Naltrexone for the management of alcohol dependence

Liver Transplantation for Alcoholic Liver Disease

Alcohol-related liver disease is the second most frequent indication for liver transplantation (LT), yet as many as 90% to 95% of patients with alcohol-related end-stage liver disease are never formally evaluated for LT. Furthermore, despite its significance as a cause of chronic liver disease and indication for LT, it has received little attention in recent years for several reasons, including the good posttransplant short-term results, and the lack of specific "drugs" used for this disease. A writing group, endorsed by the International Liver Transplant Society, was convened to write guidelines on Liver Transplantation for Alcoholic Liver Disease to summarize current knowledge and provide answers to controversial and delicate ethical as well as clinical problems. We report here a short version of the guidelines (long version available at www.ilts.org) with the final recommendations graded for level of evidence. The writing group membership is expected to remain active for 5 years, reviewing the guideline annually, and updating the online version when appropriate.

Review article: pharmacotherapy for alcohol dependence - the why, the what and the wherefore

BACKGROUND

The development of alcohol dependence is associated with significant morbidity and mortality. For the majority of affected people the most appropriate goal, in terms of drinking behaviour, is abstinence from alcohol. Psychosocial intervention is the mainstay of the treatment but adjuvant pharmacotherapy is also available and its use recommended.

AIM

To provide an updated analysis of current and potential pharmacotherapeutic options for the management of alcohol dependence. In addition, factors predictive of therapeutic outcome, including compliance and pharmacogenetics, and the current barriers to treatment, including doctors' unwillingness to prescribe these agents, will be explored.

METHODS

Relevant papers were selected for review following extensive, language- and date-unrestricted, electronic and manual searches of the literature.

RESULTS

Acamprosate and naltrexone have a substantial evidence base for overall efficacy, safety and cost-effectiveness while the risks associated with the use of disulfiram are well-known and can be minimised with appropriate patient selection and supervision. Acamprosate can be used safely in patients with liver disease and in those with comorbid mental health issues and co-occurring drug-related problems. A number of other agents are being investigated for potential use for this indication including: baclofen, topiramate and metadoxine.

CONCLUSION

Pharmacotherapy for alcohol dependence has been shown to be moderately efficacious with few safety concerns, but it is substantially underutilised. Concerted efforts must be made to remove the barriers to treatment in order to optimise the management of people with this condition.

Binding mode analyses of NAP derivatives as mu opioid receptor selective ligands through docking studies and molecular dynamics simulation

Mu opioid receptor selective antagonists are highly desirable because of their utility as pharmacological probes for receptor characterization and functional studies. Furthermore, the mu opioid receptors act as an important target in drug abuse and addiction treatment. Previously, we reported NAP as a novel lead compound with high selectivity and affinity towards the mu opioid receptor. Based on NAP, we have synthesized its derivatives and further characterized their binding affinities and selectivity towards the receptor. NMP and NGP were identified as the two most selective MOR ligands among NAP derivatives. In the present study, molecular modeling methods were applied to assess the dual binding modes of NAP derivatives, particularly on NMP and NGP, in three opioid receptors, in order to analyze the effects of structural modifications on the pyridyl ring of NAP on the binding affinity and selectivity. The results indicated that the steric hindrance, electrostatic, and hydrophobic effects caused by the substituents on the pyridyl ring of NAP contributed complimentarily on the binding affinity and selectivity of NAP derivatives to three opioid receptors. Analyses of these contributions provided insights on future design of more potent and selective mu opioid receptor ligands.

Neurochemical and metabolic effects of acute and chronic alcohol in the human brain: Studies with positron emission tomography

The use of Positron emission tomography (PET) to study the effects of acute and chronic alcohol on the human brain has enhanced our understanding of the mechanisms underlying alcohol's rewarding effects, the neuroadaptations from chronic exposure that contribute to tolerance and withdrawal, and the changes in fronto-striatal circuits that lead to loss of control and enhanced motivation to drink that characterize alcohol use disorders (AUD). These include studies showing that alcohol's reinforcing effects may result not only from its enhancement of dopaminergic, GABAergic and opioid signaling but also from its caloric properties. Studies in those suffering from an AUD have revealed significant alterations in dopamine (DA), GABA, cannabinoids, opioid and serotonin neurotransmission and in brain energy utilization (glucose and acetate metabolism) that are likely to contribute to compulsive alcohol taking, dysphoria/depression, and to alcohol-associated neurotoxicity. Studies have also evaluated the effects of abstinence on recovery of brain metabolism and neurotransmitter function and the potential value of some of these measures to predict clinical outcomes. Finally, PET studies have started to provide insights about the neuronal mechanisms by which certain genes contribute to the vulnerability to AUD. These findings have helped identify new strategies for prevention and treatment of AUD. This article is part of the Special Issue entitled "Alcoholism".

The Reasons for Heavy Drinking Questionnaire: Factor Structure and Validity in Alcohol-Dependent Adults Involved in Clinical Trials

OBJECTIVE

People consume alcohol at problematic levels for many reasons. These different motivational pathways may have different biological underpinnings. Valid, brief measures that discriminate individuals' reasons for drinking could facilitate inquiry into whether varied drinking motivations account for differential response to pharmacotherapies for alcohol use disorders. The current study evaluated the factor structure and predictive validity of a brief measure of alcohol use motivations developed for use in randomized clinical trials, the Reasons for Heavy Drinking Questionnaire (RHDQ).

METHOD

The RHDQ was administered before treatment to 265 participants (70% male) with alcohol dependence according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, in three pharmacotherapy randomized clinical trials. Principal components analysis was used in half the sample to determine the RHDQ factor structure. This structure was verified with confirmatory factor analysis in the second half of the sample. The factors derived from this analysis were evaluated with respect to alcohol dependence severity indices.

RESULTS

A two-factor solution was identified. Factors were interpreted as Reinforcement and Normalizing. Reinforcement scores were weakly to moderately associated with severity, whereas normalizing scores were moderately to strongly associated with severity. In all cases in which significant associations between RHDQ scores and severity indices were observed, the relationship was significantly stronger for normalizing than for reinforcing.

CONCLUSIONS

The RHDQ is a promising brief assessment of motivations for heavy alcohol use, particularly in the context of randomized clinical trials. Additional research should address factor structure stability in non-treatment-seeking individuals and the RHDQ's utility in detecting and accounting for changes in drinking behavior, including in response to intervention.

Reward-Induced Eating: Therapeutic Approaches to Addressing Food Cravings

The homeostatic controls over eating are inextricably linked to the reward aspects of eating. The result is an integrated response that coordinates the internal milieu with the prevailing environment. Thus, appetite, which reflects a complex interaction among the external environment, behavioral profile, and subjective states as well as the storage and metabolism of energy, has an important role in the regulation of energy balance. In the prevailing food environment which offers an abundance of food choices it is likely that the motivation to consume from a wide range of delectable foods plays a greater role in contributing to overeating than in the past when the motivation to eat was largely governed by metabolic need. The response to food-related cues can promote strong desires to eat known as cravings by activating the mesocorticolimbic dopamine neurocircuitry. Cravings are associated with subsequent eating and weight-related outcomes. Being able to control food cravings is a determinant of success at adhering to an energy-restricted diet regimen. Increased understanding of the neurocircuitry of appetite regulation, especially reward-related eating behavior, has provided potential targets for therapeutic anti-obesity agents specifically directed at reward mechanisms. The naltrexone-bupropion combination and lorcaserin, which are both approved by the US Food and Drug Administration (FDA) for long-term weight management, have shown promise in addressing craving-related eating behavior. Phentermine and liraglutide are approved as monotherapies for weight management. Preliminary research suggests that liraglutide, as well as phentermine alone or in combination with lorcaserin, may be effective in targeting food cravings. Food components such as thylakoid membranes have also been shown to influence food cravings. This review explores the concepts related to appetite and reward-induced eating behavior, as well as the pharmacological options and food-derived components that may be used to address food cravings.

Unhealthy Alcohol Use

Unhealthy alcohol use is common and routine screening is essential to identify patients and initiate appropriate treatment. At-risk or hazardous drinking is best managed with brief interventions, which can be performed by any provider and are designed to enhance patients' motivations and promote behavioral change. Alcohol withdrawal can be managed, preferably with benzodiazepines, using a symptom-triggered approach. Twelve-step programs and provider-driven behavioral therapies have robust data supporting their effectiveness and patients with alcohol use disorder should be referred for these services. Research now support the use of several FDA-approved medications that aid in promoting abstinence and reducing heavy drinking.

Reductions in Alcohol Craving Following Naltrexone Treatment for Heavy Drinking

AIMS

The role of craving for alcohol as a response to alcohol treatment is not well understood. We examined daily diary ratings of craving over the course of 28 days among individuals participating in an inpatient substance abuse treatment program.

METHODS

Participants were alcohol dependent patients (n = 100) in the Hazelden residential treatment program who were offered and agreed to take naltrexone and an age- and gender-matched comparison group (n = 100) of alcohol-dependent patients in the same program who declined the offer of treatment with naltrexone. Changes in craving over time were compared between the two groups.

RESULTS

The naltrexone-treated group reported a more rapid decrease in craving than the usual care group.

CONCLUSIONS

The change in the trajectory of craving is consistent with prior reports suggesting that craving reduction is a mechanism of naltrexone's efficacy in treating alcohol dependence. Providing naltrexone to individuals seeking treatment for alcohol dependence may accelerate a reduction in their craving, consistent with a primary target of many addiction treatment programs.

SHORT SUMMARY

Craving ratings by 100 residential patients taking naltrexone for alcohol dependence were compared to ratings by 100 patients who did not take naltrexone. Craving for alcohol decreased more rapidly in the patients taking naltrexone. Providing naltrexone to individuals seeking treatment for alcohol dependence may accelerate a reduction in craving, which may benefit treatment efforts.

Lipophilic nalmefene prodrugs to achieve a one-month sustained release

Nalmefene is an opioid antagonist which as a once-a-day tablet formulation has recently been approved for reducing ethanol intake in alcoholic subjects. In order to address the compliance issue in this patient population, a number of potential nalmefene prodrugs were synthesized with the aim of providing a formulation that could provide plasma drug concentrations in the region of 0.5-1.0ng/mL for a one-month period when dosed intramuscular to dogs or minipigs. In an initial series of studies, three different lipophilic nalmefene derivatives were evaluated: the palmitate (C16), the octadecyl glutarate diester (C18-C5) and the decyl carbamate (CB10). They were administered intramuscularly to dogs in a sesame oil solution at a dose of 1mg-eq. nalmefene/kg. The decyl carbamate was released relatively quickly from the oil depot and its carbamate bond was too stable to be used as a prodrug. The other two derivatives delivered a fairly constant level of 0.2-0.3ng nalmefene/mL plasma for one month and since there was no significant difference between these two, the less complex palmitate monoester was chosen to demonstrate that dog plasma nalmefene concentrations were dose-dependent at 1, 5 and 20mg-eq. nalmefene/kg. In a second set of experiments, the effect of the chain length of the fatty acid monoester promoieties was examined. The increasingly lipophilic octanoate (C8), decanoate (C10) and dodecanoate (C12) derivatives were evaluated in dogs and in minipigs, at a dose of 5mg-eq. nalmefene/kg and plasma nalmefene concentrations were measured over a four-week period. The pharmacokinetic profiles were very similar in both species with Cmax decreasing and Tmax increasing with increasing fatty acid chain length and the target plasma concentrations (0.5-1.0ng/mL over a month-long period) were achieved with the dodecanoate (C12) prodrug. These data therefore demonstrate that sustained plasma nalmefene concentrations can be achieved in both dog and minipig using nalmefene prodrugs and that the pharmacokinetic profile of nalmefene can be tuned by varying the length of the alkyl group.

Bupropion-SR plus naltrexone-SR for the treatment of mild-to-moderate obesity

Naltrexone-bupropion is a recently approved drug combination for chronic weight management. In this article, we discuss the rationale for its use as a combination followed by a comprehensive review of safety and efficacy data from major preclinical, phase II and III clinical trials.

Naltrexone Maintenance Decreases Cannabis Self-Administration and Subjective Effects in Daily Cannabis Smokers

Given that cannabis use is increasing in the United States, pharmacological treatment options to treat cannabis use disorder are needed. Opioid antagonists modulate cannabinoid effects and may offer a potential approach to reducing cannabis use. In this double-blind, placebo-controlled human laboratory study, we assessed the effects of naltrexone maintenance on the reinforcing, subjective, psychomotor, and cardiovascular effects of active and inactive cannabis. Nontreatment-seeking, daily cannabis smokers were randomized to receive naltrexone (50 mg: n=18 M and 5 F) or placebo (0 mg; n=26 M and 2 F) capsules for 16 days. Before, during, and after medication maintenance, participants completed 10 laboratory sessions over 4-6 weeks, assessing cannabis' behavioral and cardiovascular effects. Medication compliance was verified by observed capsule administration, plasma naltrexone, and urinary riboflavin. Relative to placebo, maintenance on naltrexone significantly reduced both active cannabis self-administration and its positive subjective effects ('good effect'). Participants in the placebo group had 7.6 times (95% CI: 1.1-51.8) the odds of self-administering active cannabis compared with the naltrexone group. This attenuation of reinforcing and positive subjective effects also influenced cannabis use in the natural ecology. Naltrexone had intrinsic effects: decreasing ratings of friendliness, food intake, and systolic blood pressure, and increasing spontaneous reports of stomach upset and headache, yet dropout rates were comparable between groups. In summary, we show for the first time that maintenance on naltrexone decreased cannabis self-administration and ratings of 'good effect' in nontreatment-seeking daily cannabis smokers. Clinical studies in patients motivated to reduce their cannabis use are warranted to evaluate naltrexone's efficacy as a treatment for cannabis use disorder.

Downregulation of the endogenous opioid peptides in the dorsal striatum of human alcoholics

The endogenous opioid peptides dynorphins and enkephalins may be involved in brain-area specific synaptic adaptations relevant for different stages of an addiction cycle. We compared the levels of prodynorphin (PDYN) and proenkephalin (PENK) mRNAs (by qRT-PCR), and dynorphins and enkephalins (by radioimmunoassay) in the caudate nucleus and putamen between alcoholics and control subjects. We also evaluated whether PDYN promoter variant rs1997794 associated with alcoholism affects PDYN expression. Postmortem specimens obtained from 24 alcoholics and 26 controls were included in final statistical analysis. PDYN mRNA and Met-enkephalin-Arg-Phe, a marker of PENK were downregulated in the caudate of alcoholics, while PDYN mRNA and Leu-enkephalin-Arg, a marker of PDYN were decreased in the putamen of alcoholics carrying high risk rs1997794 C allele. Downregulation of opioid peptides in the dorsal striatum may contribute to development of alcoholism including changes in goal directed behavior and formation of a compulsive habit in alcoholics.

Randomized controlled trial of a mobile phone intervention for improving adherence to naltrexone for alcohol use disorders

Background

Naltrexone is a front-line treatment for alcohol use disorders, but its efficacy is limited by poor medication adherence. This randomized controlled trial evaluated whether a mobile health intervention could improve naltrexone adherence.

Methods

Treatment-seeking participants with an alcohol use disorder (N = 76) were randomized to intervention and control conditions. All participants received naltrexone (50 mg/day) with a medication event monitoring system (MEMS) and a prepaid smartphone, and received a daily text message querying medication side effects, alcohol use, and craving. Those in the intervention arm received additional medication reminders and adherence assessment via text message.

Results

The primary outcome, proportion of participants with adequate adherence (defined as ≥80% of prescribed doses taken through Week 8), did not differ between groups in intent-to-treat analyses (p = .34). Mean adherence at study midpoint (Week 4) was 83% in the intervention condition and 77% in the control condition (p = .35). Survival analysis found that the intervention group sustained adequate adherence significantly longer (M = 19 days [95% CI = 0.0–44.0]) than those in the control group (M = 3 days [95% CI = 0.0–8.1]) during the first month of treatment (p = .04). Medication adherence did not predict drinking outcomes.

Conclusions

These results suggest that in the context of daily monitoring and assessment via cell phone, additional text message reminders do not further improve medication adherence. Although this initial trial does not provide support for the efficacy of text messaging to improve adherence to pharmacotherapy for alcohol use disorders, additional trials with larger samples and alternate designs are warranted.

Trial Registration

ClinicalTrials.gov: NCT01349985

Views about responsibility for alcohol addiction and negative evaluations of naltrexone

BACKGROUND

Moral philosophers have debated the extent to which persons are individually responsible for the onset of and recovery from addiction. Empirical investigators have begun to explore counselors' attitudes on these questions. Meanwhile, a separate literature has investigated counselors' negative attitudes towards naltrexone, an important element of medication-assisted treatment for alcohol addiction. The present study bridges the literature on counselor views about responsibility for addiction with the literature on attitudes towards naltrexone. It investigates the extent to which a counselor's views of individual responsibility for alcohol addiction are related to that counselor's views of naltrexone.

METHODS

Using a vignette-based survey of 117 addiction treatment professionals, the study analyzes the relationship between an addiction counselor's views about individual responsibility for alcohol addiction and using naltrexone to treat it.

RESULTS

We find a significant difference in counselors who assign greater responsibility to a person for the onset of alcohol addiction. They agreed more strongly with several objections to naltrexone, including worries about compliance, naltrexone's side effects outweighing its benefits, naltrexone treating symptoms but not underlying causes, and the idea that medication may undermine a person's motivation to recover. Combined views of greater responsibility for addiction's onset and recovery also significantly predicted stronger agreement with objections.

CONCLUSIONS

We conclude that there is a strong relationship between a counselor assigning higher individual responsibility for addiction and holding more negative views about naltrexone. The study also sheds light on one reason why the model of addiction as a brain disease has had limited impact on clinical practice.

An inpatient treatment and discharge planning protocol for alcohol dependence: efficacy in reducing 30-day readmissions and emergency department visits

BACKGROUND

Alcohol dependence results in multiple hospital readmissions, but no discharge planning protocol has been studied to improve outcomes. The inpatient setting is a frequently missed opportunity to discuss treatment of alcohol dependence and initiate medication-assisted treatment, which is effective yet rarely utilized.

AIM

Our aim was to implement and evaluate a discharge planning protocol for patients admitted with alcohol dependence.

SETTING

The study took place at the San Francisco General Hospital (SFGH), a university-affiliated, large urban county hospital.

PARTICIPANTS

Learner participants included Internal Medicine residents at the University of California, San Francisco (UCSF) who staff the teaching service at SFGH. Patient participants included inpatients with alcohol dependence admitted to the Internal Medicine teaching service.

PROGRAM DESCRIPTION

We developed and implemented a discharge planning protocol for patients admitted with alcohol dependence that included eligibility assessment and initiation of medication-assisted treatment.

PROGRAM EVALUATION

Rates of medication-assisted treatment increased from 0% to 64% (p value < 0.001). All-cause 30-day readmission rates to SFGH decreased from 23.4% to 8.2% (p value = 0.042). All-cause emergency department visits to SFGH within 30 days of discharge decreased from 18.8% to 6.1% (p value = 0.056).

DISCUSSION

Through implementation of a discharge planning protocol by Internal Medicine residents for patients admitted with alcohol dependence, there was a statistically significant increase in medication-assisted treatment and a statistically significant decrease in both 30-day readmission rates and emergency department visits.

Reduced processing of alcohol cues predicts abstinence in recently detoxified alcoholic patients in a three-month follow up period: an ERP study

One of the major challenges in alcohol dependence is relapse prevention, as rates of relapse following detoxification are high. Drug-related motivational processes may represent key mechanisms in alcoholic relapse. In the present study, event-related potentials (ERPs) were recorded during a visual oddball task administered to 29 controls (11 females) and 39 patients (9 females). Deviant stimuli were related or unrelated to alcohol. For patients, the task was administered following a 3-week detoxification course. Of these, 19 relapsed during the three months follow-up period. The P3, an ERP component associated with activation of arousal systems in the brain and motivational engagement, was examined with the aim to link the fluctuation of its amplitude in response to alcohol versus non-alcohol cues to the observed relapse rate. Results showed that compared to relapsers, abstainers presented with a decreased P3 amplitude for alcohol related compared to non-alcohol related pictures (p=.009). Microstate analysis and sLORETA topography showed that activation for both types of deviant cues in abstainers originated from the inferior and medial temporal gyrus and the uncus, regions implicated in detection of target stimuli in oddball tasks and of biologically relevant stimuli. Through hierarchical regression, it was found that the P3 amplitude difference between alcohol and non-alcohol related cues was the best predictor of relapse vulnerability (p=.013). Therefore, it seems that a devaluation of the motivational significance of stimuli related to alcohol, measurable through electrophysiology, could protect from a relapse within three months following detoxification in alcohol-dependent patients.

Effects of naltrexone plus topiramate on ethanol self-administration and tyrosine hydroxylase gene expression changes

The purpose of this study was to evaluate the effects of naltrexone (0.7 mg/kg) and/or topiramate (25 mg/kg) on ethanol consumption and the motivation to drink in an oral-operant conditioning paradigm in C57BL/6 mice. Subsequent real-time polymerase chain reaction (PCR) experiments were performed to analyze gene expression changes in tyrosine hydroxylase (TH) in the ventral tegmental area (VTA). The administration of naltrexone significantly reduced ethanol consumption and the motivation to drink during the different stages of the experiment, whereas the treatment with topiramate resulted in a much lower effect. Interestingly, the administration of naltrexone plus topiramate reduced ethanol consumption markedly compared with single-drug treatment. The water self-administration paradigm was also performed using the same drugs and no differences were found between treatment groups. Real-time PCR analyses revealed that naltrexone significantly normalized the increase of TH gene expression in the VTA induced by ethanol, whereas the administration of topiramate did not produce any significant effect. In the ethanol self-administration procedure, the combination of both drugs further reduced TH gene expression, reaching statistical significance compared with the vehicle, naltrexone or topiramate groups. Taken together, these findings indicate that the administration of naltrexone plus topiramate further reduced ethanol consumption and the motivation to drink in comparison with single-drug treatment. This action may be due, at least in part, to a greater decrease in TH gene expression in the VTA. These results suggest that the combination of both drugs deserves further exploration for the treatment of problems related to alcohol consumption.

Naltrexone/bupropion for obesity: an investigational combination pharmacotherapy for weight loss

The mechanism of action of the combination therapy, naltrexone/bupropion (NB), for obesity has not been fully described to date. Weight loss attempts rarely result in long-term success. This is likely a result of complex interactions among multiple peripheral and CNS systems that defend against weight loss, and may explain the overwhelming lack of effective obesity treatments. NB is an investigational combination therapy for obesity that was developed based on evidence that obesity involves alterations in the hypothalamic melanocortin system as well as brain reward systems that influence food craving and mood. Naltrexone and bupropion both have actions in these brain regions that may cause them to influence food intake, food craving, and other aspects of eating behavior that affect body weight. We review the individual actions of naltrexone and bupropion in brain hypothalamic and reward systems, and describe the current in vitro, in vivo, and clinical evidence for how NB influences food intake and produces weight loss.

Treatment of fetishism with naltrexone: a case report

Fetishism is a paraphilic sexual disorder characterized by recurrent, intense sexually arousing fantasies, sexual urges or behaviors involving the use of nonliving objects. We describe a case of fetishism with comorbid alcohol and cannabis dependence. A 40-year-old man was presented with sexual fantasies and urges toward women's undergarments since the age of 25 years. He had fetish behavior even during prolonged period of abstinence from substance use. Our case remitted from fetishism and cannabis and alcohol use on treatment with naltrexone and maintains remission for the last 11 months. Experience with our patient suggests that naltrexone may be effective to treat fetishism with comorbid substance use. Our case is reported as it is the first reported case of successful use of naltrexone in fetishism comorbid with cannabis and alcohol dependence.

Alcoholic hepatitis: Prognosis and treatment

Alcoholic hepatitis (AH) is a type of acute-on-chronic liver failure and is the most severe form of alcoholic liver disease. AH occurs in patients with heavy alcohol abuse and underlying liver disease. In its severe form, AH carries a poor short-term prognosis. Although the existence of AH can be strongly suspected based on clinical and biochemical criteria, a definitive diagnosis requires a liver biopsy. There is a clear need to develop non-invasive markers for these patients. The prognosis of patients with AH can be established by different score systems (Maddrey's DF, ABIC, MELD and Glasgow). Recently, a histological scoring system able to estimate prognosis has been developed (Alcoholic Hepatitis Histological Score - AHHS). The management of patients with AH has changed little in the last few decades. In patients with severe form of AH, prednisolone and pentoxifylline are the first line therapy. Unfortunately, many patients do not respond and novel targeted therapies are urgently needed. Current research is aimed at identifying the main disease drivers and to develop animal models of true AH. For non-responders to medical therapy, the only curative option is to perform a salvage liver transplantation. This particular indication of liver transplantation is currently under debate and prospective studies should evaluate the specific patient evaluation and selection criteria.

Pharmacologic treatment of alcoholism

Progress in understanding the neuroscience of addiction has significantly advanced the development of more efficacious medications for the treatment of alcohol use disorders (AUD). While several medications have been approved by regulatory bodies around the world for the treatment of AUD, they are not universally efficacious. Recent research has yielded improved understanding of the genetics and brain circuits that underlie alcohol reward and its habitual use. This research has contributed to pharmacogenetic studies of medication response, and will ultimately lead to a more "personalized medicine" approach to AUD pharmacotherapy. This chapter summarizes work on clinically available medications (both approved by regulatory bodies and investigational) for the treatment of alcohol dependence, as well as the psychiatric disorders that are commonly comorbid with AUD. Studies that have evaluated genetic influences on medication response and those that have employed neuroimaging to probe mechanisms of medication action or response are highlighted. Finally, new targets discovered in animal models for possible pharmacologic intervention in humans are overviewed and future directions in medications development provided.

Binding mode characterization of 6α- and 6β-N-heterocyclic substituted naltrexamine derivatives via docking in opioid receptor crystal structures and site-directed mutagenesis studies: application of the 'message-address' concept in development of mu opioid receptor selective antagonists

Highly selective opioid receptor antagonists are essential pharmacological probes in opioid receptor structural characterization and opioid agonist functional studies. Currently, there is no highly selective, nonpeptidyl and reversible mu opioid receptor antagonist available. Among a series of naltrexamine derivatives that have been designed and synthesized, two compounds, NAP and NAQ, were previously identified as novel leads for this purpose based on their in vitro and in vivo pharmacological profiles. Both compounds displayed high binding affinity and selectivity to the mu opioid receptor. To further study the interaction of these two ligands with the three opioid receptors, the recently released opioid receptor crystal structures were employed in docking studies to further test our original hypothesis that the ligands recognize a unique 'address' domain in the mu opioid receptor involving Trp318 that facilitates their selectivity. These modeling results were supported by site-directed mutagenesis studies on the mu opioid receptor, where the mutants Y210A and W318A confirmed the role of the latter in binding. Such work not only enriched the 'message-address' concept, also facilitated our next generation ligand design and development.

Naltrexone may block euphoria-like placebo effect

Naltrexone is a first-line treatment for alcohol use disorders in North America and Europe. It was prescribed to a 63-year-old patient in order to help control amounts of alcohol consumed per drinking occasion. The patient experienced a paradoxical, but consistent side effect of feeling inebriated each time he took naltrexone. In order to investigate this phenomenon we administered naltrexone and a placebo in a randomised double-blind fashion. The patient exhibited a 'high-like' response to all placebo capsules and a decrease in the subjectively perceived euphoria shortly after ingestion of naltrexone. Given that this placebo effect could be mediated via opioid receptors we suggest that this case illustrates the ability of naltrexone to eliminate the placebo effect. This feature of naltrexone, upon further investigation, might be used in randomised clinical trials in addition to or as an alternative to a placebo.

Training and fidelity monitoring of alcohol treatment interventions integrated into routine tuberculosis care in Tomsk, Russia: the IMPACT Effectiveness Trial

IMPACT (Integrated Management of Physician-Delivered Alcohol Care for Tuberculosis patients) is a randomized, controlled effectiveness trial based in Tomsk, Russia, that assesses the effect of oral naltrexone and brief behavioral counseling on tuberculosis outcomes and alcohol use in 200 patients. Tuberculosis physicians without addiction experience delivered interventions as part of routine care over a 6-month period, focusing on alcohol intake reduction to support successful tuberculosis treatment. We describe design, training, and fidelity monitoring using a Russian and American team of physicians, bilingual coders, and supervisors. Culturally appropriate adaptations, limitations, and implications for future trials are discussed. The clinical trial identification number is NCT00675961. Funding came from the National Institutes of Health and National Institute on Drug Abuse.

Treating the "unhealthy alcohol user" on medical wards: beyond withdrawal

BACKGROUND

Alcohol use disorders (AUDs) are common among patients admitted to general hospitals. Unfortunately, AUDs often go undetected and untreated. Psychiatrists are frequently called upon to assist in the management of cases involving alcohol withdrawal. However, there is a dearth of knowledge regarding potential therapeutic approaches to AUDs beyond the acute withdrawal stage.

OBJECTIVE

This article presents an overview of the epidemiology, clinical characteristics, and treatment of AUDs on medical wards, with a specific focus on the post alcohol-withdrawal phase.

METHOD

This article is based on a survey of the published literature on AUDs and their treatment in the medical ward using the PubMed database.

RESULTS

Various screening tools are available to facilitate the detection of AUDs. Among non-medically ill patients, brief psychological interventions have proven to be effective in primary care and emergency room settings, while pharmacotherapy has been shown to reduce the risk of relapse. Existing data on the implementation of these interventions in the general hospital setting remain scarce.

CONCLUSION

Current evidence suggests the need for additional research in this area with a view toward clarifying AUD treatment guidelines for medically ill inpatients. The hospital stay could provide a valuable opportunity to initiate interventions for AUDs with medically ill patients, leading to significant changes in alcohol use behaviors and better health-related outcomes.

Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful?

AIMS

Although debates over the efficacy of oral naltrexone and acamprosate in treating alcohol use disorders tend to focus on their global efficacy relative to placebo or their efficacy relative to each other, the underlying reality may be more nuanced. This meta-analysis examined when naltrexone and acamprosate are most helpful by testing: (i) the relative efficacy of each medication given its presumed mechanism of action (reducing heavy drinking versus fostering abstinence) and (ii) whether different ways of implementing each medication (required abstinence before treatment, detoxification before treatment, goal of treatment, length of treatment, dosage) moderate its effects.

METHODS

A systematic literature search identified 64 randomized, placebo-controlled, English-language clinical trials completed between 1970 and 2009 focused on acamprosate or naltrexone.

RESULTS

Acamprosate had a significantly larger effect size than naltrexone on the maintenance of abstinence, and naltrexone had a larger effect size than acamprosate on the reduction of heavy drinking and craving. For naltrexone, requiring abstinence before the trial was associated with larger effect sizes for abstinence maintenance and reduced heavy drinking compared with placebo. For acamprosate, detoxification before medication administration was associated with better abstinence outcomes compared with placebo.

CONCLUSIONS

In treatment for alcohol use disorders, acamprosate has been found to be slightly more efficacious in promoting abstinence and naltrexone slightly more efficacious in reducing heavy drinking and craving. Detoxification before treatment or a longer period of required abstinence before treatment is associated with larger medication effects for acamprosate and naltrexone respectively.

Safety and efficacy of acamprosate for the treatment of alcohol dependence

Acamprosate (calcium acetylhomotaurine) is an amino acid modulator that has displayed efficacy in some clinical trials in reducing craving and promoting abstinence in alcohol dependent patients following detoxification. While acamprosate is safe and generally well-tolerated, not all studies have demonstrated clinical efficacy that is superior to placebo. In addition, the precise neurochemical mechanisms of action of acamprosate have still not yet been identified. In this review, we summarize current clinical data on the safety, efficacy, and pharmacokinetic properties of acamprosate, as well theories on its potential mechanism of action. We also discuss tolerability and patient preference issues and conclude with a discussion of the place of acamprosate in addiction medicine and therapy.

The endogenous opioid system in human alcoholics: molecular adaptations in brain areas involved in cognitive control of addiction

The endogenous opioid system (EOS) plays a critical role in addictive processes. Molecular dysregulations in this system may be specific for different stages of addiction cycle and neurocircuitries involved and therefore may differentially contribute to the initiation and maintenance of addiction. Here we evaluated whether the EOS is altered in brain areas involved in cognitive control of addiction including the dorsolateral prefrontal cortex (dl-PFC), orbitofrontal cortex (OFC) and hippocampus in human alcohol-dependent subjects. Levels of EOS mRNAs were measured by quantitative reverse transcription-polymerase chain reaction (qRT-PCR), and levels of dynorphins by radioimmunoassay (RIA) in post-mortem specimens obtained from 14 alcoholics and 14 controls. Prodynorphin mRNA and dynorphins in dl-PFC, κ-opioid receptor mRNA in OFC and dynorphins in hippocampus were up-regulated in alcoholics. No significant changes in expression of proenkephalin, and µ- and δ-opioid receptors were evident; pro-opiomelanocortin mRNA levels were below the detection limit. Activation of the κ-opioid receptor by up-regulated dynorphins in alcoholics may underlie in part neurocognitive dysfunctions relevant for addiction and disrupted inhibitory control.

A randomized trial evaluating an mHealth system to monitor and enhance adherence to pharmacotherapy for alcohol use disorders

BACKGROUND

Nonadherence to prescribed medication regimens is a substantial barrier to the pharmacological management of alcohol use disorders. The availability of low-cost, sustainable interventions that maximize medication adherence would likely lead to improved treatment outcomes. Mobile health (mHealth) technologies are increasingly being adopted as a method of delivering behavioral health interventions and represent a promising tool for adherence interventions. We are evaluating a cell-phone-based intervention called AGATE that seeks to enhance adherence with regular text-messaging.

METHODS/DESIGN

A randomized controlled effectiveness trial in the context of an eight-week open label naltrexone efficacy trial delivered in a naturalistic clinical setting. Treatment-seeking heavy drinkers (N = 105) are currently being recruited and randomly assigned to the AGATE intervention or a control condition. Daily measures of alcohol use and medication side effects are being recorded via cell phone in both conditions. Additionally, participants randomized to the AGATE condition receive medication reminders via SMS text message according to a schedule that adjusts according to their level of adherence.

DISCUSSION

Results from this trial will provide initial information about the feasibility and efficacy of mHealth interventions for improving adherence to alcohol pharmacotherapies.

TRIAL REGISTRATION

NCT01349985.

Treatments for alcohol-related disorders in China: a developing story

AIMS

Alcohol-related disorders (ARDs) have become an increasing mental health and social challenge in China. Research from China may provide important clinical information for researchers and clinicians around the world. However, most of the Chinese research on ARDs has only been published in Chinese language journals. This article summarizes publications related to treatments for ARDs found in the Chinese literature.

METHODS

A descriptive study based on literature identified from searches of the China National Knowledge Infrastructure (1979-2012), Pubmed databases and hand-picked references with emphasis on traditional Chinese medicine (TCM).

RESULTS

More than 1500 Chinese language papers on treatment for ARDs were found and ~110 were selected. Many medications used in the Western countries (e.g. disulfiram and acamprosate) are not available in China, and no drugs have been officially approved for alcohol dependence. TCM approaches (including acupuncture, electroacupunture and herbals) have played a role in treatment for ARDs with some positive results. These unique methods are reviewed and the need for additional controlled studies is noted.

CONCLUSION

Currently, very limited facilities, medications or programs are available for patients with ARDs in China, thus much improvement is needed in the field, including setting up intervention/treatment programs.

Advancing addiction treatment: what can we learn from animal studies?

Substance addiction is a maladaptive behavior characterized by compulsive and uncontrolled self-administration of a substance (drug). Years of research indicate that addictive behavior is the result of complex interactions between the drug, the user, and the environment in which the drug is used; therefore, addiction cannot simply be attributed to the neurobiological actions of a drug. However, despite the obvious complexity of addictive behavior, animal models have both advanced understanding of addiction and contributed importantly to the development of medications to treat this disease. We briefly review recent animal models used to study drug addiction and the contribution of data generated by these animal models for the clinical treatment of addictive disorders.

Alcohol use in Polish 9/11 responders: implications for cross-cultural treatment

More than 35,000 individuals are estimated to have responded to the World Trade Center (WTC) site following the terrorist attacks of September 11, 2001. The federally funded WTC Medical Monitoring and Treatment Program (WTCMMTP) provides medical monitoring and occupational medicine treatment as well as counseling regarding entitlements and benefits to the workers and volunteers who participated in the WTC response. A major component of the WTCMMTP is the WTC Mental Health Program (WTCMHP), which offers annual mental health assessments and ongoing treatment for those found to have 9/11 associated mental health problems. In the program's 9.5 years of evaluating and treating mental health problems in thousands of Ground Zero responders, diversity in multiple domains (e.g., gender, family, profession and employment status, state of physical health, cultural identity, and immigration status) has been a hallmark of the population served by the program. To illustrate the types of issues that arise in treating this diverse patient population, the authors first present a representative case involving a Polish asbestos worker with an alcohol use disorder. They then discuss how accepted alcohol treatment modalities can and often must be modified in providing psychiatric treatment to Polish responders, in particular, and to foreign-born patients in general. Treatment modalities discussed include cognitive and behavioral therapy, relapse prevention strategies, psychodynamic therapy, motivational approaches, family therapy, group peer support, and pharmacotherapy. Implications for the practice of addiction psychiatry, cultural psychiatry, and disaster psychiatry are discussed.

Chronic treatment with the opioid antagonist naltrexone favours the coupling of spinal cord μ-opioid receptors to Gαz protein subunits

Sustained administration of opioid antagonists to rodents results in an enhanced antinociceptive response to agonists. We investigated the changes in spinal μ-opioid receptor signalling underlying this phenomenon. Rats received naltrexone (120 μg/h; 7 days) via osmotic minipumps. The antinociceptive response to the μ-agonist sufentanil was tested 24 h after naltrexone withdrawal. In spinal cord samples, we determined the interaction of μ-receptors with Gα proteins (agonist-stimulated [(35)S]GTPγS binding and immunoprecipitation of [(35)S]GTPγS-labelled Gα subunits) as well as μ-opioid receptor-dependent inhibition of the adenylyl cyclase (AC) activity. Chronic naltrexone treatment augmented DAMGO-stimulated [(35)S]GTPγS binding, potentiated the inhibitory effect of DAMGO on the AC/cAMP pathway, and increased the inverse agonist effect of naltrexone on cAMP accumulation. In control rats, the inhibitory effect of DAMGO on cAMP production was antagonized by pertussis toxin (PTX) whereas, after chronic naltrexone, the effect became resistant to the toxin, suggesting a coupling of μ-receptors to PTX-insensitive Gα(z) subunits. Immunoprecipitation assays confirmed the transduction switch from Gα(i/o) to Gα(z) proteins. The consequence was an enhancement of the antinociceptive response to sufentanil that, in consonance with the neurochemical data, was prevented by Gα(z)-antisense oligodeoxyribonucleotides but not by PTX. Such changes in opioid receptor signalling can be a double-edged sword. On the one hand, they may have potential applicability to the optimisation of the analgesic effects of opioid drugs for the control of pain. On the other hand, they represent an important homeostatic dysregulation of the endogenous opioid system that might account for undesirable effects in patients chronically treated with opioid antagonists. This article is part of a Special Issue entitled 'Post-Traumatic Stress Disorder'.

Hepatic safety and antiretroviral effectiveness in HIV-infected patients receiving naltrexone

BACKGROUND

We sought to determine the impact of naltrexone on hepatic enzymes and HIV biomarkers in HIV-infected patients.

METHODS

We used data from the Veterans Aging Cohort Study-Virtual Cohort, an electronic database of administrative, pharmacy, and laboratory data. We restricted our sample to HIV-infected patients who received an initial oral naltrexone prescription of at least 7 days duration. We examined aspartate aminotransferase (AST) and alanine aminotransferase (ALT) and HIV biomarker (CD4 and HIV RNA) values for the 365 days prior to, during, and for the 365 days post-naltrexone prescription. We also examined cases of liver enzyme elevation (LEE; defined as >5 times baseline ALT or AST or >3.5 times baseline if baseline ALT or AST was >40 IU/l).

RESULTS

Of 114 HIV-infected individuals, 97% were men, 45% white, 57% Hepatitis C co-infected; median age was 49 years; 89% of the sample had a history of alcohol dependence and 32% had opioid dependence. Median duration of naltrexone prescription was 49 (interquartile range 30 to 83) days, representing 9,525 person-days of naltrexone use. Mean ALT and AST levels remained below the upper limit of normal. Two cases of LEE occurred. Mean CD4 count remained stable and mean HIV RNA decreased after naltrexone prescription.

CONCLUSIONS

In HIV-infected patients, oral naltrexone is rarely associated with clinically significant ALT or AST changes and does not have a negative impact on biologic parameters. Therefore, HIV-infected patients with alcohol or opioid dependence can be treated with naltrexone.

Prodynorphin CpG-SNPs associated with alcohol dependence: elevated methylation in the brain of human alcoholics

The genetic, epigenetic and environmental factors may influence the risk for neuropsychiatric disease through their effects on gene transcription. Mechanistically, these effects may be integrated through regulation of methylation of CpG dinucleotides overlapping with single-nucleotide polymorphisms (SNPs) associated with a disorder. We addressed this hypothesis by analyzing methylation of prodynorphin (PDYN) CpG-SNPs associated with alcohol dependence, in human alcoholics. Postmortem specimens of the dorsolateral prefrontal cortex (dl-PFC) involved in cognitive control of addictive behavior were obtained from 14 alcohol-dependent and 14 control subjects. Methylation was measured by pyrosequencing after bisulfite treatment of DNA. DNA binding proteins were analyzed by electromobility shift assay. Three PDYN CpG-SNPs associated with alcoholism were found to be differently methylated in the human brain. In the dl-PFC of alcoholics, methylation levels of the C, non-risk variant of 3'-untranslated region (3'-UTR) SNP (rs2235749; C > T) were increased, and positively correlated with dynorphins. A DNA-binding factor that differentially targeted the T, risk allele and methylated and unmethylated C allele of this SNP was identified in the brain. The findings suggest a causal link between alcoholism-associated PDYN 3'-UTR CpG-SNP methylation, activation of PDYN transcription and vulnerability of individuals with the C, non-risk allele(s) to develop alcohol dependence.

Alcoholism: a modern look at an ancient illness

Alcohol dependency (alcoholism) has existed throughout recorded history. It remains a highly stigmatized illness, looked down on by society, the patients themselves, and the medical establishment. Science defines alcoholism as a primary progressive illness with a powerful genetic predisposition, highly amenable to intervention, evaluation, and treatment, and responsive to continuing care like other chronic illnesses. Society, led by an educated medical community, needs to revisit the disease of alcoholism, challenge its outdated assumptions and prejudices, and embark on a new course with the goals of positively affecting these patients, their families, and communities and improving the nation's health.

Twenty per hour: altered mental state due to ethanol abuse and withdrawal

This article discusses the physiology and clinical syndromes involved in ethanol absorption, intoxication, and withdrawal, with special emphasis on the evidentiary backing for common treatments, as well as some discussion of the medicolegal sequelae of treatment of ethanol abusers in the emergency department.

Substance use disorders: realizing the promise of pharmacogenomics and personalized medicine

Current pharmacological and psychosocial approaches to the treatment of alcohol dependence may best be described as modestly effective, and it is unlikely that a magic bullet for the treatment of any substance use disorder will ever be developed. Rather, it seems more likely that there will be a number of treatment options, each of which will target different mechanisms. Thus, future treatment gains are likely to depend on the ability to match individuals with the treatment most likely to benefit them, which in turn is contingent on our ability to understand the mechanisms that drive the maintenance of substance use disorders on an individual level. On a more global scale, this type of effort has been described as "personalized medicine" and has focused largely on the human genome as a source of information that can be used to match individuals to treatments. This review enumerates barriers to realizing the potential of personalized medicine for substance use disorders and identifies opportunities to overcome those barriers, which involve the development of translational approaches that focus on the development of brain-based phenotypes that serve as the target of both treatment development and of genetic research.

Neurologic aspects of drug abuse

Neurologic aspects of drug abuse vary. This article explains the general nature of drug abuse, identifies the physiologic effects of certain drugs, and briefly describes the neurobiology of addiction. This article also reviews available treatment options for those addicted to substances of abuse, and clarifies common misconceptions, including the differences between tolerance, abuse, and addiction.

The pharmacotherapy of alcohol dependence: a state of the art review

The psychopharmacology of alcohol dependence is today poised at interesting crossroads. Three major drugs Naltrexone, Disulfiram and Acamprosate have been tried and tested in various trials and have many meta-analyses each to support them. While Naltrexone may reduce craving, Acamprosate scores on cost effectiveness worldwide with Disulfiram being an alcohol deterrent drug. Studies support, refute and criticize the use of each of these drugs. Combining one or more of them is also a trend seen. The most important factor in efficacy has been the combination of psychosocial treatment with medication. Studies from the early 1970s to date have been reviewed and the findings presented in a manner useful for the busy clinician to judge the best pharmacological option in the management of alcohol dependence. The role of depot disulfiram, naltrexone, and medications like Topiramate and SSRIs under research for alcohol dependence, are also addressed.