Ethyl glucuronide--a marker of alcohol consumption and a relapse marker with clinical and forensic implications

Ethyl glucuronide (EtG) is a non-volatile, water-soluble, direct metabolite of ethanol that can be detected in body fluids and hair. We investigated urine and serum samples from three patient groups: (1) 33 in-patients in acute alcohol withdrawal; (2) 30 detoxified in-patients (treated for at least 4 weeks) from a 'motivation station'; and (3) 43 neuro-rehabilitation patients (non-alcoholics; most of them suffering from stroke, traumatic brain injury, Parkinson's disease etc.) using gas chromatography/mass spectrometry (GC/MS) with deuterium-labelled EtG as the internal standard and additionally in the second group of patients using liquid chromatography (LC/MS-MS). We found no correlation between the concentration of EtG in urine at hospitalization and the blood-ethanol concentration (r = 0.17), the time frame of detection (r = 0.5) or the total amount of clomethiazole required for the treatment of withdrawal symptoms (r = 0.28). In four out of 30 in-patients from the 'motivation station'--where neither clinical impression nor routine laboratory findings gave indications of relapse--concentrations of EtG in urine ranged between 4.2 and 196.6 mg/l. EtG concentrations in urine of between 2.89 and 23.49 mg/l were found in seven out of 43 neuro-rehabilitation patients using GC/MS. The GC/MS and the LC/MS-MS results showed a correlation of 0.98 with Pearson's correlation test and 1.0 with Spearman's correlation test. We suggest that EtG is a marker of alcohol consumption that can be detected for an extended time period after the complete elimination of alcohol from the body. When used as a relapse marker with a specific time frame of detection intermediate between short- and long-term markers, EtG fills a clinically as well as forensically important gap. Its specificity and sensitivity exceed those of all other known ethanol markers.

A case of gamma-hydroxybutyric acid withdrawal syndrome during alcohol addiction treatment: utility of diazepam administration

Gamma-hydroxybutyric acid (GHB) is an emerging drug for alcoholism therapy. We present a case of GHB withdrawal syndrome secondary to GHB addiction during alcoholism treatment. A complete disappearance of drug withdrawal syndrome was achieved with oral diazepam and the symptoms resolved without sequelae. GHB has been used for alcoholism therapy for only a few years now, but the trend is increasing, and other cases similar to this one are foreseeable. This risk could be higher in some countries in which GHB use is increasing not for alcoholism therapy, but for its euphoric and anabolic effects. The present experience indicates that administration of benzodiazepines would seem to be sufficient to achieve total regression of the withdrawal syndrome in a short time, at least if recognized early.

Trazodone and valproate in patients discontinuing long-term benzodiazepine therapy: effects on withdrawal symptoms and taper outcome

Recent uncontrolled research suggested that trazodone and sodium valproate may be helpful in benzodiazepine (BZ) discontinuation. We therefore undertook a double-blind study to assess whether trazodone and valproate, as compared to placebo, would attenuate withdrawal and facilitate discontinuation in BZ-dependent patients with a minimum of 1 year daily BZ use. Seventy-eight patients, taking a mean dose of 19+/-17 mg/day of diazepam (or its equivalent), were stabilized for several weeks on their BZ (16 diazepam, 25 lorazepam, 37 alprazolam) and then for 1-2 weeks, pretreated with trazodone, sodium valproate or placebo before being tapered at 25% per week. All treatments were continued for 5 weeks post-taper. BZ-free status was assessed after 5 and 12 weeks post-taper. Neither trazodone nor valproate had any significant effect on withdrawal severity. Peak physician withdrawal checklist change from baseline to peak severity was 16.4 for trazodone, 18.04 sodium valproate and 18.24 placebo (F = 0.10; NS). Taper success rates were significantly effected by both active agents at the 5-week, but not 12-week, assessment. At 5 weeks post-taper, 79% of sodium valproate and 67% of trazodone, but only 31% of placebo patients were BZ-free (chi2 = 7.34; df 2; P<0.03). Major adverse events for trazodone were sedation and dry mouth, and for valproate, diarrhea, nausea and headaches.

Generalized pustular psoriasis following withdrawal of oral cyclosporin treatment for palmo-plantar pustulosis

We report the cases of two patients who developed generalized pustular psoriasis on the withdrawal of oral Cyclosporin treatment for persistent palmoplantar pustulosis. This complication does not appear to have been reported previously.

The role of gamma-hydroxybutyric acid in the treatment of alcoholism: from animal to clinical studies

Since its discovery nearly 40 years ago, gamma-hydroxybutyric acid (GHB) has attracted several waves of scientific interest due to new developments in the knowledge of its mechanisms of action and ideas for its potential use in clinical practice. Its effects have been claimed to treat different psychiatric conditions, but over time its use has become limited to a few specific situations (e.g. sedating patients in non-painful surgical procedures and narcolepsy). New interest in the drug derives from its potential use in the treatment of alcoholism. Recent studies demonstrated a marked effect of the substance in suppressing ethanol (ETOH) withdrawal symptoms and in reducing craving for alcohol, compared to other available drugs. However, GHB has to be given under very careful supervision because of its side-effects, including the risk of abuse and dependence and possible interference with the metabolic pathways of endogenous GHB and ETOH. This short review discusses these and related issues and we hope that it will stimulate further interest in GHB.

Buprenorphine and naloxone combinations: the effects of three dose ratios in morphine-stabilized, opiate-dependent volunteers

Sublingual buprenorphine is a promising new treatment for opiate dependence, but its opioid agonist effects pose a risk for parenteral abuse. A formulation combining buprenorphine with the opiate antagonist naloxone could discourage such abuse. The effects of three intravenous (IV) buprenorphine and naloxone combinations on agonist effects and withdrawal signs and symptoms were examined in 12 opiate-dependent subjects. Following stabilization on a daily dose of 60 mg morphine intramuscularly, subjects were challenged with IV doses of buprenorphine alone (2 mg) or in combination with naloxone in ratios of 2:1, 4:1, and 8:1 (1, 0.5, or 0.25 mg naloxone), morphine alone (15 mg) or placebo. Buprenorphine alone did not precipitate withdrawal and had agonist effects similar to morphine. A naloxone dose-dependent increase in opiate withdrawal signs and symptoms and a decrease in opioid agonist effects occurred after all drug combinations. Buprenorphine with naloxone in ratios of 2:1 and 4:1 produced moderate to high increases in global opiate withdrawal, bad drug effect, and sickness. These dose ratios also decreased the pleasurable effects and estimated street value of buprenorphine, thereby suggesting a low abuse liability. The dose ratio of 8:1 produced only mild withdrawal symptoms. Dose combinations at 2:1 and 4:1 ratios may be useful in treating opiate dependence.

Opioid detoxification in pregnancy

OBJECTIVE

Opioid withdrawal has been associated with poor fetal growth, preterm delivery, and fetal death. We sought to evaluate the safety of antepartum opioid detoxification in selected gravidas.

METHODS

Between 1990 and 1996, women with singleton gestations who reported opioid use were offered inpatient detoxification. Predetoxification sonography was performed to confirm gestational age and to exclude fetuses with growth restriction and oligohydramnios. Women with mild withdrawal symptoms were given clonidine initially, and methadone was substituted if symptoms persisted. Objective signs of withdrawal were treated with methadone from the outset. Antenatal testing was performed once gestations reached 24 weeks. Newborns were observed for signs of neonatal abstinence syndrome and were treated as necessary. Obstetric and neonatal outcome data were collected.

RESULTS

Thirty-four gravidas elected to undergo opioid detoxification at a mean gestational age of 24 weeks. The median maximum dose of methadone was 20 mg per day (range 10-85 mg), and the median time to detoxification was 12 days (range 3-39 days). Overall, 20 women (59%) successfully underwent detoxification and did not relapse, ten (29%) resumed antenatal opioid use, and four (12%) did not complete detoxification and opted for methadone maintenance. There was no evidence of fetal distress during detoxification, no fetal death, and no delivery before 36 weeks. Fifteen percent of neonates were treated for narcotic withdrawal.

CONCLUSION

In selected patients, opioid detoxification can be accomplished safely during pregnancy.

Benzodiazepine treatment for alcohol-dependent patients

Benzodiazepines (BZDs) are the preferred pharmacological agents for treatment of acute alcohol withdrawal. Treatment with BZDs can be administered on an out-patient basis for subjects experiencing mild to moderate withdrawal and on an in-patient basis for the most severe forms of withdrawal. The efficacy of BZDs for long-term treatment of alcoholism has been more controversial. Controlled studies indicate that BZD treatment does not improve abstinence rate. Most reviews of drug treatment of alcoholism conclude that routine use of BZDs is not indicated on a long-term basis. However, the clinical reality is that many alcoholics are treated by BZDs during detoxification and then continue to receive them for the treatment of anxiety disorders or insomnia, often secondary to alcohol dependence. After a review of the biological properties of BZDs related to their therapeutic issues, this review discusses the major indications for BZD treatment of alcoholism. BZDs are first prescribed to prevent and treat symptoms of alcohol withdrawal. Indication of BZD administration during alcohol withdrawal and criteria of choice of an agent according to its half-life or its route of administration are discussed. The different protocols of BZD treatment during withdrawal are considered (e.g. loading techniques, symptom-triggered therapy). The use of BZDs in the treatment of anxiety associated with alcohol dependence is examined. Among unwanted effects, risk of abuse, memory impairment, confusion, and delirium are described. Finally, practical guidelines for the use of BZDs in the treatment of alcoholism are proposed.

Temporal effects of nicotine nasal spray and gum on nicotine withdrawal symptoms

Nicotine nasal spray and nicotine gum have been found to be effective in relieving nicotine withdrawal symptoms. In this randomized single-blind study, 91 cigarette smokers were randomly assigned to a single 1 mg dose of active nicotine nasal spray (n=29), active 4 mg nicotine gum (n=31), saline placebo nasal spray (n=16) or placebo gum (n=15). Following overnight abstinence, subjects repeatedly completed visual analog scales for assessing nicotine withdrawal symptoms over 30 min preceding (time -30 min to time 0) and 120 min following a single dose of study medication. This sequence was performed 3 times during the day. Nicotine withdrawal symptoms were assessed on a 41-point visual analog scale (1=no withdrawal, 41=extreme withdrawal). At the initial session only, blood samples for serum nicotine levels were taken at baseline, then at 5, 10, 30 and 120 min following study drug administration. The mean (+/-SD) age of the subjects was 38.6 (+/-10.1) years, 48% were females, smoking rate was 24.5 (+/-7.8) cigarettes per day, and years of smoking was 19.9 (+/-10.0). A single 1 mg dose of nicotine nasal spray provided more immediate relief for craving for a cigarette compared to a single 4 mg dose of nicotine gum. Serum venous nicotine levels for the active nicotine nasal spray and nicotine gum were comparable at 5 and 10 min while the levels were higher for nicotine gum at 30 and 120 min. Changes in withdrawal symptoms were not found to be related to serum venous nicotine levels. Our findings provide a rationale for the as needed use of nicotine nasal spray to control withdrawal symptoms, possibly in combination with other medications with longer acting effects.

CB1 cannabinoid receptor antagonist-induced opiate withdrawal in morphine-dependent rats

Recent reports have provided evidence of a link between the endogenous brain cannabinoid system and the endogenous central opioid systems. Here we report that the selective CB1 receptor antagonist SR 141716A induced behavioral and endocrine alterations associated with opiate withdrawal in morphine-dependent animals in a dose-dependent manner and that naloxone induced an opiate withdrawal syndrome in animals made cannabinoid-dependent by repeated administration of the potent cannabinoid agonist HU-210. Additionally CB1 and mu-opioid receptor mRNAs were co-localized in brain areas relevant for opiate withdrawal such as the nucleus accumbens, septum, dorsal striatum, the central amygdaloid nucleus and the habenular complex. These results suggest that CB1 cannabinoid receptors may play a role in the neuroadaptive processes associated with opiate dependence, and they lend further support for the hypothesis of a potential role of cannabinoid receptors in the neurobiological changes that culminate in drug addiction.

Opioid tolerance in neonates: mechanisms, diagnosis, assessment, and management

Opioid tolerance and withdrawal have been challenges for decades. The neurochemical mechanisms of tolerance and dependence are clinically important only because they can affect weaning schedules and the adjustment of doses for neonates. Analgesic effects are characterized by an increased depolarization threshold for the neuron, shorter duration of the action potential generated, and reduced release of neurotransmitters. Tolerance and withdrawal are associated with the reversal of these cellular effects. Adverse clinical effects associated with the use of opioids in neonates include respiratory depression, chest wall rigidity, urinary retention, and decreased gastrointestinal motility. The physiological systems most prominently affected by opioid withdrawal include the central nervous system, gastrointestinal system, and the autonomic nervous system. Opioid withdrawal symptoms in neonates can be assessed by using easily available scoring systems, although these need to be validated for different populations. Management of opioid withdrawal includes the use of other opioids, benzodiazepines and alpha-2 adrenergic receptor antagonist, clonidine. Careful titration of opioids with attention given to appropriate weaning schedules can reduce the incidence of withdrawal in neonates.

The effect of sucrose on acute tobacco withdrawal in women

Carbohydrate consumption is thought to attenuate symptoms of tobacco withdrawal, but direct evidence for this idea does not exist. Using a 2 x 2 (smoking/smoking deprived x sucrose/placebo) factorial design, we examined in 67 women whether sucrose would decrease acute withdrawal symptoms observed after 12 h of tobacco abstinence. Sucrose decreased tobacco abstinence-induced drowsiness and anxiety and preference for foods high in carbohydrate and fat content. Sucrose, however, had no effect on several other acute withdrawal symptoms, including restlessness, irritability and concentration difficulties. These results provide modest support for the idea that increased carbohydrate intake during tobacco withdrawal reduces certain withdrawal symptoms even after only 12 h of abstinence.

[The inhibitory effect of melatonin on morphine withdrawal syndromes and serum monoamines in morphine dependent mice]

OBJECTIVE

To observe the inhibitory effect of melatonin on morphine withdrawal syndromes and serum monoamines in morphine dependent mice.

METHODS

A physical dependent model in mice was established by subcutaneous injection of morphine. The intensity of withdrawal syndromes was evaluated according to the jumping latency and jumping times. The concentration of serum monoamines was detected with HPLC-ECD.

RESULTS

The physical withdrawal syndromes in morphine dependent mice were inhibited partly by four different doses (25, 50, 100, 200 mg/kg) of melatonin and showed a significant dose-dependent manner. The increased concentration of serum norepinephrine and dopamine in morphine-dependent mice could be reduced by large dose (100 mg/kg) of melatonin.

CONCLUSION

The jumping withdrawal syndromes and serum monoamiues in morphine-dependent mice could be inhibited partly by melatonin.

3-Alkyl ethers of clocinnamox: delayed long-term mu-antagonists with variable mu efficacy

In recent years there has been considerable interest in the relationship between clocinnamox (C-CAM) and its methyl ether methoclocinnamox (MC-CAM). While C-CAM appears to be an insurmountable mu-antagonist, MC-CAM has been shown to be a potent partial agonist at mu-opioid receptors. To further investigate this relationship we prepared other ethers of C-CAM and evaluated these in opioid receptor binding assays and in vivo in mouse antinociceptive assays and in morphine-dependent monkeys. In opioid binding assays, the ethers were generally mu-selective with affinity equivalent to that of C-CAM itself. Although they displayed little or no efficacy in vitro, some of the ethers showed substantial agonist activity in the in vivo antinociceptive tests. Two of the ethers, the propargyl ether 7 and the cyclopropylmethyl ether 5, were chosen for more detailed analysis in vivo. 7 was shown to have significant mu-agonist character and was able to substitute for morphine in morphine-dependent monkeys. Interestingly, when this agonist effect abated, 7 displayed long-lasting mu-antagonism. In contrast, 5 displayed little agonist activity in vivo and was characterized as a potent, long-acting mu antagonist. Although further work is needed to determine whether metabolism is a crucial factor in determining the pharmacological profile of these ethers, it is clear that 3-O-alkylation is a useful means of varying the mu efficacy displayed by this class of acyl-substituted 14-aminomorphinones. MC-CAM itself has generated considerable interest as a potential pharmacotherapy for opiate abuse. These analogues with differing mu efficacy but retaining the long-lasting mu-antagonist effects provide further opportunities for the development of treatment drugs.

The anti-craving drug acamprosate inhibits the conditioned place aversion induced by naloxone-precipitated morphine withdrawal in rats

The anti-craving drug acamprosate (Ca N-acetylhomotaurinate) is therapeutically used to prevent a relapse in weaned alcoholics. In the present place conditioning study, the effect of this compound on the motivational impact of morphine withdrawal was examined. Withdrawal was precipitated in rats by administration of the opioid antagonist naloxone (0.1 mg/kg, s.c.) 5-6 days after the subcutaneous implantation of a 75 mg morphine pellet. Aversion against the naloxone-paired cues was observed after conditioning in the drug-free state. The acquisition of conditioned place aversion was completely inhibited by the pretreatment with acamprosate (200 mg/kg, i.p.) 12 h and 30 min prior to conditioning. These results clarify that acamprosate inhibits the motivational component of morphine withdrawal and suggest that ethanol and opiates share similar properties in the neuronal mechanisms of conditioned withdrawal and craving.

Rational treatment of addiction

Treatment of alcohol and drug addictions, which has been neglected medically for a long time, is currently sparked with optimism. Craving for alcohol can be treated with two newly registered drugs: naltrexone and acamprosate. New approaches to symptom relief during detoxification or during maintenance therapies are rationally based on experimental and clinical work. It is now clear that addictive drugs are surrogates of natural substances involved in the 'reward system'.

Infusional high-dose application of the calcium-channel-blocking and antiglutamatergic agent caroverine in the treatment of alcohol withdrawal (DSM-III-R 291.80)

In an open study, nineteen in-patients fulfilling the criteria for an alcohol withdrawal syndrome (DSM-III-R 291.80) were treated with intravenous caroverine (400 mg/12 h). Caroverine is a class B calcium-channel-blocker and antiglutamatergic agent with significant effects on the brain function. Caroverine exhibits competitive AMPA antagonism, and at higher concentrations, non-competitive NMDA antagonism. All rating scales showed a significant improvement from the start of the treatment throughout the whole study period (CIAW-Ar: P=0.0000; NGI 1: P=0.0000, NGI 2: P=0.0304; CGI 1: P=0.0000, CGI 2: P=0.0208, CGI 3: P=0.0003). The heart rate also stabilised from 111/min before treatment to 81/min after 12 h (P=0.0000). Caroverine was well tolerated, showed no sedative side effects, and no epileptic seizures were observed.

NMDA-R1 antisense oligonucleotide attenuates withdrawal signs from morphine

To test the involvement of NMDA receptor in the development of physical dependence on opioid, the effects of an antisense oligonucleotide against NMDA receptors on the naloxone precipitated withdrawal from morphine were studied. Antisense oligonucleotide (15 nmol/5 microl) corresponding to the nucleotides 4-21 of rat NMDA-RI subunit, sense oligonucleotide, or saline was injected into the lateral ventricle of rats every 12 h for 6 days. On day 4, the rats were intracerebroventricularly (i.c.v.) infused with morphine (26 nmol microl(-1) h(-1)) through osmotic minipumps. Rats then received simultaneous treatment with morphine and oligonucleotides or saline for 3 days. Antisense oligonucleotide, but not saline or sense oligonucleotide, significantly attenuated naloxone precipitated withdrawal signs including jumping, rearing, stretching, teeth chattering, vocalization, and penis licking. Treatment with antisense oligonucleotide, but not sense oligonucleotide, significantly reduced the Bmax of [3H]MK801 ¿[3-3H](+)-5-methyl-10,11-dihydro-5H-dibenzo(a,d)cyclohepten-5,10- imine¿ binding without significant changes in Kd. These results support the hypothesis that NMDA receptors are involved in the physical dependence on opioid.