounds in clinical and translational research, and with expertise in the evaluation and dynamic reshaping of medical education programs. The leadership will work directly with both the trainees and their mentors to promote multidisciplinary team-based research that addresses complex medical and/or societal aspects of health and healthcare delivery so as to provide real and measurable positive impacts on health and healthcare in the US and around the world. To objectively judge our success in achieving these goals across such a diverse group of trainees, the leadership team has developed a logic model to clearly define the inputs of the umbrella TL1 and its three sister training programs as well as the activities of individual trainees, and to quantitatively and qualitatively evaluate both program content and achievement of short- and long-term goals by the trainees. This will allow real-time improvements in trainee support and in program content to optimize our training of the next generation of successful translational researchers.

ABSTRACT Compulsive alcohol motivation and loss of control alcohol intake are hallmark features of binge/heavy and chronic alcohol use but the mechanisms that drive this excessive alcohol consumption are not well studied. Excessive alcohol use leads to neuroendocrine adaptations in the hypothalamic-pituitary adrenal (HPA) axis and neural changes in the reward and motivation pathways which may lead to compulsive alcohol motivation and loss of control alcohol intake. In preliminary studies we find in binge/heavy (BH) relative to moderate non- binge (MD) social drinkers that altered stress and cue related cortisol responses and high subjective alcohol craving predicts compulsive alcohol motivation and intake in the alcohol taste test (ATT), used here as an implicit test of compulsive alcohol motivation and intake. Furthermore, high alcohol intake led to an increased and sensitized cortisol response and high alcohol craving only in the BH and not the MD group. Expanding on these results, we propose to develop a neuroimaging approach utilizing multiband, arterial spin labelling (ASL) measurement combined with simultaneous neuroendocrine and breath alcohol levels to test the hypothesis that high alcohol motivation and intake leads to increased cortisol responses and greater dorsal striatal blood flow which in turn predicts increased subjective craving and compulsive alcohol motivation and intake in binge/heavy (BH) relative to moderate (MD) social drinkers. Thirty-two MD and 32 BH socially drinking men and women (ages 21-45; equal gender) will be studied in a neuroimaging session to address the following specific aims: Specific Aim 1: To assess subjective and behavioral alcohol motivation and intake, CBF changes in the striatum and ventromedial prefrontal cortex (VmPFC), HPA axis and alpha-amylase response in the non-alcoholic and alcoholic beer taste test conditions in binge heavy and moderate SD groups. Specific Aim 2: To evaluate if alcohol amount and ascending breath alcohol levels predict increased cortisol and CBF response in the ventral and dorsal striatum in the BH compared to MD group. Specific Aim 3: To examine whether increased cortisol and striatal CBF and lower VmPFC CBF predict increased subjective craving and alcohol motivation and intake in post-scan alcohol taste test. Exploratory Aims: To explore sex differences in the above aims and also assess alcohol- and cortisol-related changes in brain connectivity in BH and MD groups. Using state-of-the-art neuroimaging technologies, this project promises to develop and validate a multimethod neural and neuroendocrine imaging protocol to assess whether alcohol-related glucocorticoid signaling plays a role in compulsive alcohol motivation. Successful completion of the aims could lead to new approaches for testing novel therapeutics in prevention and treatment of alcoholism.

Summary - The Yale KL2 Mentored Clinical Scholars Program began in 2006 as the educational arm of the Yale Center for Clinical Investigation. The mission remains to attract a diverse group of highly talented junior faculty across multiple disciplines in the Schools of Medicine, Nursing, Public Health and Biomedical Engineering who are interested in pursuing careers in any aspect (T1-T4) of translational research: to imbue them with a spirit of discovery; to train them in the use of state-of-the-art research tools; to give them the skills to work in complex and diverse multidisciplinary research teams; and to support their professional development. This Program has been highly successful, attracting to date 105 Scholars who have successfully competed for more than 140 individual NIH awards and of whom 98% have gone on to positions in academia or industry after completion of the Program. Going forward we seek to build on this exciting success in developing the next generation of translational researchers by promoting our core strengths of strong mentor/mentee relationships, outstanding learning opportunities, and strong programs for career development while simultaneously encouraging even greater numbers of this diverse group of Scholars to participate in multidisciplinary team science, community-based participatory research, and industry-academia partnering. To oversee these diverse and highly motivated junior investigators, we have established an educational leadership team consisting of 3 premier investigators with strong mentoring skills and expertise in different areas of translational research, along with 2 outstanding education experts with expertise in the evaluation and dynamic reshaping of medical education programs. The leadership team will work directly with Scholars and their mentors to develop programs in team-based research that address complex medical and/or societal problems of health and healthcare delivery, and to use this research to solve problems in patient care in ways that provide real and measurable positive impacts on health in the US and around the world. In recognition of the complexity of the research needs and the career paths of these Scholars, the leadership team has adopted a logic model to track and evaluate the activities of the Scholars, track the success of the program, and continuously improve the program to meet the Scholars' needs. With these new additions to an already strong curriculum, we believe that the Yale Mentored Clinical Scholars Program will be ideally positioned to train the next generation of representative and diverse translational researchers as they navigate the rapidly changing healthcare challenges and opportunities inherent in successfully performing outstanding clinical and translational research.

ABSTRACT Childhood obesity is a significant public health problem that predisposes to adult obesity and serious obesity-related diseases. Obesity is particularly common in low-income families and children of obese parents, who also report higher levels of stress. High stress in parents is associated with decreased physical activity, overeating, and increased weight in parents and their children. While nutrition and behavioral preventions have been tested for low-income families, parent stress has not been targeted in highly stressed, low-income obese parents of at-risk preschoolers. In a previous pilot R21 project, we developed a novel program, Parenting Mindfully for Health, that targets parent stress and includes Nutrition and physical activity counseling (PMH+N), to reduce stress, improve parenting and healthy family choices to prevent childhood obesity in 2-5-year-old children. Findings indicated that PMH+N is feasible, acceptable, and improved parent stress and parenting to prevent increases in child body mass index (BMI) percentile relative to the contact Control with Nutrition (C+N). Building on promising preliminary findings, we now propose a 5-year R01 project to assess PMH+N vs. C+N in a large sample of parent-child dyads, and including a long-term 2-year follow-up to establish enduring effects of PMH+N on reducing parent stress, improving parenting to promote healthy eating and physical activity (PA) in parents and children, and in turn, prevent childhood obesity risk in preschoolers from highly-stressed, low- income families. Low-income, highly-stressed, obese parent-child dyads (N=240, children aged 2-5) will be randomly assigned to receive a 12-week PMH+N or C+N intervention and participation in a Toy Wait Task(TWT) challenge to assess observed parent-child interaction as a bio-behavioral measure pre/post intervention to assess parenting and stress responses. The following specific aims will be addressed: (1) test the efficacy of 12-week PMH+N vs. C+N in reducing parent stress and improving parenting and health behaviors in parent and child to decrease childhood obesity risk; (2) examine parent stress response, observed parenting, and family food intake and physical activity as mediators of PMH+N vs. C+N effects on parent and child BMI; (3) examine the enduring effects of PMH+N vs. C+N on parenting and health behaviors and child BMI percentile in reducing obesity risk over a 2-year follow-up period; and (4) examine the enduring effects of changes on parent stress, parenting and health behaviors, parent weight and metabolic functioning post intervention during 2-year follow-up. Successful completion of the proposed interdisciplinary project will provide support for an innovative approach to decrease early childhood obesity risk in low-income, stressed families while also addressing stress and obesity in high-risk adult parents. Findings will provide critical longitudinal data on parent stress and family and parenting factors in the development of obesity in at-risk children, that may inform future public health interventions to curb the growing epidemic of obesity in children and adults.

PROJECT SUMMARY/ABSTRACT Alcohol Use Disorder (AUD) is a chronic relapsing illness associated with high rates of relapse and in which there is great need to develop and evaluate novel treatments to decrease relapse rates and the associated burden of AUD. This application proposes a novel, mechanistic combined laboratory and clinical outcome study to examine whether the neuroactive steroid precursor Pregnenolone (PREG) via its conversion to the potent GABAergic neuroactive steroid Allopregnanolone (ALLO) decreases provoked alcohol craving and anxiety, normalizes stress dysregulation, and improves cognitive flexibility and alcohol use outcomes in treatment seeking individuals with AUD. Previous research by our group and others has shown that chronic alcohol abuse dysregulates brain stress pathways including the hypothalamic pituitary adrenal (HPA) axis responses and is associated high provoked alcohol craving, anxiety, and cognitive flexibility, which in turn, are predictive of subsequent alcohol relapse and clinical outcomes. Promising new preliminary findings from our laboratory indicate that potentiating ALLO via administration of its precursors, including PREG, may reverse such stress-related disruptions and decrease alcohol craving and relapse risk. However, the mechanism by which PREG, and the specific doses at which it may potentially decrease alcohol craving and relapse risk is not known. On the basis of these findings, we propose a proof-of-concept 4-year, randomized, double-blind, dose dependent laboratory and clinical study to evaluate the preliminary efficacy of PREG treatment (200/400 mg/day for 8 weeks) versus placebo (PBO) in 90 AUD men and women. The following specific aims will be addressed: Aim 1: To evaluate the safety/tolerability of 200mg and 400mg/daily of PREG in AUD individuals. Aim 2a: To evaluate the effects of PREG doses (PBO, 200 and 400 mg/day) on ALLO levels and on experimentally provoked craving, HPA dysregulation, anxiety, mood and cognitive flexibility in AUD patients. Aim 2b: To assess whether PREG-stimulated ALLO levels mediate its effects on provoked craving, HPA dysregulation, anxiety, mood and cognitive flexibility in the laboratory component. Aim 3a: To assess the preliminary efficacy of 8-week PREG doses versus PBO treatment on primary alcohol use outcomes and secondary outcomes of alcohol craving, anxiety and negative mood. Aim 3b: To assess whether PREG- stimulated ALLO levels mediate its effects on primary alcohol use outcomes and on secondary clinical outcomes during the 8-week treatment phase. Exploratory Aim: To explore whether pre-treatment patient characteristics (gender, family history of alcoholism (FH), trauma history and co-morbid drug use) influence PREG-potentiated ALLO levels and primary and secondary alcohol use outcomes. Successful completion of the proposed aims has the potential to support further development of novel neuroactive steroid targets such as PREG and ALLO in the treatment of AUD, particularly to target chronic alcohol-related stress dysregulation, alcohol craving and high alcohol relapse risk.

Abstract Substance Use Disorders (SUDs) present a serious public health problem with significant health-related morbidity, and no FDA-approved treatments target cocaine use disorder (CUD) or co-occurring substance abuse. A major obstacle to SUD treatment are the high relapse rates, and high drug craving and reduced cognitive flexibility, particularly in stress, drug cue and challenge contexts, are target processes that contribute to such high relapse rates. Furthermore, CUD women show greater drug craving and poor cognitive flexibility during stress and drug cue challenge contexts, and preliminary data show that treatment with the alpha-2 adrenergic agonist, Guanfacine (GUA) at 3mg/s day versus placebo (PBO) reverses these effects in CUD women but not men. Preliminary data also show that GUA 3 mg/day vs. PBO led to higher drug-negative urines in an 8- week outpatient setting in CUD women than men. On the basis of this previous development work, we propose a 3- year R01 pilot clinical and laboratory outcome study to test the overall hypothesis that GUA (3mg/day) will reduce target drug craving and improve cognitive flexibility processes in CUD women, and that such targeted engagement will result in lower cocaine and other drug use outcomes in women with CUD. One hundred treatment seeking CUD women will be randomly assigned to GUA (3 mg/day) vs Placebo (PBO) over a 10-week clinical trial across 2 sites (N=50 per site), and will also be assessed in a pre-treatment and week 9 laboratory challenge test with exposure to stress and drug cue provocation. The primary target engagement outcome will be reduction in drug craving and improved cognitive flexibility and the primary target validation outcome will be reduced cocaine use as measured by percent negative drug urines and last three weeks of abstinence. The following aims will be addressed. Aim #1 - Target Engagement: To examine whether GUA will reduce drug craving and improve cognitive flexibility in laboratory challenge and in clinical assessments over the 10-week period. Aim #2: Target Validation: To evaluate whether GUA vs PBO effects on drug craving and cognitive flexibility significantly predicts CUD clinical outcomes in the 10-week trial. Aim #3: Data Replication and Scalability: To replicate target engagement and validation outcomes across two sites (Yale and SUNY-Stony Brook) and inform scalability for larger clinical trials. Exploratory Aim 1: To explore GUA?s role in mediating the relationship between target drug craving and cognitive flexibility processes and cocaine use and other drug use outcomes. Exploratory Aim 2: To explore the role of co-morbid psychiatric symptoms (mood, anxiety and PTSD) in moderating the proposed target engagement and validation processes. Acknowledging the heterogeneity in CUD and significant sex differences, this project utilizes an experimental therapeutics approach to further develop and test whether GUA?s targeted effects on drug craving and cognitive flexibility impacts substance use clinical outcomes, thereby providing critical data on whether such a personalized medicine approach to the development of GUA in the treatment of women with CUD is warranted.

ABSTRACT The United States is at the forefront of the global obesity epidemic. To understand the mechanisms driving increases in obesity, this first cycle of the R01-DK099039 project developed and validated a novel laboratory model for overeating highly palatable (HP) foods in the context of HP food cue and stressful environments, both of which are associated with weight gain and obesity risk. Findings supported that BMI-related adaptations in cortisol, ghrelin, insulin sensitivity, HP food craving and hunger each predicted HP overeating in a Food Snack Test (FST) in a laboratory experiment, and remarkably, these measures also prospectively predicted weight gain over a longitudinal 2-year outcome period. Recent data suggests glucagon-like peptide-1 (GLP-1) modulates stress biology along with its effects on metabolism. Preliminary work by led by Dr. Jastreboff indicate GLP-1 analogue (GLP-1a) treatment decreases craving, hunger and food intake in both the laboratory and real-world setting. Thus, in this competitive renewal, we propose a multi-PI experimental therapeutics approach with the GLP-1a, semaglutide, in the unique and predictive laboratory model developed in the current project to test the hypothesis that GLP-1a treatment will attenuate HP food cue- and stress-induced food motivation and intake in obesity and also improve metabolic and stress responses and such changes will predict weight outcomes. A randomized, double-blind, placebo-controlled 12-week study with GLP-1a in men and women (N=96) with obesity (BMI 30-39.9 kg/m2) is proposed to test the above overall hypothesis both in a laboratory experiment and over a 12 -week treatment period to assess real-world outcomes. Specific aims are: 1) to examine the effects of GLP-1a vs. PBO treatment on food craving, hunger, food-cue- and stress- induced FST intake and eating topography in the FST; 2) to assess the effects of GLP-1a vs. PBO treatment on weekly food craving and food calorie intake in the real-world setting during the 12-week treatment period; and 3) to examine the effects of GLP-1a treatment on metabolic and stress responses (ghrelin, cortisol, and insulin resistance) on HP food craving and intake in the experimental lab model of food craving and FST intake. Exploratory aims will GLP-1a changes in laboratory outcomes predict weight outcomes and whether specific factors such as gender, chronic stress, disordered eating, diet and physical activity affect outcomes. Utilizing a novel experimental therapeutics approach, the next phase of this project will apply the current cycle?s validated laboratory model of identifying processes underlying greater HP food craving, intake and weight gain to test mechanisms by which a GLP-1a analogue exerts significant weight effects in obesity. Positive findings will not only inform how GLP-1a exerts effects on weight, but also provide a unique, stress and food cue sensitive, innovative and cost-effective human laboratory approach for testing novel therapeutics to decrease HP food craving, overeating and weight gain.

Project Abstract Alcohol Use Disorder (AUD) is a chronic relapsing illness in which alcohol withdrawal symptoms (AW) are associated with greater treatment failure risk and higher rates of relapse and alcohol intake. Efficacy of current approved medications in AUD are modest, and none have been shown to be efficacious in those with AW. Thus, there is great need to develop and evaluate treatments to address specific prognostic indicators of high relapse and treatment failure to reduce the associated burden of AUD. Based on this previous clinical research, we hypothesized that in AUD patients with AW (AUD+AW), PR (16 mg/day) compared to PBO will significantly improve alcohol use outcomes, craving and also reduce associated anxiety and depression symptoms and improve physical health (SBP and liver enzymes) functioning and patient-related outcomes during the course of the trial and with enduring effects during over a 3 month follow up period, thereby validating AW as a prognostic indicator both of Prazosin efficacy and in AUD treatment outcome. A 12-week Phase II, single site, randomized clinical trial of Prazosin (PR: 16 mg/day, t.i.d dosing) is proposed in 150 treatment seeking men and women with AUD+ AW (3 or more symptoms) to address the following specific aims: Aim #1: To evaluate the effects of PR vs PBO on the primary alcohol use outcome of percent of subjects with no heavy drinking day (PSNHDD) and secondary drinking outcomes of %heavy drinking day (HDD%), any drinking day (DD%) and average drinks/day (AvgD) in AUD+AW patients. Aim #2: To assess the effects of PR vs PBO on other secondary stress-related outcomes of alcohol craving, depression and anxiety symptoms during the trial. Aim #3: To assess enduring short-term treatment effects of PR versus PBO on primary and other secondary outcomes at 1- and 3- month post-treatment follow-up time points. Exploratory Aim 1: To assess the effects of PR vs PBO treatment during the trial and at follow up on secondary physical health (SBP/DBP and liver enzymes) and patient-reported functioning outcomes. Exploratory Aim 2: To explore whether pre-treatment patient characteristics (gender, adversity/trauma history and lifetime PTSD) influence Prazosin effects on primary and secondary alcohol use and related outcomes. Prazosin is a commonly prescribed medication that most clinicians feel comfortable using. If successful, findings will provide important efficacy data on Prazosin?s role in AUD+AW treatment and in related secondary psychological and physical health outcomes. It will further validate AW at outpatient treatment entry as a prognostic indicator for AUD treatment and for Prazosin use among AUD+AW subgroup of patients. It will also support development of the precision medicine goal of providing specific treatment options for AUD patients with AW and stress-related pathophysiology to improve their AUD treatment outcomes.

The Yale TL1 provides support for the training, mentoring and career development of exceptional trainees across the relevant communities within Yale (Medicine, Nursing, Public Health, Biomedical Engineering, Psychology) to prepare them to successfully pursue careers in research focused on improving human health, reducing health disparities, and improving health systems. In recognition of the critical need to foster the development of young investigators at multiple points during training, we established four training opportunities within our program that span pre- and post-doctoral training. Each of these programs builds on a remarkable track record of accomplishment, but each is also newly adapted to respond to the current educational context and the emerging research opportunities. In so doing, our training programs embrace education in team learning, data science and organizational practice so as to prepare the next generation of translational researchers to emerge as leaders. These 4 programs, presented as specific aims include: 1) The National Clinician Scholars Program (NCSP) that provides two years of outstanding training for post-doctoral fellows in either nursing or medicine who are focused on careers in T3-T4 translational research to improve health and healthcare policy for communities and populations; 2) The Investigative Medicine PhD Program (IMP) that provides 3-5 years of rigorous PhD training for physicians who have completed their clinical training and haven chosen to pursue careers in translational (T1-T4) research; and 3) The Multidisciplinary Pre-Doctoral Training Program in Translational Research (MPreDTP) that provides pre-doctoral trainees in the Schools of Medicine, Nursing, Public Health and Biomedical engineering with one or two full year devoted to training across the full span (T1-T4) of clinical and translational research. 4) The Multidisciplinary Post-Doctoral Training Program in Translational Research (MPostDTP) that provides post-doctoral PhD trainees in the Schools of Medicine, Nursing, Public Health and Biomedical engineering with one or two full years devoted to training across the full span (T1-T4) of clinical and translational research. The objectives of this TL1 application are to: 1) identify and support a representative and diverse group of outstanding trainees for entry into the appropriate one of these four programs; 2) provide them with a strong multidisciplinary education anchored in courses offered through degree-granting programs; 3) provide a mentored translational research experience in a biological, social behavioral, community-engaged and/or public health domain; 3) provide training and hands-on experience in multidisciplinary team science; 4) provide ongoing mentoring in how to conduct meaningful translational research and in support of their career development; 5) provide instruction to increase their abilities to translate research into real-world contexts to impact policies and practices for interventions and preventive practices that affect health; and 6) to objectively evaluate the umbrella TL1, its four training programs, and achievement of short- and long-term goals by the individual trainees in order to modify the TL1 activities accordingly. Team-based approaches to research are specifically emphasized by providing year-long didactic training in team science and team building, coupled with inter-program experiential team research performed jointly by the TL1 and KL2 trainees.