Conditions: Cocaine Use Disorder Anxiety
Keywords: cocaine sleep anxiety craving addiction orexin cue reactivity suvorexant Belsomra
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 20
Healthy volunteers: no

Brief summary:
The purpose of this study is to determine the effectiveness of a medication called suvorexant in reducing anxiety, improving sleep, and reducing cocaine cravings or cocaine use.

Detailed description:
Preclinical research has established important functions for the orexin system in mediating arousal/sleep, stress, and cue-induced reinstatement of drug taking (e.g., relapse). The role of stress/anxiety and drug cue reactivity in human drug relapse is well established, but to date, the role of the orexin system in modulating these phenomena has not been examined in humans with substance use disorders (e.g., cocaine). The goal of the present first-in-human study will be to examine the effects of an orexin antagonist (suvorexant) on interactions among stress/anxiety, sleep, and drug-cue reactivity. The study will utilize a battery of highly sensitive, drug-specific, laboratory measures of drug cue reactivity (a relapse risk model), and well-established metrics of stress/anxiety and sleep. The hypothesis is that antagonism of the orexin system will attenuate the link between (1) stress/anxiety and drug cue reactivity, and (2) sleep and drug cue reactivity. These results will elucidate a unique biochemical mechanism for understanding relapse, and provide a potential medication target for relapse prevention.

Arms:
arm 1: Subjects will receive suvorexant (10 mg week 1, 20 mg week 2), once daily at 10 PM. arm 2: Subjects will receive placebo once daily at 10 PM.

Interventions: intervention 1: suvorexant intervention 2: Placebo (for suvorexant)
Intervention descriptions: intervention 1: Subjects will receive suvorexant capsules (10 mg week 1, 20 mg week 2), once daily at 10 PM. intervention 2: Subjects will receive placebo capsules once daily at 10 PM.

Protocol document:
Prot_SAP_000.pdf: 
IRB NUMBER: HSC-MS-16-0120 
IRB APPROVAL DATE: 04/25/2017 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Role of the orexin receptor system in stress, sleep and cocaine use 
 
NCT02785406 
 
Version Date: 04/25/2017 
 
 


IRB NUMBER: HSC-MS-16-0120 
IRB APPROVAL DATE: 04/25/2017 
 
Title:  Role of the orexin receptor system in stress, sleep and cocaine use 
 
Principal Investigator: 
Scott D. Lane 
Co-Investigators: 
Joy M. Schmitz, Charles E. Green, Jin H. Yoon, Michael F. Weaver 
 
 
ABSTRACT 
 
Preclinical research has established important functions for the orexin system in mediating 
arousal/sleep, stress, and cue-induced reinstatement of drug taking (e.g., relapse). The role of 
stress/anxiety and drug cue reactivity in human drug relapse is well established, but to date, the role of 
the orexin system in modulating these phenomena has not been examined in humans with substance use 
disorders (e.g., cocaine). The goal of the present first-in-human study will be to examine the effects of an 
orexin antagonist (suvorexant) on interactions among stress/anxiety, sleep, and drug-cue reactivity. We 
will utilize a battery of highly sensitive, drug-specific, laboratory measures of drug cue reactivity (a 
relapse risk model), and well-established metrics of stress/anxiety and sleep. We hypothesize that 
antagonism of the orexin system will attenuate the link between (1) stress/anxiety and drug cue 
reactivity, and (2) sleep and drug cue reactivity. These results will elucidate a unique biochemical 
mechanism for understanding relapse, and provide a potential medication target for relapse prevention 
 
 
SCIENTIFIC IMPACT 
 
Given the promising preclinical data on the orexin system in modulating sleep, anxiety, and drug cue 
reactivity, this research project has high translational scientific value. Several recent publications make a 
strong argument for the importance of the orexin system in addictions. This project is innovative in two 
important ways (a) use of a laboratory-based, multivariate measurement approach, and (b) it will 
represent a first-in-human substance abuser research study of the orexin system. Successful completion 
of this project is assured by a strong team of investigators, and a highly coordinated research team with a 
strong track record in addictions research, integrated via our UT-supported center of addictions research 
(CNRA). Confirmation of the study hypotheses will advance the field by (a) elucidating the role of the 
orexin system as a neurobiological factor in addiction, and (b) providing a target biochemical system for 
the development of pharmacotherapeutics. 


IRB NUMBER: HSC-MS-16-0120 
IRB APPROVAL DATE: 04/25/2017 
 
Role of the orexin receptor system at the nexus of stress, sleep and drug abuse 
 
PROPOSAL 
 
Significance of the problem. Stimulant dependence continues to be a significant public health 
problem with no FDA-approved options to facilitate abstinence or prevent relapse. Of the stimulants, 
cocaine presents the largest burden to the healthcare and criminal justice systems in terms of mortality, 
morbidity, violent crime, and unemployment – and this trend has not declined significantly for decades 1- 
3.  Prevalence rates in North America approach 6.5 million users, 40% of whom meet diagnostic criteria 
for cocaine use disorder, or CUD 2,4. CUD leads to persistent disruption of neurotransmitter function 
corresponding to a state of “allostatis” that manifests in cognitive deficits, compulsive drug use, loss of 
control over drug-taking, and repeated relapses despite the desire to quit 5. Even current treatments are 
marked by high relapse rates 6,7, prompting a need for innovative and novel neurobiological research, and 
eventually new treatment options. 
Stress/anxiety in addiction. Stress and anxiety contribute substantially to all phases in the 
development of SUD: from risk for binge use, to the onset of dependence, to triggering relapse. 
Importantly, stress and anxiety increase the magnitude of drug-cue reactivity, and serve as risk factors 
for both the initiation of substance use and addiction relapse 8-10. The use of illicit substances to reduce 
physiological and psychological stressors has been extensively characterized across laboratory, clinical, 
and epidemiological domains 11-13. Lifetime stress is significantly associated with cocaine use severity 14. 
Sleep in addiction. Sleep architecture is disrupted in chronic stimulant use – including cocaine, 
including both slow-wave and REM sleep 15-18. These alterations produce deficits in total sleep, and are 
associated with exacerbation in psychiatric symptoms and cognitive functions 18,19. Importantly, there is 
a reciprocal relationship between cocaine use severity and sleep quality and duration, creating a viscous 
cycle of impaired sleep, increased stress, and increased risk for cocaine use 14,20,21. Previous work 
revealed that the medication modafinil significantly reduced cocaine-free urines over 6-weeks, and 
increases in slow wave sleep time mediated the drug effect 19. The foregoing suggests that medications 
that improve sleep quality can aid in reducing substance use, and sleep enhancement is a documented 
SUD treatment strategy 20. 
Drug cue reactivity, addiction and relapse. Drug cue reactivity is a well-documented and robust 
predictor of relapse. This relationship has been established for a variety of abused drugs, including 
cocaine. Craving and attentional bias are two of the best-documented indices of reactivity to drug cues. 
Both cue-induced craving and attentional bias have been identified as factors in nearly every major drug 
of abuse, and both are predictive of relapse following treatment 22-26, including cocaine 27-31. Indeed, 
physiological, neural, and attentional response to drug cues are now considered hallmark characteristics 
of addiction 32,33. The neurobiological overlap and documented correlations between drug craving and 
attentional bias 34-36 are likely because they are measures of the same construct (cue reactivity) and are 
modulated largely by the same neurocircuitry. Both cue-induced craving and attentional bias are 
amenable to pharmacological modulation 37,38, supporting cue-reactivity as a relevant target for 
pharmacological interventions in CUD. 
Novelty and promise of the orexin system.  The orexins are a class of recently discovered amino 
acid peptides concentrated in the hypothalamus with projections widely distributed throughout the 
brain. Two orexin receptors (OXR1, OXR2) have been identified. The orexin system is neuromodulatory, 
increasing neural action potentials via the regulation of glutamate and GABA. Its primary role appears to 
be in energy homeostasis (e.g., arousal, vigilance). Accordingly, antagonism (blockade) of OXR1 and 
OXR2 promotes sleep 39,40. In addition, there is strong preclinical and phase 1 evidence that orexin 
antagonists modulate three key cocaine-related variables documented above: sleep 39,40, stress/anxiety 41- 
43, reactivity to stimulant drug cues, including cocaine 44-47. Only one approved FDA compound with 
specificity for the orexin receptor system (suvorexant) is currently available in the US market. It is 
indicated for treatment of insomnia. We propose that, due to the ability to regulate stimulant drug-cue 
reactivity, anxiety/stress, and sleep, suvorexant is an intriguing and potentially efficacious compound for 
the prevention of relapse in CUD. 


IRB NUMBER: HSC-MS-16-0120 
IRB APPROVAL DATE: 04/25/2017 
 
Summary. Medications that attenuate drug cue reactivity (attentional bias, craving), reduce 
stress/anxiety, and enhance sleep quality may be effective pharmacotherapeutics for SUD. As these three 
factors all contribute to relapse, orexin receptor antagonists may be ideally suited to address the dynamic 
interaction of these factors, thereby helping in the prevention of relapse. 
 
Overall Aim. According to the conceptual model posited in Figure 1, the overarching aim of this 
project is to conduct a first-in-human drug user study to examine the effects of the orexin antagonist 
suvorexant on drug-cue reactivity and its interactions with stress/anxiety and sleep. 
 
HYPOTHESES and SPECIFIC AIMS 
1. Main effect: To characterize the direct effect of suvorexant on drug cue reactivity. We 
hypothesize that suvorexant will significantly attenuate cocaine cue reactivity (attentional bias, craving). 
2. Stress/anxiety interaction: To characterize the degree to which stress/anxiety mediates 
the effect of suvorexant on drug cue reactivity. We hypothesize an indirect effect of suvorexant on drug 
cue reactivity via stress/anxiety, such that attenuation of cocaine cue reactivity (attentional bias, craving) 
will be greater in those with larger reductions in stress/anxiety duration. 
3. Sleep interaction: To characterize the degree to which sleep mediates the effect of 
suvorexant on drug cue reactivity. We hypothesize an indirect effect of suvorexant on drug cue reactivity 
via sleep, such that attenuation of cocaine cue reactivity (attentional bias, craving) will be greater in those 
with larger improvements in sleep duration. 
 
Figure 1. Summary of Conceptual Model 
 
 
 
 
 
 
 
 
 
 
 
Research Plan 
 
Our group at the University of Texas Center for Neurobehavioral Research on Addiction (CNRA) has 
developed, utilized, and validated laboratory models of drug relapse, allowing us to examine 
pharmacotherapeutic and cognitive-behavioral interventions for relapse prevention. 
 
Study design.  To accomplish the project aims, we will utilize a mixed-model experimental design, with 
a between-groups factor of dose (suvorexant vs. placebo) and a within-subjects factor of time. Subjects 
will receive suvorexant (10 mg week 1, 20 mg week 2) or placebo PO, once daily at 10 PM. Medication 
condition will be double-blind, with urn-randomized assignment to dose condition balanced by gender 
and severity of cocaine use. A summary of timelines and measures is shown in the Table below. 
 
Mon 
Wed 
Fri 
Mon 
Wed 
Fri 
Mon 
1,4,5,6,7 
1,2,3,4,5 
1,2,3,4,5 
1,2,3,4,5,6,7 
1,2,3,4,5 
1,2,3,4,5 
1,2,3,4,5,6,7 
Key: (1) Provide medication (MEMS bottle); (2) Compliance data for medication adherence (MEMS, pill 
count, riboflavin, text message); (3) Side effects data, med check, UA toxicology; (4) Sleep data; (5) 
stress /anxiety data; (6) acute stressor challenge (cold pressor); (7) Cue reactivity data 


IRB NUMBER: HSC-MS-16-0120 
IRB APPROVAL DATE: 04/25/2017 
 
Participants and setting. The study will test 30 current cocaine users (enroll 45 to complete 30), 19 
to 55 years old, who meet current DSM-5 criteria for cocaine use disorder (CUD) of at least moderate 
severity (≥4 symptoms). Subjects meeting criteria for substance use disorders other than cocaine, 
marijuana, or nicotine will be excluded. Notably, because the study medication (suvorexant) is 
contraindicated with alcohol use, we will exclude subjects with alcohol use disorders (via screening at 
intake). We will also exclude those individuals who are drinking > 10 alcoholic drinks per week (NIAAA 
criteria problem drinking = at least 14 drinks per week), and who are unwilling to stop using alcohol in 
the evening for the two weeks of the study. We will exclude those who report binge drinking (NIAAA 
criteria = in < 2.5 hours, 5 drinks for men, 4 drinks for women). 
Other exclusion criteria will include significant and unstable medical/ psychiatric disorders which 
might make participation hazardous; acute or chronic health conditions; and concomitant medication 
use contraindicated with the study medication (suvorexant). This will be accomplished via full medical 
evaluation at intake by Dr. Michael Weaver, M.D., CNRA Medical Director. The study will be conducted 
at the Neurobehavioral Research Laboratory at the CNRA, directed by Dr. Lane. Recruitment strategies 
will include local advertising in print media, public service announcements on radio, and referrals to 
CNRA in the Houston metropolitan area. Based on previous and current CNRA recruitment rates of 
participants with CUD, we expect to enroll 3-4 participants per month to meet recruitment goals. 
 
Measurements 
Cue reactivity: Attention bias (AB) task is a saccade-based eye-tracking measurement, developed 
by Dr. Lane to assess attentional bias to drug cues 48. Eye movements (saccades) have advantages over 
other variables because they are directly observable, ecologically valid, and typically stable across 
repeated measures 49,50. AB measures utilizing eye movements have produced moderate to robust effects 
for a broad class abused substances 51-53, including cocaine 34,48,54. Using our drug specific anti-saccade 
task, the between-group effect size for anti-saccade error rates in the presence of cocaine cues was large: 
CUD vs. control Cohen’s dav  = 0.6 48. 
Cue Reactivity: Cocaine Craving Questionnaire (CCQ, 55) is self-report 14-item measure with five 
conceptual domains: Desire to Use, Intention to Use, Anticipation of Positive Outcome, Anticipation of 
Relief from Dysphoria, and Lack of Control over use. The measure is well validated and has been used in 
multiple studies of CUD 55,56. 
Sleep: Misft Shine (Misfit © 2012). Sleep activity is monitored with a 3-axis accelerometer inside 
the watch device, using a general heuristic based on time and motion. The two primary data outcomes 
from sleep mode are total sleep and sleep quality (deep sleep duration). The device is waterproof and 
worn on the wrist 24 hrs per day. Data are downloaded to smartphone via Bluetooth. 
Sleep: Pittsburg Sleep Quality Index (PSQI, 57). The PSQI is an 18-item self-report measure of 
sleep, providing a well-validated and reliable measure of sleep quality, latency, duration, duration 
efficiency, and disturbance, and an overall summary. It has been used in several studies of individuals 
with SUD, including cocaine 21,58,59. 
Stress/Anxiety: Cold Pressor Test (CPT). The CPT reliably increases activity of the sympathetic 
nervous system and the HPA axis, and produces reliable increases in heart rate and cortisol 75, 76. 
Subjects are requested to submerge the dominant arm up to the wrist or elbow in ice-cold water (0° to 4° 
C) for as long as possible with a maximum of 90 seconds. The procedure activates afferent nerves and 
elicits a CNS stress response 75, 76, 77. This procedure produces no lasting biological or psychological 
distress beyond the acute challenge period, and physiological effects return to baseline within 90 min 78. 
In fact, the CPT is used to study pain in children 79, and is considered a noninvasive, exempt educational 
experimental activity by the IRB of the University of Texas-Austin 80. It has been used extensively in 
cardiology, endocrinology, psychiatry, and psychology since 1940 as a challenge to the peripheral and 
central stress axis 75, 76. 
Stress/Anxiety: DASS21 60 is a 21-item self report questionnaire assessing the severity of clinically 
agreed upon core depression, anxiety, and stress symptoms. It is well validated in multiple languages and 
countries 61, and has been utilized in SUD treatment and withdrawal studies 62-64. 
Stress/Anxiety: VAS-Stress: current stress level is ranked on a 0 – 10 visual analog scale (0 = no 
stress, 10 = extreme stress) cued by the question “Please rate your current stress level”. We have utilized 
this measure in previous studies of stress and SUD in our lab 48,65. 


IRB NUMBER: HSC-MS-16-0120 
IRB APPROVAL DATE: 04/25/2017 
 
Medication compliance. Because the medication must be taken in the evening, compliance is a 
high priority. Accordingly, we will use a four-level approach to measurement of compliance: (1) Medical 
Event Monitoring System (MEMS, Aprex Corp.) bottles, (2) pill counts, (3) riboflavin markers, and (4) 
text reminders / replies. Text-based reminders to take the medication will be enabled via using a HIPAA 
secure texting service (Talksoft ©), used broadly in medical settings. Participants will be prompted each 
night at 10 PM to take their medication, and instructed to text back “yes” when they have taken their 
medication. Compliance-based payment contingencies (M, W, F): 4/4 = 100%, 3/4 = 75%, 2/4 = 50%, 
etc.  These contingencies produce high compliance based on previous work in our laboratory using 
similar designs, where compliance rates averaged near 90% 66,67. 
 
Data Analyses.  We will use multilevel modeling to evaluate cue reactivity (attentional bias, craving) as 
a function of suvorexant, time, and the interaction of suvorexant x time. Hypothesis evaluation will 
utilize both Frequentist and Bayesian methods. Power and sample size focus on the effect of suvorexant 
on drug cue reactivity (AB, CCQ). From a Frequentist perspective, assuming a correlation of r = 0.5 
between measurement points and alpha = 0.05, a sample of N=30 participants will provide 80% power 
to detect a moderate effect (Cohen’s f= .0.24) for the interaction if treatment and time. For Bayesian 
analyses, multilevel priors will be vague and neutral: coefficients ~Normal (mean = 0, variance = 1x106), 
level 1 variance ~ Gamma (shape=.001, scale=.001), level 2 variances ~ Uniform (0,100). Frequentist 
statistical models will utilize traditional mediation analyses as recommended by Baron and Kenny 68, 
which permits unbiased OLS estimates appropriate for this experimental design and sample size 69, and 
which we have utilized in previous published research 70. Bayesian statistical models will utilize path 
analysis (BSEM) to evaluate the mediating effects of stress/anxiety (biological and subjective-rated) and 
sleep (biological and subject-rated) for the effects of suvorexant on drug cue reactivity. An example of a 
mediation analysis using Bayesian SEM may be found Arbuckle 71. Uncertainty surrounding the Bayesian 
estimate for the indirect effect employs the posterior distribution of the parameter (i.e. the product 
coefficient): a density denoting the probability that different values of the parameter obtain given the 
observed data. This approach may be particularly important for evaluating more complex mediation 
models (e.g. multiple mediators, latent variables) in the context of small sample sizes. Use of the MCMC 
(Monte Carlo Markov Chain) approach in Bayesian analyses has demonstrated superior small sample 
performance relative to maximum likelihood-based approaches in continuous, normally distributed data 
72. These properties are likely due to the MCMC approach’s lack of reliance on large sample size 
assumptions 73. BSEM prior specification will adapt recommendations from Muthén and Asparouhov 74. 
 
Subject Payment. The payment schedule is detailed below. Subjects will be paid the medication 
compliance, study visit bonus, and participation earnings at the end of each experimental day (M, W, F). 
Subjects will receive an additional bonus ($50) for completing of the study. Total possible payment for 
meeting all study requirements and collecting all bonus payments will be $337. 
Medication compliance. $2 for each metric: 1) Medical Event Monitoring System (MEMS) bottle 
opening, (2) pill counts (empty bag), (3) positive riboflavin markers, and (4) text reply to reminder. 
Absence of each will result in payment not being earned for that specific metric. Total possible payment = 
$8 per day X 14 study days = $112. Study visit bonus. $10 for on time arrival and providing an alcohol- 
free breath sample and urine sample. Total possible payment = $10 per day X 7 visit days = $70. 
Participation. Total possible payment = $15 per day X 7 visit days = $105. Completion bonus $50. 
 
Subject participation requirements.  Subjects must take the medication as close as possible to 
10:00 PM each evening, and reply “yes” to the medication text prompt (texts will be sent at 15-minute 
intervals from 9:45 PM to 10:30 PM). On M, W, F over 2 consecutive weeks (see Study Design), subjects 
will visit the lab at 10 AM. At every visit, they will provide the following: medication update (MEMS 
bottle), side effects data questionnaire, med check up with nurse, UA fluorescence and toxicology, sleep 
data (wrist monitor and sleep questionnaire), and stress/anxiety questionnaires. The visit will take 
approximately 1 hour. In addition, on each Monday (day 1, 7, and 14) subjects will complete: (1) the cold 
pressor test (with cardiovascular measures and saliva sample for cortisol level), (2) the saccade-based 
attentional bias test, and (3) the cocaine cue reactivity questionnaire. On these three study days, the visit 
will take approximately 2 hours. 


IRB NUMBER: HSC-MS-16-0120 
IRB APPROVAL DATE: 04/25/2017 
 
Data Safety Monitoring Plan 
E1. Human Subjects Involvement and Participant Characteristics 
The study will test 30 current cocaine users (enroll 45 to complete 30), 19 to 55 years old, who 
meet current DSM-5 criteria for cocaine use disorder (CUD) of at least moderate severity (≥4 symptoms). 
Subjects meeting criteria for substance use disorders other than cocaine, marijuana, or nicotine will be 
excluded.  Notably, because the study medication (suvorexant) is contraindicated with alcohol use, we 
will exclude subjects with alcohol use disorders (via screening at intake). We will also exclude those 
individuals who are drinking > 7 alcoholic drinks per week, and who are unwilling to stop using alcohol in 
the evening for the two weeks of the study. Other exclusion criteria will include significant and unstable 
medical/ psychiatric disorders which might make participation hazardous; acute or chronic health 
conditions; and concomitant medication use contraindicated with suvorexant (e.g., medications with 
sedative properties). This will be accomplished via full medical evaluation at intake by Dr. Michael 
Weaver, M.D., CNRA Medical Director. The study will be conducted at the Neurobehavioral Research 
Laboratory at the CNRA, directed by Dr. Lane.  Recruitment strategies will include local advertising in 
print media, public service announcements on radio, and referrals to CNRA in the Houston metropolitan 
area. Based on previous and current recruitment rates of cocaine treatment-seeking men and women for 
studies at the CNRA, we expect to enroll 3-4 participants per month to meet recruitment goals. Subjects 
will be required to participate for 2 days (intake, screening) + 2 weeks (formal experimental study), 
coming to the CNRA lab M, W, F. 
Research data will be collected at scheduled time points during intake, baseline, experimental 
conditions, and end-of-study. Urine assays will assess recent cocaine use as urine benzoylecgonine < 
300 ng/mL confirmation. 
Demographic characteristics of cocaine-dependent patients recruited into treatment studies show 
a mean age of 41 years, 83% are male, 15% Caucasian, 75% African-American, 10% Hispanic. Men and 
women of all ethnic backgrounds will be recruited to participate. It is anticipated that the subject 
demographic profile will closely mirror the larger population from which they are recruited, however, 
because we are recruiting non-treatment seekers, we expect to a broader range of subjects to select 
from and anticipate a 70% / 30% male/female subject distribution. Efforts will be made to increase the 
percentage of women in the study. These efforts will include (1) having the outreach coordinator present 
educational material and referral information at women’s clinics in the greater Houston area. 
Children (defined here per NIH guidelines as 19-21 years old) will be included in this research. 
The incidence of severe cocaine use disorder is relatively small in the population of youth less than 18 
years old. From a safety perspective, risks of exposure to the proposed study medication in substance 
dependent children have not been established. The safety and efficacy of the proposed study medication 
should be established in adults first, before conducting this type of treatment research in children. 
Exclusion criteria will include: (1) current DSM-IV diagnosis of any psychoactive substance 
dependence other than cocaine, marijuana, or nicotine; (2) have a DSM-IV axis I psychiatric disorder or 
neurological disease or disorder requiring ongoing treatment and/or making study participation unsafe; 
(3) significant current suicidal or homicidal ideation; (4) medical conditions contraindicating administration 
of suvorexant (e.g., severe pulmonary disease, severe cardiovascular disease or clinically abnormal 
EEG, severe liver or kidney disease, seizure disorder, or sleep disorder – particularly narcolepsy); (5) 
taking medications known to have significant drug interactions with the study medication(s) (e.g., MAO 
inhibitors, anticonvulsants, haloperidol, phenothiazines, anesthetics, and all sedatives); (6) currently or 
recently (last 3 months) treated for substance use [other than cocaine or nicotine] or another psychiatric 
condition; (7) conditions of probation or parole requiring reports of drug use to officers of the court; (8) 
impending incarceration; (9) pregnant or nursing for female patients; (10) inability to read, write, or speak 
English [required for lab tasks and psychometric scales]; (11) unwillingness to sign a written informed 
consent form; (12) subjects with alcohol use disorders or are drinking > 7 alcoholic drinks per week. All 
subjects who are excluded will be given referral information to other local treatment programs. 


IRB NUMBER: HSC-MS-16-0120 
IRB APPROVAL DATE: 04/25/2017 
 
E2. Sources of Materials. 
We will obtain information about subjects from structured interview evaluations, physical 
examinations, self-report measures, and computerized behavioral tasks. This information will be 
collected at specified time points during the study phases of intake, baseline assessment, experimental 
testing, and end-of-study. The biological specimens obtained from all subjects will include urine, saliva 
for cortisol assessment, and breath samples for alcohol detection. Individuals who volunteer to participate 
will be assigned a subject number (e.g., 10500), under which all information collected will be filed. All 
materials will be obtained for the specific purposes of this research. 
 
E3. Potential Risks 
 
Suvorexant (BELSOMRA) is an orexin receptor antagonist indicated for the treatment of 
insomnia, characterized by difficulties with sleep onset and sleep maintenance. Recommended dose is 
10 mg, 1x per night taken within 30 minutes of going to bed, with at least 7 hours of planned time before 
awakening. If the 10 mg dose is well tolerated but not optimally effective, it can be increased but not to 
exceed 20 mg once daily.  Medication is taken PO, with dosage in tablets of 5, 10, 15, and 20 mg. 
Contraindicated in patients with narcolepsy. Precautions include daytime somnolence; dose-related risk 
of impaired alertness and motor coordination, including impaired driving; patients taking 20 mg should be 
cautioned against next-day driving; nighttime “sleep-driving” and other complex behaviors while out of 
bed and/or not fully awake; worsening of depression or suicidal thinking; compromised respiratory 
function; sleep paralysis, hypnagogic/hypnopompic hallucinations. Risk of the above symptoms 
increases with use of CNS depressants and alcohol. In obese women (BMI > 30), there is increased risk 
of exposure-related adverse effects. Belsomra is a schedule-IV compound with mild/modest abuse- 
potential in the same class as existing sleep medications and anxiolytics. The most common adverse 
reactions include somnolence and slowed motor coordination. Not recommended for use in patients 
taking strong CYP3A inhibitors, efficacy may be reduced, or for patients with severe hepatic impairment. 
Based on animal data, Belsomra may cause fetal harm. 
 
Risks for Behavioral and Psychometric Testing. Behavioral tests are administered via custom 
written computer programs that track subject’s eye movements. This testing could produce frustration or 
fatigue if subjects have trouble with acquisition or mastery of the task or concentrating eye gaze for 10-12 
minutes. Items on certain psychological/psychiatric questionnaires and interviews might be perceived as 
personally discomforting to some subjects. While subjects may be uncomfortable reporting these issues, 
the risks of serious sequelae are extremely low. 
 
Risks for Cold Pressor Test. Individuals with cardiovascular disorders and neurological 
disorders should not participate. This information will be obtained during medical screening. Due to 
individual variation in pain and cold sensitivity, for some subjects the cold water may become too painful 
to sustain immersion for 90 seconds. There are no lasting effects from placing the hand and wrist in ice 
water (0° Celsius) for 90 seconds. 
 
Risks for Physical Examination. There is a slight risk of bruising and infection in the blood draw 
procedures. This draw and the intake screening and physical exam are part of the CNRA General 
Evaluation protocol, and are approved under protocol HSC-MS-05-0322 and detailed therein. 
 
E4. Adequacy of Protection Against Risks 
 
Procedures to Minimize Drug-Related Risks. 
We will screen very carefully for alcohol use and depressive symptoms. It will be made explicit 
that participants are not to drink alcohol in evening. We will use the Alcohol Use Disorders Identification 
Test (AUDIT) score and our mental health counselors SCID-screeners to enroll only those with low risk 
for alcohol abuse.  Subjects will report no current depressive symptomatology (Beck Depression 


IRB NUMBER: HSC-MS-16-0120 
IRB APPROVAL DATE: 04/25/2017 
 
Inventory, or BDI < 15), with no past depressive episodes or suicidal ideation. The Columbia Suicide 
Severity Rating Scale (CSSRS) will be administered at each visit (see additional details below), as per 
NIH/FDA guidelines. Indication of regular alcohol use by AUDIT score, intake self-report, or breath 
alcohol, or indication of increase in depressive symptomatology / suicidality as measured by the CSSRS 
will result in study stopping (see details below). Will exclude for any patients taking CYP3A inhibitors; 
patients with severe hepatic impairment; and women who are or become pregnant. Pregnancy and drug 
tests are administered on via urinalysis on lab testing days. Women of childbearing capacity must be 
taking one form of birth control.  We will exclude for women with BMI > 30 to decrease risk of side 
effects, although it should be noted that in our cocaine use disorder population, we rarely encounter 
obese patients. 
In addition to the rigorous screening criteria for inclusion. At the end of each experimental day, 
cardiovascular measures will be taken and the subject will be evaluated for signs of impairment or side 
effects, first by a research assistant and then by the research nurse, medical director, or PI. The 
assessment battery includes subjective effects questionnaire, nystagmus, touching nose, balance, and 
walking a straight line). If cardiovascular measures are normal, within the range of pre-dose levels, and 
the subject is determined to be unimpaired, the subject will be released. If any signs of intoxication are 
detected, participants will be required to remain at the experimental site until such symptoms are no 
longer observed. 
In the event of either an unexpected adverse event or a prolonged period of intoxication, we have 
several measures in place. First, Dr. Weaver (CNRA medical director) has clinical experience and 
training in emergency medicine. Thus, a physician will be in the immediate vicinity of laboratory at all 
times. Offices and clinical space are within 100 feet of the lab. Collaborating MDs can be paged at any 
time during the day. Second, Ben Taub Hospital, a level 5 emergency medical center is located just 
minutes away from BBSB. Finally, in the event of extended sedation, intoxication, or impairment, in which 
any subject does not appear clear-headed, feeling well, and in full control of his or her behavior, two 
steps will be taken. First, the subject will remain in the lab until such time that the primary or a co- 
investigator deems that it is safe for him or her to leave (e.g., passing the sobriety test described above). 
The large majority of our cocaine use disorder subjects use the METRO system, thus driving hazards are 
expected to be rare. However, in the event of extended impairment, we will arrange (and pay for) a taxi 
service to drive the subject back to his/her home rather than having to use METRO. We will administer 
the Columbia Suicide Severity Rating Scale (CSSRS screening version) at each visit to assess suicidality 
and depressive symptoms, consistent with current FDA best practices. If the screening indicates change 
in suicidal ideation, we will administer the full version. If suicidality is judged to clinically significant as per 
CSSRS scoring criteria, we will (1) report the event to CPHS within 48 hours; (2) remove the patient from 
the study; (3) make a referral to either the BBSB outpatient mood disorders clinic or UT HCPC, 
depending on consultation from Dept of Psychiatry outpatient faculty at BBSB. 
For the cold pressor task, participants will be told that if the level of pain is too uncomfortable, 
they should remove the hand immediately and not wait to the end of the 90 sec test period. Each 
participant will be able to test the water temperature for 10 sec prior to beginning the procedure. These 
details are presented in the informed consent document. Because there are no sustained effects of cold 
water, if a participant cannot sustain the immersion for 90 sec on one test day, it will not preclude 
repeated testing on other lab test days (the cold pressor test will be repeated 3 times). 
 
Other Protections Against Risk. The following procedures will be taken to safeguard against 
adverse medication events: (1) careful initial intake evaluation to determine eligibility based on 
inclusion/exclusion criteria; (2) thorough physical evaluation prior to treatment, consisting of physical 
examination, standard laboratory tests, electrocardiogram, toxicology screen, pregnancy test, and vital 
signs; (3) repeated tests during treatment; (4) daily monitoring of pill taking using MEMS caps, returned 
pill counts, and self-report; (5) weekly review of adverse events and medication compliance; (6) regular 
evaluation by the study physician (Dr. Weaver). Specific criteria will be used to exclude potential subjects 
for whom any of the study medications is contraindicated. Any abnormal physiological, psychological, or 
behavioral event will be evaluated and, if indicated, will result in the subject’s removal from the study. 


IRB NUMBER: HSC-MS-16-0120 
IRB APPROVAL DATE: 04/25/2017 
 
For all three experiments included in this project, we will use an Adverse Event Log (AEL) based 
on NIDA SAFTEE procedures. The AEL will record the duration, severity, and frequency or any adverse 
events, signs, and symptoms. An evaluation will be made as to the event’s relationship to the study 
drug(s), scaled as unrelated, unlikely, possible, and probable. The AEL will be included in the report to 
DSMB. 
Subjects will be monitored regularly for compliance with the study requirements, including the 
dosing regimen and breath alcohol testing upon arrival at the laboratory each day of testing. Written and 
verbal information about the medication will be given to all participants. This information will remind the 
subject to: (1) take food shortly after medication if needed to relieve gastric irritation; (2) inform the 
treatment research clinic nurse or physician of any over-the-counter and prescription medication taken, 
especially: cough medication, diarrhea medication, narcotic medication; (2) notify treatment research 
clinic nurse or physician of any side effects that persist or worsen. The study physician, nurse, and PI will 
review cases involving clinical deterioration of increased symptomatology or substance abuse. 
Appropriate actions will be taken, including study termination with proper referral. 
Confidentiality will be protected in several ways. All information collected solely for research 
purposes will be kept in locked, restricted access files. Individual subject information will be transferred to 
outside sources only with the express written request of the subject. Subjects will receive a copy of their 
signed consent form. All personnel associated with this grant have successfully completed ethics training in 
the Protection and Welfare of Human Participants, and certification is on file at the Health Science Center 
CPHS and office of sponsored projects. All intake and experimental data that are collected will be uploaded 
onto a laboratory database, computers dedicated to data storage and management. These computers are 
protected by password. All data will be treated as confidential information. All data including urine samples, 
medical and psychiatric intake exams, and behavioral and drug administration data – will be obtained solely 
for research purposes. All individuals who elect to participate and sign the informed consent agreement will 
be assigned a subject number (e.g., 3200), which will serve as that subject’s identifier (rather than name or 
SS#). A log book and electronic database that connect participants’ identifying information with subject 
number are kept in a locked file cabinet and room and password protected, respectively. 
 
Recruitment and Informed Consent. Participants will be self-referred in response to various 
study advertisements via newspaper (Grensheet, Houston Press) and radio. All CNRA recruitment 
materials have been approved by CPHS for ongoing studies over the past 5 years. Individuals who call 
for information will be given a brief description of the study. Those interested will then be asked to 
answer questions about their current substance use. A trained research assistant will conduct this 
telephone-screening interview. Eligible subjects will be scheduled for an in-person intake visit at the 
CNRA, first floor BBSB. The first intake appointment will begin with the presentation of the informed 
consent form. The consent form will detail the requirements of study participation (e.g., # of visits, type of 
data collected, time commitment, etc.). 
Subjects will be told that the purpose of the study is to evaluate the effects of medications on 
human behavior related to mood, sleep, and substance abuse (cocaine users). Information about the 
components of the experimental procedure will be explained. Details of the random assignment 
procedure (placebo or active dose) will be explained. Subjects will be informed of their attendance 
expectations. Other information on the consent form will include a full description of study requirements, 
reimbursement, risks, benefits, alternatives, and the role of the local IRB. All questions will be answered 
before written consent is requested. All research conducted in our laboratory and the CNRA has prior 
approval from the Committee for the Protection of Human Subjects (CPHS) of the University of Texas 
Health Science Center - Houston. 
 
E5. Potential Benefits of the Proposed Research to the Subject and Others 
All services provided in these studies will be free. The studies should help compliment and advise 
clinical research focused on stopping cocaine use, preventing relapse, and improving cognitive and 
behavioral functioning related to impairment following cocaine abuse. Subjects will be told if unusual 
information is discovered during the study that will make a difference in treatment for this or other 


IRB NUMBER: HSC-MS-16-0120 
IRB APPROVAL DATE: 04/25/2017 
 
problems. By taking part in this research subjects may help themselves toward recovery and others with 
similar problems. 
Subject Payment.  The payment schedule is detailed below.  Subjects will be paid the 
medication compliance, study visit bonus, and participation earnings at the end of each experimental day 
(M, W, F). Subjects will receive an additional bonus ($50) for completing of the study. Total possible 
payment for meeting all study requirements and collecting all bonus payments will be $337. 
Medication compliance. $2 for each metric: 1) Medical Event Monitoring System (MEMS) bottle 
opening, (2) pill counts (empty bag), (3) positive riboflavin markers, and (4) text reply to reminder. 
Absence of each will result in payment not be earned for that specific metric. Total possible payment = 
$8 per day X 14 study days = $112. Study visit bonus. $10 for on time arrival and providing an alcohol- 
free breath sample and urine sample. Total possible payment = $10 per day X 7 visit days = $70. 
Participation. Total possible payment = $15 per day X 7 visit days = $105. Completion bonus $50. 
 
E6. Importance of the Knowledge to be Gained. 
Research participation may assist non-treatment seeking subjects in abstaining from cocaine 
during study, and via study completion protocol, bring them into contact with treatment resources at our 
research center and in the community. Cocaine dependence is marked by repeated relapse, leading to 
devastating consequences on a personal and societal level. Currently, there is no medication that has 
been shown to be broadly effective in reducing cocaine use. Suvorexant (and orexin agonists more 
broadly), may help reduce sleep disruptions and anxiety, and attenuate craving and biased attention 
toward drug cues – helping to reduce risk of relapse. This experiment will compliment and provide 
valuable information to our ongoing and future addiction work, and contribute to the knowledge base in 
the treatment of cocaine dependence. Our procedures have been designed to minimize the probability of 
risks. Our research center has an excellent track record in conducting human psychopharmacology 
experiments and clinical trials with the utmost attention to safety. 
 
E7. Inclusion of Women and Minorities 
Women, minorities, and children will be included at minimum to the extent they are reflected in 
this cocaine-dependent population. In previous cocaine clinical studies at the Treatment Research Clinic 
(TRC), the percentage of females and males is approximately 20% and 80% respectively. We will 
continue recruitment efforts to achieve a 50-50 balance and thus permit meaningful analyses by sex 
across groups. One effort will be to have the TRC outreach coordinator present educational material and 
referral information at women’s clinics in Houston and the surrounding communities. In the past this has 
helped to enhance recruitment of women with cocaine dependence. 
 
The ethnic representation has been 67% Black, 25% White, and 8% Hispanic. In the absence of data on 
the prevalence of cocaine dependence disorder in the Houston area, we cannot define ethnic base rates. 
The medical center environment is not known to be uniquely avoided by any particular ethnic group and 
patients view it as favorable and neutral. Nevertheless, we are prepared to implement recruitment 
procedures to ensure a more diverse patient population. These procedures include: 1) Targeted 
advertising in newspapers which serve minority communities (e.g., Hispanic or Latino communities). 2) 
Distribution of flyers and notices in neighborhoods known to have a high minority population. 3) 
Engaging in outreach activities on an ongoing basis, e.g., contacting church and community leaders in 
the Hispanic communities to provide educational material about cocaine dependence and its 
consequences; providing contact information to aid in referrals to our clinic (see Core for additional 
details). 
 
E8. Inclusion of Children 
Children (age 18-21years) will be included in this research. The incidence of severe cocaine 
abuse/dependence is relatively small in the population of youth less than 18 years old. From a safety 
perspective, risks of exposure to the proposed study medication in substance-dependent children have 
not been established. The safety and efficacy of the proposed study medication should be established in 
adults first, before conducting this type of treatment research in children. 


IRB NUMBER: HSC-MS-16-0120 
IRB APPROVAL DATE: 04/25/2017 
 
E9. Data and Safety Monitoring Plan (NIH/NIDA specific issues) 
1. The Principal Investigator will be responsible for knowing the policies of the local IRB (the UT – 
Houston Committee for the Protection of Human Subjects, CPHS). The PI will adhere to CPHS policies 
and maintain accurate documentation of CPHS correspondence and reports (e.g., annual report). The PI 
is responsible for documentation and handling of all possible study-related adverse events. The 
Treatment Research Clinic (TRC) within our Center for Neurobehavioral Research on Addictions (CNRA) 
has longstanding data collection and safety monitoring systems in place that will be available for the 
proposed study. These include staff training, weekly audit of data collection/entry, medical screening with 
results reviewed by on-site nurse and physician, use of standardized assessments, continued medical 
monitoring during the study, procedures to monitor medication compliance (MEMS caps, texts). As PI, 
Dr. Lane will assure that the above systems are in place and functioning properly during the study. 
2. A Monitoring Committee will provide additional, independent oversight of data related to 
subject safety. This committee will perform the following activities: (a) review the research protocol and 
plans for data and safety monitoring; (b) evaluate study progress, including data quality, participant 
recruitment rates, retention rates, outcome and adverse experience data, and risk versus benefit profile; 
(c) make recommendations to the PI for a discontinuation of study medication for an individual patient 
based on adverse experiences; (d) make recommendations to terminate the study because of safety 
concerns; and (e) protect the confidentiality of the data and the results of monitoring. The Committee will 
be blind to study medication, unless they believe that termination of the trial is warranted.  This 
committee meets annually to review all CNRA studies, and this present study will be added to the DSMB 
review in 2016.  The DSMB report is submitted annually to CPHS. 
3. Adverse events (AE) will be reported to the UT-CPHS on an annual basis. Serious adverse 
events will be reported immediately (verbally within 24 hours) to the UT-CPHS, the Monitoring 
Committee, and to the NIDA. A written report will follow as soon as possible but in no more than three 
days. The written report will be in the format required by the local IRB and will contain information 
regarding the date of the AE, description of the AE, severity rating (Grade 1 to 4), assessment of cause, 
whether the AE indicates an increased risk for current or future subjects, and whether changes to the 
informed consent form are necessary. 
4. We will also use an ongoing Adverse Event Log (AEL) based on NIDA SAFTEE procedures. 
The AEL will record the duration, severity, and frequency or any adverse events, signs, and symptoms. 
An evaluation will be made as to the event’s relationship to the study drug(s), scaled as unrelated, 
unlikely, possible, and probable. The AEL will be included in the report to DSMB. 
 
E10. Specific Issues: NIDA / NACDA Guidelines on Administration of Drugs to Human Subjects. 
Risk/Benefit. These issues are described in sections E1 through E6. As noted above, the potential for 
advances in scientific and treatment domains related to addiction are considerable. Based on the 
qualifications and long history of work in this area by the investigative team and the careful screening 
and monitoring for subject safety, we feel there is a favorable balance of potential benefit against risk. 
 
Data Safety Monitoring Board is described in E9. 
Informed Consent is described in section E4. 
Subject Selection is described in section E1. 
Confidentiality is described in section E4. 
Medical and Psychological Screening and Services are described in sections E1, E4, and E9, as well 
as sections D1 and D2 of the application. 
 
Administration of Drugs to Individuals Who Have Never Used Drugs. Study drugs will not be 


IRB NUMBER: HSC-MS-16-0120 
IRB APPROVAL DATE: 04/25/2017 
 
administered to subjects who have never used drugs. By definition all subjects will be individuals with 
substance use disorder (cocaine). Most of our subjects with cocaine use disorders also have an 
extensive history of use of other illicit drugs. 
 
Involvement of Individuals Currently Addicted to Drugs and/or Are Frequent Drug Abusers. We 
have taken into consideration the need to assess the participant's ability to provide informed consent (via 
use of screening and the Shipley-2 aptitude assessment). While these are non-treatment seeking 
individuals, a serious and concerted effort will be made to link these individuals to drug abuse treatment. 
At study end, subjects will receive a follow up medical examination and a session with a licensed 
counselor in our treatment research clinic, who will provide information about treatment options and 
referrals. As described thoroughly in D1, D2, E1 and E4 we have rigorous medical examination and 
screening procedures to assure the absence of any medical or mental condition for which further drug 
exposure would be contraindicated. Our procedures do not entail exposure to higher doses, rates of 
administration, or new route of administration than they would normally encounter by under usual 
circumstances. If subjects have participated in prior clinical drug intervention trials at our treatment 
research clinic, a complete list of drugs and dosing protocols will be reviewed and kept in his/her 
evaluation record. Subjects using any current CNS active medications will be excluding from testing and 
rescheduled (if medication use was idiosyncratic, e.g., OTC for recent cold or headache) or excluded (if 
medication use is regular or for a chronic condition). In particular, we will exclude those with alcohol use 
disorders or who report frequent alcohol consumption (> 7 time drinks per week), as suvorexant is 
contraindicated with alcohol due to potentially dangerous interactions with regard to sedative effects. 
 
Administration of Drugs to Incarcerated Individuals. Individuals who are currently on parole or 
probation with random drug testing by court officers, or who are currently incarcerated, will be excluded 
 
Administration of Drugs to Individuals with Mental Disorders. Individuals with DSM-IV Axis - I 
mental disorders other than SUD will be excluded. 
 
Drug Doses and Routes of Administration. The proposed doses in these experiments (10 mg, 20 mg) 
have all been safely given to human subjects in previous laboratory experiments and clinical trials. 
Standard routes of administration (PO capsules) will be used. No doses will be given outside the range of 
those already administered to humans in previous studies and indicated in the prescribing information in 
the investigator’s brochure. 
 
Prior and Current Drug Treatment Status. All subjects in the proposed experiments will be non- 
treatment seeking. Although appropriate measures for help with addiction will be provided at study end, 
where subjects will receive a follow up medical examination and a session with a licensed counselor in 
our treatment research clinic, who will provide information about treatment options and referrals. 
 
Prior and Current Treatment Experience. If subjects have participated in prior clinical drug intervention 
trials at our treatment research clinic, a complete list of drugs and dosing protocols will be reviewed and 
kept in his/her evaluation record. Subjects using any current CNS active medications will be excluding 
from testing and rescheduled (if medication use was idiosyncratic, e.g., OTC for recent cold or 
headache) or excluded (if medication use is regular or for a chronic condition). 
 
Women of childbearing potential will not be excluded from these experiments. 
 
Pregnant Women will be excluded from these experiments, and urine pregnancy testing will be 
performed at each visit to the research center (3 to 5 days per week). 
 
Special Considerations Across the Lifespan. Individuals under the age of 19 will be excluded from 
this research due to risks and unknown effects of these drugs in adolescents, and ethical concerns of 
administering drugs of abuse to individuals this age. Additionally, individuals this age may be in school, 


IRB NUMBER: HSC-MS-16-0120 
IRB APPROVAL DATE: 04/25/2017 
 
which would preclude the normal daytime participation time. We will also exclude individuals over age 
55, as elderly subjects also constitute a vulnerable population with regard to drug effects. Additionally, 
changes in anatomy and physiology in the elderly that may alter the metabolism and short and long-term 
effects of drugs, compromising both safety and scientific validity. 
 
Study Personnel Training and Experience. All medical and psychiatric screening and interviews will be 
conducted by trained clinicians, who are first trained by experienced SCID interviewers using 
standardized training videotapes from Biometrics Research, NY. All personnel associated with this grant 
have successfully completed ethics training in the Protection and Welfare of Human Participants, and 
certification is on file at the Health Science Center CPHS and office of sponsored projects. CNRA 
pharmacists will carry out preparation of medication; distribution of medication by research assistants will 
follow after training has been conducted by the PI (Lane). 
 
Infection Risk Reduction Counseling and Testing. As described in sections D1, D2, E1 and E4, we 
recognize these risks and have included the necessary tests and precautions for disease transmission 
and infection risk (HIV, tuberculosis (TB), hepatitis, syphilis). HIV counseling will be made available as 
deemed appropriate by medical personnel in the treatment research center. 
 
Safety of Research Participants Outside of the Research Site. These issues are addressed in 
section E4. They are repeated here for clarity. In addition to the screening criteria for inclusion, each visit 
to the laboratory will include a full side effects profile. Additionally, subjects will be evaluated for signs of 
impairment or side effects, first by a research assistant and then by a PI and CNRA research nurse. The 
assessment battery includes subjective questionnaire, nystagmus, touching nose, balance, and walking 
a straight line. If the subject is determined to be unimpaired, s/he will be released promptly. If any signs 
of sedation or other impairment are detected, participants will be required to remain at the experimental 
site until such symptoms are no longer observed. In the event of either an unexpected adverse event or 
heavy sedation, we have several measures in place. First, Dr. Weaver (CNRA medical director) is a 
licensed MD with clinical experience and training in emergency medicine. Thus, a physician will be in the 
immediate vicinity of laboratory. Offices and clinical space are contiguous to the lab. Second, Ben Taub 
Hospital, a level 5 emergency medical center is located less then 5 minutes away from our building. 
Finally, in the event of extended sedation or impairment, in which any subject does not appear clear- 
headed, feeling well, and in full control of his or her behavior, two steps will be taken. First, the subject 
will remain in the lab until such time that the PI, medical director, or research nurse deems that it is safe 
for him or her to leave (e.g., passing the test described above). Second, if necessary, we will arrange for 
a taxi service to drive the subject back to his/her home. 
The following procedures will be taken to safeguard against adverse medication events: (1) 
careful initial intake evaluation to determine eligibility based on inclusion/exclusion criteria (including 
exclusion for alcohol use disorder or frequent regular use); (2) thorough physical evaluation prior to 
treatment, consisting of physical examination, standard laboratory tests, electrocardiogram, toxicology 
screen, pregnancy test and vital signs; (3) repeated tests during treatment; (4) daily monitoring of pill 
taking using MEMS caps, returned pill counts, and self-report; (5) weekly review of adverse events and 
medication compliance; (6) evaluation by the study physician (Dr. Weaver). Specific criteria will be used 
to exclude potential subjects for whom any of the study medications is contraindicated. Any abnormal 
physiological, psychological, or behavioral event will be evaluated and, if indicated, will result in the 
subject’s removal from the study. 
For this project, we will use an Adverse Event Log (AEL) based on NIDA SAFTEE procedures. 
The AEL will record the duration, severity, and frequency or any adverse events, signs, and symptoms. 
An evaluation will be made as to the event’s relationship to the study drug, scaled as unrelated, unlikely, 
possible, and probable. The AEL will be included in the report to DSMB. Relevant information is also 
included in section E9. 
 
Referral to Treatment. As noted above, at study end subjects will receive a follow up medical 
examination and a session with a masters-level licensed counselor or RN in our treatment research 


IRB NUMBER: HSC-MS-16-0120 
IRB APPROVAL DATE: 04/25/2017 
 
clinic, who will provide information about treatment options and referrals. If depression or suicidal 
ideation is measured at risk during the study, participation will be terminated and appropriate referrals 
made (see above). 
 
Incomplete Disclosure. We have no elements of deception in this project, other than withholding of 
dose information to subjects about dose contents on days of testing (e.g., suvorexant or placebo). 
However, informed consent documents will contain full disclosure of the drug that may be received 
during the course of the experiments, along with potential side effects. No information about study risks 
will be withheld from subjects. 
 
Payment for Participation in Research. Subjects will be paid daily for attendance and for performance 
on the behavioral tasks, and a bonus at the end of the study for completion. Subjects will be paid the 
medication compliance, study visit bonus, and participation earnings at the end of each experimental day 
(M, W, F). Subjects will receive an additional bonus ($50) for completing of the study. Total possible 
payment for meeting all study requirements and collecting all bonus payments will be $337. Medication 
compliance. $2 for each metric: 1) Medical Event Monitoring System (MEMS) bottle opening, (2) pill 
counts (empty bag), (3) positive riboflavin markers, and (4) text reply to reminder. Absence of each will 
result in payment not be earned for that specific metric. Total possible payment = $8 per day X 14 study 
days = $112. Study visit bonus. $10 for on time arrival and providing an alcohol-free breath sample and 
urine sample. Total possible payment = $10 per day X 7 visit days = $70. Participation. Total possible 
payment = $15 per day X 7 visit days = $105. Completion bonus $50. 
 
F. Vertebrate Animals 
Not applicable. 


IRB NUMBER: HSC-MS-16-0120 
IRB APPROVAL DATE: 04/25/2017 
 
 
 
References 
 
1 
SAMSHA. SAMHSA's latest report on the nation's mental health. Psychiatr Serv 63, 619, 
doi:10.1176/appi.ps.20120p619 (2012). 
2 
SAMHSA. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings. 
NSDUH Series H-46; Substance Abuse and Mental Health Services Administration, Rockville, MD. HHS 
Publication No (SMA) 13-4795. (2013). 
3 
Mena, G. et al. Cocaine-related health emergencies in Europe: a review of sources of information, trends 
and implications for service development. Eur Addict Res 19, 74-81, doi:10.1159/000341719 (2013). 
4 
SAMHSA.  Vol. NSDUH Series H-49   (HHS Publication No. (SMA) 14-4887., Rockville, MD, 2014). 
5 
Koob, G. F. & Volkow, N. D. Neurocircuitry of addiction. Neuropsychopharmacology 35, 217-238, 
doi:10.1038/npp.2009.110 (2010). 
6 
Verrico, C. D., Haile, C. N., Newton, T. F., Kosten, T. R. & De La Garza, R., 2nd. Pharmacotherapeutics for 
substance-use disorders: a focus on dopaminergic medications. Expert Opin Investig Drugs 22, 1549-1568, 
doi:10.1517/13543784.2013.836488 (2013). 
7 
Haile, C. N. & Kosten, T. R. Pharmacotherapy for stimulant-related disorders. Curr Psychiatry Rep 15, 415, 
doi:10.1007/s11920-013-0415-y (2013). 
8 
Sinha, R. New findings on biological factors predicting addiction relapse vulnerability. Curr Psychiatry Rep 
13, 398-405, doi:10.1007/s11920-011-0224-0 (2011). 
9 
Sinha, R. The role of stress in addiction relapse. Curr Psychiatry Rep 9, 388-395 (2007). 
10 
de Dios, M. A. et al. General anxiety disorder symptoms, tension reduction, and marijuana use among 
young adult females. J Womens Health (Larchmt) 19, 1635-1642, doi:10.1089/jwh.2010.1973 (2010). 
11 
Sinha, R. Chronic stress, drug use, and vulnerability to addiction. Annals of the New York Academy of 
Sciences 1141, 105-130, doi:10.1196/annals.1441.030 (2008). 
12 
Mantsch, J. R. et al. Neurobiological mechanisms that contribute to stress-related cocaine use. 
Neuropharmacology 76 Pt B, 383-394, doi:10.1016/j.neuropharm.2013.07.021 (2014). 
13 
Goeders, N. E. The impact of stress on addiction. Eur Neuropsychopharmacol 13, 435-441 (2003). 
14 
Mahoney, J. J., 3rd, Newton, T. F., Omar, Y., Ross, E. L. & De La Garza, R., 2nd. The relationship between 
lifetime stress and addiction severity in cocaine-dependent participants. Eur Neuropsychopharmacol 23, 
351-357, doi:10.1016/j.euroneuro.2012.05.016 (2013). 
15 
Brower, K. J., Aldrich, M. S. & Hall, J. M. Polysomnographic and subjective sleep predictors of alcoholic 
relapse. Alcohol Clin Exp Res 22, 1864-1871 (1998). 
16 
Landolt, H. P. & Gillin, J. C. Sleep abnormalities during abstinence in alcohol-dependent patients. Aetiology 
and management. CNS Drugs 15, 413-425 (2001). 
17 
Le Bon, O. Contribution of sleep research to the development of new antidepressants. Dialogues Clin 
Neurosci 7, 305-313 (2005). 
18 
Morgan, P. T. & Malison, R. T. Cocaine and sleep: early abstinence. ScientificWorldJournal 7, 223-230, 
doi:10.1100/tsw.2007.209 (2007). 
19 
Morgan, P. T., Pace-Schott, E., Pittman, B., Stickgold, R. & Malison, R. T. Normalizing Effects of Modafinil 
on Sleep in Chronic Cocaine Users. American Journal of Psychiatry 167, 331-340 (2010). 
20 
SAMHSA. Vol. 8 (ed U.S. Department of Health & Human Services) 1-8 (U.S. Department of Health & 
Human Services, Rockville, MD, 2015). 
21 
Tang, J. et al. Sleeping problems in Chinese illicit drug dependent subjects. BMC Psychiatry 15, 28, 
doi:10.1186/s12888-015-0409-x (2015). 


IRB NUMBER: HSC-MS-16-0120 
IRB APPROVAL DATE: 04/25/2017 
 
22 
Conklin, C. A., Parzynski, C. S., Salkeld, R. P., Perkins, K. A. & Fonte, C. A. Cue reactivity as a predictor of 
successful abstinence initiation among adult smokers. Exp Clin Psychopharmacol 20, 473-478, 
doi:10.1037/a0029599 (2012). 
23 
Cox, W. M., Hogan, L. M., Kristian, M. R. & Race, J. H. Alcohol attentional bias as a predictor of alcohol 
abusers' treatment outcome. Drug Alcohol Depend 68, 237-243 (2002). 
24 
Ditre, J. W. et al. Effects of divalproex on smoking cue reactivity and cessation outcomes among smokers 
achieving initial abstinence. Exp Clin Psychopharmacol 20, 293-301, doi:10.1037/a0027789 (2012). 
25 
Field, M. & Cox, W. M. Attentional bias in addictive behaviors: a review of its development, causes, and 
consequences. Drug Alcohol Depend 97, 1-20, doi:10.1016/j.drugalcdep.2008.03.030 (2008). 
26 
Garland, E. L., Franken, I. H. & Howard, M. O. Cue-elicited heart rate variability and attentional bias 
predict alcohol relapse following treatment. Psychopharmacology (Berl) 222, 17-26, doi:10.1007/s00213- 
011-2618-4 (2012). 
27 
Back, S. E. et al. Reactivity to laboratory stress provocation predicts relapse to cocaine. Drug Alcohol 
Depend 106, 21-27, doi:10.1016/j.drugalcdep.2009.07.016 (2010). 
28 
Carpenter, K. M., Martinez, D., Vadhan, N. P., Barnes-Holmes, D. & Nunes, E. V. Measures of attentional 
bias and relational responding are associated with behavioral treatment outcome for cocaine 
dependence. Am J Drug Alcohol Abuse 38, 146-154, doi:10.3109/00952990.2011.643986 (2012). 
29 
Kosten, T. R. et al. Cue-induced brain activity changes and relapse in cocaine-dependent patients. 
Neuropsychopharmacology 31, 644-650, doi:10.1038/sj.npp.1300851 (2006). 
30 
Marhe, R., Luijten, M. & Franken, I. H. The clinical relevance of neurocognitive measures in addiction. 
Front Psychiatry 4, 185, doi:10.3389/fpsyt.2013.00185 (2014). 
31 
Sterling, R. C., Dean, J., Weinstein, S. P., Murphy, J. & Gottheil, E. Gender differences in cue exposure 
reactivity and 9-month outcome. J Subst Abuse Treat 27, 39-44, doi:10.1016/j.jsat.2004.03.008 (2004). 
32 
Noel, X., Brevers, D. & Bechara, A. A neurocognitive approach to understanding the neurobiology of 
addiction. Curr Opin Neurobiol 23, 632-638, doi:10.1016/j.conb.2013.01.018 (2013). 
33 
Redish, A. D., Jensen, S. & Johnson, A. A unified framework for addiction: vulnerabilities in the decision 
process. Behav Brain Sci 31, 415-437; discussion 437-487, doi:10.1017/s0140525x0800472x (2008). 
34 
Field, M., Marhe, R. & Franken, I. H. The clinical relevance of attentional bias in substance use disorders. 
CNS Spectr 19, 225-230, doi:10.1017/S1092852913000321 (2014). 
35 
Field, M., Munafo, M. R. & Franken, I. H. A meta-analytic investigation of the relationship between 
attentional bias and subjective craving in substance abuse. Psychol Bull 135, 589-607, 
doi:10.1037/a0015843 (2009). 
36 
Waters, A. J. et al. Cognition and craving during smoking cessation: an ecological momentary assessment 
study. Nicotine Tob Res 16 Suppl 2, S111-118, doi:10.1093/ntr/ntt108 (2014). 
37 
Luijten, M., Field, M. & Franken, I. H. Pharmacological interventions to modulate attentional bias in 
addiction. CNS Spectr 19, 239-246, doi:10.1017/S1092852913000485 (2014). 
38 
O'Brien, C. P. Anticraving medications for relapse prevention: a possible new class of psychoactive 
medications. Am J Psychiatry 162, 1423-1431, doi:10.1176/appi.ajp.162.8.1423 (2005). 
39 
Bennett, T., Bray, D. & Neville, M. W. Suvorexant, a dual orexin receptor antagonist for the management 
of insomnia. Pharmacy & Therpeutics 39, 264-266 (2014). 
40 
Tsujino, N. & Sakurai, T. Orexin/hypocretin: a neuropeptide at the interface of sleep, energy homeostasis, 
and reward system. Pharmacol Rev 61, 162-176, doi:10.1124/pr.109.001321 (2009). 
41 
Arendt, D. H. et al. Anxiolytic function of the orexin 2/hypocretin A receptor in the basolateral amygdala. 
Psychoneuroendocrinology 40, 17-26, doi:10.1016/j.psyneuen.2013.10.010 (2014). 
42 
Johnson, P. L., Molosh, A., Fitz, S. D., Truitt, W. A. & Shekhar, A. Orexin, stress, and anxiety/panic states. 
Prog Brain Res 198, 133-161, doi:10.1016/b978-0-444-59489-1.00009-4 (2012). 
43 
Johnson, P. L. et al. A key role for orexin in panic anxiety. Nat Med 16, 111-115, doi:10.1038/nm.2075 
(2010). 


IRB NUMBER: HSC-MS-16-0120 
IRB APPROVAL DATE: 04/25/2017 
 
44 
Aston-Jones, G., Smith, R. J., Moorman, D. E. & Richardson, K. A. Role of lateral hypothalamic orexin 
neurons in reward processing and addiction. Neuropharmacology 56 Suppl 1, 112-121, 
doi:10.1016/j.neuropharm.2008.06.060 (2009). 
45 
Harris, G. C., Wimmer, M. & Aston-Jones, G. A role for lateral hypothalamic orexin neurons in reward 
seeking. Nature 437, 556-559, doi:10.1038/nature04071 (2005). 
46 
Mahler, S. V., Smith, R. J., Moorman, D. E., Sartor, G. C. & Aston-Jones, G. Multiple roles for 
orexin/hypocretin in addiction. Prog Brain Res 198, 79-121, doi:10.1016/B978-0-444-59489-1.00007-0 
(2012). 
47 
Plaza-Zabala, A., Maldonado, R. & Berrendero, F. The hypocretin/orexin system: implications for drug 
reward and relapse. Mol Neurobiol 45, 424-439, doi:10.1007/s12035-012-8255-z (2012). 
48 
Dias, N. R. et al. Anti-saccade error rates as a measure of attentional bias in cocaine dependent subjects. 
Behav Brain Res 292, 493-499, doi:10.1016/j.bbr.2015.07.006 (2015). 
49 
Holmqvist, K. et al. Eye tracking: A comprehensove guide to methods and measures. (Oxford University 
Press, 2011). 
50 
Munoz, D. P. & Everling, S. Look away: the anti-saccade task and the voluntary control of eye movement. 
Nat Rev Neurosci 5, 218-228, doi:10.1038/nrn1345 (2004). 
51 
Field, M., Eastwood, B., Bradley, B. P. & Mogg, K. Selective processing of cannabis cues in regular cannabis 
users. Drug Alcohol Depend 85, 75-82, doi:10.1016/j.drugalcdep.2006.03.018 (2006). 
52 
Schmechtig, A. et al. Effects of risperidone, amisulpride and nicotine on eye movement control and their 
modulation by schizotypy. Psychopharmacology (Berl) 227, 331-345, doi:10.1007/s00213-013-2973-4 
(2013). 
53 
Weafer, J. & Fillmore, M. T. Acute alcohol effects on attentional bias in heavy and moderate drinkers. 
Psychol Addict Behav 27, 32-41, doi:10.1037/a0028991 (2013). 
54 
Marks, K. R. et al. Fixation time is a sensitive measure of cocaine cue attentional bias. Addiction 109, 1501- 
1508, doi:10.1111/add.12635 (2014). 
55 
Heinz, A. J. et al. Heroin and cocaine craving and use during treatment: measurement validation and 
potential relationships. J Subst Abuse Treat 31, 355-364, doi:10.1016/j.jsat.2006.05.009 (2006). 
56 
Jobes, M. L. et al. Clonidine blocks stress-induced craving in cocaine users. Psychopharmacology (Berl) 
218, 83-88, doi:10.1007/s00213-011-2230-7 (2011). 
57 
Buysse, D. J., Reynolds, C. F., 3rd, Monk, T. H., Berman, S. R. & Kupfer, D. J. The Pittsburgh Sleep Quality 
Index: a new instrument for psychiatric practice and research. Psychiatry Res 28, 193-213 (1989). 
58 
Brooks, A. T., Krumlauf, M. C., Whiting, B. P., Clark, R. J. & Wallen, G. R. Are you Sleeping? Pilot 
Comparison of Self-Reported and Objective Measures of Sleep Quality and Duration in an Inpatient 
Alcoholism Treatment Program. Subst Abuse 6, 135-139, doi:10.4137/sart.s10385 (2012). 
59 
Mahfoud, Y., Talih, F., Streem, D. & Budur, K. Sleep disorders in substance abusers: how common are 
they? Psychiatry (Edgmont) 6, 38-42 (2009). 
60 
Antony, M. M., Bieling, P. J., Cox, B. J., Enns, M. W. & Swinson, R. P. Psychometric properties of the 42- 
item and 21-item versions of the Depression Anxiety Stress Scales (DASS) in clinical groups and a 
community sample. Psychological Assessment 10, 167-181 (1998). 
61 
Lovibond, S. H. & Lovibond, P. F. Manual for the Depression Anxiety Stress Scales. (2nd. Ed.) (1995). 
62 
Nasirzadeh, M., Eslami, A. A., Sharifirad, G. & Hasanzadeh, A. The mental health and substance abuse 
among youths aged 18 to 29: A comparative study. J Educ Health Promot 2, 34, doi:10.4103/2277- 
9531.115822 (2013). 
63 
Kok, T., de Haan, H. A., van der Meer, M., Najavits, L. M. & De Jong, C. A. Screening of current post- 
traumatic stress disorder in patients with substance use disorder using the Depression, Anxiety and Stress 
Scale (DASS-21): a reliable and convenient measure. Eur Addict Res 21, 71-77, doi:10.1159/000365283 
(2015). 
64 
Habibi, Z., Tourani, S., Sadeghi, H. & Abolghasemi, A. Effectiveness of stress management skill training on 
the depression, anxiety and stress levels in drug addicts after drug withdrawal. Int J High Risk Behav 
Addict 2, 82-86, doi:10.5812/ijhrba.10695 (2013). 


IRB NUMBER: HSC-MS-16-0120 
IRB APPROVAL DATE: 04/25/2017 
 
65 
Vujanovic, A. A., Wardle, M. C., Liu, S., Dias, N. R. & Lane, S. D. Attentional Bias in Adults with Cannabis 
Use Disorders: Preliminary Data on a New Experimental Paradigm. Journal of Addictive Diseases (under 
review). 
66 
Lane, S. D. in NIDA meeting of the Centers of Excellence in Substance Abuse and Dependence. 
(Bethesda, 
MD, 2013). 
67 
Liu, S. et al. The influence of dopamine beta-hydroxylase gene polymorphism rs1611115 on 
levodopa/carbidopa treatment for cocaine dependence: a preliminary study. Pharmacogenet Genomics 
24, 370-373, doi:10.1097/fpc.0000000000000055 (2014). 
68 
Baron, R. M. & Kenny, D. A. The moderator-mediator variable distinction in social psychological research: 
Conceptual, strategic and statistical considerations. Journal of Personality and Social Psychology 51, 1173- 
1182 (1986). 
69 
Bickel, R. Multilevel Analysis for Applied Research.  (The Guilford Press, 2007). 
70 
Gowin, J. L. et al. The role of cortisol and psychopathy in the cycle of violence. Psychopharmacology (Berl) 
227, 661-672, doi:10.1007/s00213-013-2992-1 (2013). 
71 
Arbuckle, J. L. Amos 6.0 User's Guide.,  (IBM Amos Development Corporation, 2005). 
72 
Lee, S. Y. & Song, X. Y. Evaluation of the bayesian and maximum likelihood approaches in analyzing 
structural equation models with small sample sizes. Multivariate Behavioral Research 39, 653-686 (2004). 
73 
Dunson, D. B., Palomo, J. & Bollen, K. Bayesian Structural Equation Modeling. (Statistical and Applied 
Mathematical Sciences Institute, 2005). 
74 
Muthen, B. & Asparouhov, T. Bayesian structural equation modeling: a more flexible representation of 
substantive theory. Psychol Methods 17, 313-335, doi:10.1037/a0026802 (2012). 
75 
Lovallo, W. The cold pressor test and autonomic function: a review and integration. Psychophysiology 12, 
268-282 (1975). 
76 
McRae, A. L. et al. Stress reactivity: biological and subjective responses to the cold pressor and Trier Social 
stressors. Hum Psychopharmacol 21, 377-385, doi:10.1002/hup.778 (2006). 
77 
Velasco, M., Gomez, J., Blanco, M. & Rodriguez, I. The cold pressor test: pharmacological and therapeutic 
aspects. Am J Ther 4, 34-38 (1997). 
78 
Geliebter, A. et al. Plasma cortisol levels in response to a cold pressor test did not predict appetite or ad 
libitum test meal intake in obese women. Appetite 59, 956-959, doi:10.1016/j.appet.2012.08.025 (2012). 
79 
von Baeyer, C. L., Piira, T., Chambers, C. T., Trapanotto, M. & Zeltzer, L. K. Guidelines for the cold pressor 
task as an experimental pain stimulus for use with children. J Pain 6, 218-227, 
doi:10.1016/j.jpain.2005.01.349 (2005). 
80 
Silverthorn, D. U. & Michael, J. Cold stress and the cold pressor test. Adv Physiol Educ 37, 93-96, 
doi:10.1152/advan.00002.2013 (2013). 


IRB NUMBER: HSC-MS-16-0120 
IRB APPROVAL DATE: 04/25/2017