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Unlu H, Macaron MM, Ayraler Taner H, Kaba D, Akin Sari B, Schneekloth TD, Leggio L, Abulseoud OA. Sex difference in alcohol withdrawal syndrome: a scoping review of clinical studies. Front Psychiatry 2023; 14:1266424. [PMID: 37810604 PMCID: PMC10556532 DOI: 10.3389/fpsyt.2023.1266424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/04/2023] [Indexed: 10/10/2023] Open
Abstract
Background We conducted a review of all studies comparing clinical aspects of alcohol withdrawal syndrome (AWS) between men and women. Methods Five databases (PubMed, Cochrane, EMBASE, Scopus and Clinical Trials) were searched for clinical studies using the keywords "alcohol withdrawal syndrome" or "delirium tremens" limited to "sex" or "gender" or "sex difference" or "gender difference." The search was conducted on May 19, 2023. Two reviewers selected studies including both male and female patients with AWS, and they compared males and females in type of AWS symptoms, clinical course, complications, and treatment outcome. Results Thirty-five observational studies were included with a total of 318,730 participants of which 75,346 had AWS. In twenty of the studies, the number of patients presenting with or developing AWS was separated by sex, resulting in a total of 8,159 (12.5%) female patients and a total of 56,928 (87.5%) male patients. Despite inconsistent results, males were more likely than females to develop complicated AWS [delirium tremens (DT) and AW seizures, collective DT in Males vs. females: 1,792 (85.4%) vs. 307 (14.6%), and collective seizures in males vs. females: 294 (78%) vs. 82 (22%)]. The rates of ICU admissions and hospital length of stay did not show sex differences. Although variable across studies, compared to females, males received benzodiazepine treatment at higher frequency and dose. One study reported that the time from first hospitalization for AWS to death was approximately 1.5 years shorter for males and males had higher mortality rate [19.5% (197/1,016)] compared to females [16% (26/163)]. Conclusion Despite the significant heterogeneity of the studies selected and the lack of a focus on investigating potential sex differences, this review of clinical studies on AWS suggests that men and women exhibit different AWS manifestations. Large-scale studies focusing specifically on investigating sex difference in AWS are needed.
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Affiliation(s)
- Hayrunnisa Unlu
- Department of Psychiatry and Psychology, Mayo Clinic Arizona, Phoenix, AZ, United States
- Department of Child and Adolescent Psychiatry, Baskent University School of Medicine Hospital, Ankara, Turkey
| | | | - Hande Ayraler Taner
- Department of Child and Adolescent Psychiatry, Baskent University School of Medicine Hospital, Ankara, Turkey
| | - Duygu Kaba
- Department of Child and Adolescent Psychiatry, Baskent University School of Medicine Hospital, Ankara, Turkey
| | - Burcu Akin Sari
- Department of Child and Adolescent Psychiatry, Baskent University School of Medicine Hospital, Ankara, Turkey
| | - Terry D. Schneekloth
- Department of Psychiatry and Psychology, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Lorenzo Leggio
- Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, Translational Addiction Medicine Branch, National Institute on Drug Abuse, and National Institute on Alcohol Abuse and Alcoholism, Baltimore, MD, United States
| | - Osama A. Abulseoud
- Department of Psychiatry and Psychology, Mayo Clinic Arizona, Phoenix, AZ, United States
- Department of Neuroscience, Graduate School of Biomedical Sciences, Mayo Clinic College of Medicine, Phoenix, AZ, United States
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Faustmann TJ, Paschali M, Kojda G, Schilbach L, Kamp D. [Antipsychotic Treatment of Alcohol Withdrawal Syndrome with Focus on Delirium Tremens: a Systematic Review]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2023. [PMID: 36958342 DOI: 10.1055/a-2029-6387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
BACKGROUND Delirium tremens (DT) is a common complication of alcohol withdrawal. Pharmacological treatment of hospitalized patients with DT is important in addiction medicine but also in other medical disciplines where DT can occur as a complication of hospitalization. Patients suffering from DT require treatment with benzodiazepines (short-acting benzodiazepines for elderly patients to reduce accumulation), and in cases of psychotic symptoms, treatment with antipsychotics. Benzodiazepines are a first-line treatment for DT. A specific guideline for the use of antipsychotics has yet to be developed. This review discusses the current guidelines and literature on the antipsychotic treatment options in DT. AIM Systematic presentation of relevant antipsychotics for the treatment of DT. METHODS A systematic literature search was conducted using Scopus and PubMed. The last search was conducted on May 22nd 2022. Original articles and reviews on antipsychotic treatment in alcohol withdrawal and DT were included in this review. Further, international guidelines were also considered. The review was registered using the PROSPERO database (https://www.crd.york.ac.uk/prospero/); CRD42021264611. RESULTS Haloperidol is mainly recommended for use in the intensive care unit. There is little literature on the use of atypical antipsychotics to treat DT. Treatment with antipsychotics always should be combined with benzodiazepines, and physicians should watch out for complications like neuroleptic malignant syndrome, QTc interval prolongation, extrapyramidal symptoms and withdrawal seizures resulting from lowering the threshold for seizures. CONCLUSION Antipsychotic treatment should depend on the experience of the physician. Beside haloperidol, no other clear recommendations are available.
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Affiliation(s)
- Timo Jendrik Faustmann
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
- Abteilung für Allgemeine Psychiatrie 2, LVR-Klinikum Düsseldorf, Düsseldorf, Germany
| | - Myrella Paschali
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
- Abteilung für Gerontopsychiatrie, LVR-Klinikum Düsseldorf, Düsseldorf, Germany
| | - Georg Kojda
- Institut für Pharmakologie, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Leonhard Schilbach
- Abteilung für Allgemeine Psychiatrie 2, LVR-Klinikum Düsseldorf, Düsseldorf, Germany
- Klinik für Psychiatrie und Psychotherapie, Ludwig-Maximilians-Universität München, München, Germany
| | - Daniel Kamp
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
- Abteilung für Allgemeine Psychiatrie 2, LVR-Klinikum Düsseldorf, Düsseldorf, Germany
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Muddapah CP, Weich L. Assessing the revised Clinical Institute Withdrawal for Alcohol Scale use at Stikland Hospital. S Afr J Psychiatr 2023; 29:1915. [PMID: 36756541 PMCID: PMC9900294 DOI: 10.4102/sajpsychiatry.v29i0.1915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 09/06/2022] [Indexed: 02/04/2023] Open
Abstract
Background Alcohol use disorder (AUD) is a major public health concern in South Africa (SA). Abrupt cessation or reduction of alcohol intake in chronic users can result in withdrawal symptoms. Benzodiazepines are the treatment of choice but need to be used cautiously in patients with a lifetime history of substance abuse given their highly addictive potential. Symptom-triggered prescription of benzodiazepines during alcohol withdrawal using the Revised Clinical Institute Withdrawal for Alcohol Scale (CIWA-Ar) has been associated with improved safety and reduced benzodiazepines use. Aim To investigate if implementation of the CIWA-Ar during alcohol detoxification impacted the dose of benzodiazepines used and withdrawal-related outcomes. Setting Alcohol rehabilitation unit (ARU) at Stikland Psychiatric Hospital. Methods A retrospective cohort study of 135 admissions over a six-month period comparing two groups: before (2015) and after (2017) the implementation of the CIWA-Ar. Results The study noted no differences in sociodemographic and alcohol-associated variables between the two groups, and there were no recorded complications in either group. The 2017 group had a lower percentage of patients that required benzodiazepines (33.8% vs. 51.4%, p = 0.04) and a lower median total amount of benzodiazepines used during alcohol withdrawal (0 mg vs. 5 mg, p = 0.01). Conclusions The CIWA-Ar rating scale was an effective alternative to prescribing benzodiazepines pro re nata and decreased the total dose of benzodiazepines used during alcohol withdrawal. Contribution The use of a symptom triggered regime, like the CIWA-Ar rating scale, during withdrawal can be implemented safely in a SA treatment setting for patients with low-risk AUD.
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Affiliation(s)
- Creeshen P. Muddapah
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Lize Weich
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Li X, Shi Z, Byanyima J, Morgan PT, van der Veen JW, Zhang R, Deneke E, Wang GJ, Volkow ND, Wiers CE. Brain glutamate and sleep efficiency associations following a ketogenic diet intervention in individuals with Alcohol Use Disorder. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 5:100092. [PMID: 36311277 PMCID: PMC9601174 DOI: 10.1016/j.dadr.2022.100092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background We previously showed that ketogenic diet (KD) was effective in curbing alcohol withdrawal and craving in individuals with alcohol use disorder (AUD). We hypothesized that the clinical benefits were due to improvements in sleep. To test this, we performed a secondary analysis on the KD trial data to (1) examine the effects of KD on total sleep time (TST) and sleep quality and (2) investigate the association between KD-induced alterations in cingulate glutamate concentration and changes in TST and sleep quality. Methods AUD individuals undergoing alcohol detoxification were randomized to receive KD (n=19) or standard American diet (SA; n=14) for three weeks. TST was measured weekly by self-report, GENEActive sleep accelerometer, and X4 Sleep Profiler ambulatory device. Sleep quality was assessed using subjectively ratings of sleep depth and restedness and Sleep Profiler (Sleep Efficiency [%]). Weekly 1H magnetic resonance spectroscopy scans measured cingulate glutamate levels. Results TST was lower in KD than SA and increased with effect of time. Sleep depth, restedness, and Sleep Efficiency improved with time, but exhibited no effect of diet. In KD and SA combined, week 1 cingulate glutamate levels correlated positively with Sleep Efficiency, but not with TST. Conclusions Although cingulate glutamate levels correlated positively with Sleep Efficiency in week 1, KD-induced glutamate elevation did not produce significant sleep improvements. Rather, KD was associated with lower TST than SA. Given the well-established associations between sleep and alcohol relapse, longer follow up assessment of KD's impact on sleep in AUD is warranted.
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Affiliation(s)
- Xinyi Li
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Zhenhao Shi
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Juliana Byanyima
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Peter T. Morgan
- Department of Psychiatry, Yale University, New Haven, CT, 06519, USA
- Department of Psychiatry, Bridgeport Hospital, Bridgeport, CT, 06610, USA
| | | | - Rui Zhang
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, 20892, USA
| | - Erin Deneke
- Caron Treatment Centers, 243N Galen Hall Rd, Wernersville, PA, 19565, USA
| | - Gene-Jack Wang
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, 20892, USA
| | - Nora D. Volkow
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, 20892, USA
| | - Corinde E. Wiers
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, 20892, USA
- Corresponding author at: 3535 Market St Ste 500, Philadelphia, PA 19104.
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Alcohol use disorder: An analysis of the evidence underpinning clinical practice guidelines. Drug Alcohol Depend 2022; 232:109287. [PMID: 35063840 PMCID: PMC8885851 DOI: 10.1016/j.drugalcdep.2022.109287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 12/22/2021] [Accepted: 01/02/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND As Clinical Practice Guidelines (CPGs) provide effective guidance for providing medical care for individuals with alcohol use disorder (AUD), the evidence behind them should be robust. OBJECTIVE Our primary objective was to critically appraise the methodological and reporting quality of systematic reviews cited within CPGs regarding the treatment of AUD. Our secondary objective was to determine how frequently Cochrane Reviews were cited as justification and to evaluate appraisals between Cochrane and non-Cochrane reviews. METHODS We searched PubMed to identify CPGs for the treatment of AUD published between 2015 and 2021. Systematic reviews included in each CPG were evaluated using the Preferred Reporting Instrument for Systematic Reviews and Meta-Analyses (PRISMA) and a validated quality assessment tool (AMSTAR-2). Additional study characteristics were recorded. RESULTS From the screening process, 98 systematic reviews from 6 CPGs met inclusion criteria. PRISMA adherence ranged from 72% to 85% (mean of 79%). AMSTAR-2 adherence ranged from 52% to 73% (mean of 68%). AMSTAR appraisal ratings found 32 (35.6%) critically low, 10 (11.1%) low, 35 (38.9%) moderate, and only 13 (14.4%) high systematic reviews. Cochrane systematic reviews displayed greater PRISMA (0.92 vs. 0.75: p < 0.001) and AMSTAR-2 (0.90 vs. 0.61.; p < 0.001) scores compared to the non-Cochrane studies. CONCLUSION Systematic reviews included in CPGs for AUD treatment showed variable adherence to PRISMA and AMSTAR-2 guidelines, with almost half of the systematic reviews being critically low to low methodological quality. Given the prevalence of alcohol use disorder, methodological and reporting quality recommendations are important to strengthening evidence informing CPGs.
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Muncie HL, Anderson II G, Oge L. Care of the Alcoholic Patient. Fam Med 2022. [DOI: 10.1007/978-3-030-54441-6_66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Augustin H. Antikonvulsiva im Notfall. Notf Rett Med 2020. [DOI: 10.1007/s10049-020-00751-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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8
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Care of the Alcoholic Patient. Fam Med 2020. [DOI: 10.1007/978-1-4939-0779-3_66-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Humphrey M, Everhart S, Kosmisky D, Anderson WE. An evaluation of patient-specific characteristics on attainment of target sedation in an intensive care unit. Heart Lung 2018; 47:387-391. [PMID: 29858104 DOI: 10.1016/j.hrtlng.2018.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 05/12/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Sedation of mechanically ventilated patients should optimize comfort and safety while avoiding over-sedation and adverse outcomes. To our knowledge, characteristics associated with attaining target sedation are unknown. OBJECTIVES Evaluate current sedation practice at a single center and explore which patient characteristics are associated with attaining target sedation. METHODS This is a single-center, retrospective chart review of sedated, ventilated patients in a medical/surgical ICU. Demographic and clinical data were collected. Univariate and multivariate logistic regression analyses were used with attaining target sedation as the dependent variable. RESULTS Of the 100 patients included (median 60.5 years), 50 attained target sedation. Univariate analyses (a = 0.10) revealed factors associated with target sedation were age (P = 0.08), history of alcohol abuse (P = 0.08), multiple comorbidities (P = 0.09), and delirium monitoring (P = 0.002). Multivariate analysis revealed an association between delirium monitoring/documentation and attaining target sedation (P = 0.005; OR 9.2; 95% CI 2.3-36.8). CONCLUSIONS Patients without appropriate delirium monitoring/documentation had significantly reduced likelihood of achieving target sedation.
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Affiliation(s)
- Morgan Humphrey
- Carolinas HealthCare System NorthEast, 920 Church St. N, Concord, North Carolina 28025, USA.
| | - Sonia Everhart
- Carolinas HealthCare System NorthEast, 920 Church St. N, Concord, North Carolina 28025, USA
| | - Desiree Kosmisky
- Carolinas HealthCare System NorthEast, 920 Church St. N, Concord, North Carolina 28025, USA
| | - William E Anderson
- Center for Outcomes Research and Evaluation, Carolinas HealthCare System, 1540 Garden Terrace, Charlotte, North Carolina 28203, USA
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Mendoza RL. Is medical treatment of Alcohol Withdrawal Syndrome a Stag Hunt? Challenges and opportunities in managing risk and uncertainty in addiction cessation. Risk Manag Healthc Policy 2017; 11:1-14. [PMID: 29317849 PMCID: PMC5743126 DOI: 10.2147/rmhp.s144831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE While the individual and social costs of alcoholism or alcohol use disorder are well established, few are aware that medical problems can arise during detoxification, some of which can be life-threatening. This study determines if sustained treatment for Alcohol Withdrawal Syndrome (AWS) might be based on the strategic choices and expectations of patients and health care providers alike, as well as the risk mitigation options available to them. DESIGN/APPROACH AWS was modeled as a Stag Hunt to explain both risk and decision-making in medical treatments for detoxification, since it can deduce a set of equilibrium strategies available to both patient and provider. Modeling was based on a review of juried literature gathered from search engines with the use medical subject heading terms. MAIN FINDINGS While there is little evidence that decision-making is shared between patient and physician in AWS treatments, the outcomes of their interactions depend on utility-maximizing choices each makes in anticipation of the other. Payoff-dominant and risk-dominant treatment outcomes are equally likely and equally cost-efficient, as conditioned by the presence (or absence) of mutual trust and assurance in reciprocal transactions. CONCLUSION/VALUE Simulation games, such as the Stag Hunt, offer a viable framework to understand patient and provider incentives and health-affecting behaviors during treatments for addiction cessation. If both anticipate indefinitely interacting in the absence of any predetermined or foreseeable final visit, they can maximize future payoffs from mutual cooperation and accountability, which fosters health promotion. However, this study suggests that the effect of cooperation is distinct from the effect of time in AWS and other addiction-cessation programs.
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Muncie HL. Care of the Alcoholic Patient. Fam Med 2017. [DOI: 10.1007/978-3-319-04414-9_66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sychla H, Gründer G, Lammertz SE. Comparison of Clomethiazole and Diazepam in the Treatment of Alcohol Withdrawal Syndrome in Clinical Practice. Eur Addict Res 2017; 23:211-218. [PMID: 28898879 DOI: 10.1159/000480380] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 08/14/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND The objective of this retrospective study was to compare the effectivity and tolerability of diazepam and clomethiazole in the treatment of alcohol withdrawal syndrome (AWS) in a large clinical sample. METHODS The data of 566 patients admitted to an intensive care psychiatric unit in Germany (2010-2014) were evaluated. The course of withdrawal was analyzed on a matched sample (n = 152) consisting of a diazepam group (n = 76) and a clomethiazole group (n = 76). Medical assessment was based on a standardized point-based symptom rating scale called AESB (Alkoholentzugssymptom-Bogen), a German modified version of the Revised Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar). RESULTS Although the mean daily symptom reduction did not differ significantly, patients treated with clomethiazole were treated significantly shorter and needed less concomitant antipsychotic medication. Numbers of complications and adverse events did not show significant differences. CONCLUSION Both clomethiazole and diazepam were effective and equally safe in the treatment of AWS. Clomethiazole provided a faster withdrawal and required less concomitant antipsychotic medication and therefore might be the more favorable option for patients and physicians. Taken into account the methodological limitations of the study (retrospective design, secondary matching, missing randomization, use of clomethiazole as drug of first choice), further studies are needed to confirm this result.
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Affiliation(s)
- Hannah Sychla
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, RWTH Aachen University, Aachen, Germany
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Risks deter but pleasures allure: Is pleasure more important? JUDGMENT AND DECISION MAKING 2015. [DOI: 10.1017/s1930297500004617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AbstractThe pursuit of unhealthy behaviors, such as smoking or binge drinking, not only carries various downside risks, but also provides pleasure. A parsimonious model, used in the literature to explain the decision to pursue an unhealthy activity, represents that decision as a tradeoff between risks and benefits. We build on this literature by surveying a rural population in South Africa to elicit the perceived riskiness and the perceived pleasure for various risky activities and to examine how these perceptions relate to the pursuit of four specific unhealthy behaviors: frequent smoking, problem drinking, seatbelt nonuse, and risky sex. We show that perceived pleasure is a significant predictor for three of the behaviors and that perceived riskiness is a significant predictor for two of them. We also show that the correlation between the riskiness rating and behavior is significantly different from the correlation between the pleasure rating and behavior for three of the four behaviors. Finally, we show that the effect of pleasure is significantly greater than the effect of riskiness in determining drinking and risky sex, while the effects of pleasure and riskiness are not different from each other in determining smoking and seatbelt nonuse. We discuss how our findings can be used to inform the design of health promotion strategies.
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Minozzi S, Amato L, Davoli M, Farrell MF, Lima Reisser AARL, Pani PP, Silva de Lima M, Soares BGO, Vecchi S. WITHDRAWN: Anticonvulsants for cocaine dependence. Cochrane Database Syst Rev 2015:CD006754. [PMID: 25731153 DOI: 10.1002/14651858.cd006754.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Via di Santa Costanza, 53, Rome, Italy, 00198
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Mirijello A, D’Angelo C, Ferrulli A, Vassallo G, Antonelli M, Caputo F, Leggio L, Gasbarrini A, Addolorato G. Identification and management of alcohol withdrawal syndrome. Drugs 2015; 75:353-65. [PMID: 25666543 PMCID: PMC4978420 DOI: 10.1007/s40265-015-0358-1] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Symptoms of alcohol withdrawal syndrome (AWS) may develop within 6-24 h after the abrupt discontinuation or decrease of alcohol consumption. Symptoms can vary from autonomic hyperactivity and agitation to delirium tremens. The gold-standard treatment for AWS is with benzodiazepines (BZDs). Among the BZDs, different agents (i.e., long-acting or short-acting) and different regimens (front-loading, fixed-dose or symptom-triggered) may be chosen on the basis of patient characteristics. Severe withdrawal could require ICU admission and the use of barbiturates or propofol. Other drugs, such as α2-agonists (clonidine and dexmetedomidine) and β-blockers can be used as adjunctive treatments to control neuroautonomic hyperactivity. Furthermore, neuroleptic agents can help control hallucinations. Finally, other medications for the treatment for AWS have been investigated with promising results. These include carbamazepine, valproate, sodium oxybate, baclofen, gabapentin and topiramate. The usefulness of these agents are discussed.
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Affiliation(s)
- Antonio Mirijello
- Alcohol Use Disorders Unit, Department of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
| | - Cristina D’Angelo
- Alcohol Use Disorders Unit, Department of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
| | - Anna Ferrulli
- Alcohol Use Disorders Unit, Department of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
| | - Gabriele Vassallo
- Alcohol Use Disorders Unit, Department of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
| | - Mariangela Antonelli
- Alcohol Use Disorders Unit, Department of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
| | - Fabio Caputo
- Department of Internal Medicine, SS Annunziata Hospital, Cento, Ferrara, Italy
- Department of Clinical Medicine, “G. Fontana” Centre for the Study and Multidisciplinary Treatment of Alcohol Addiction, University of Bologna, Bologna, Italy
| | - Lorenzo Leggio
- Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, Laboratory of Clinical and Translational Studies, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, USA
- Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Baltimore, MD, USA
- Center for Alcohol and Addiction Studies, Department of Behavioral and Social Sciences, Brown University, Providence, RI, USA
| | - Antonio Gasbarrini
- Alcohol Use Disorders Unit, Department of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
| | - Giovanni Addolorato
- Alcohol Use Disorders Unit, Department of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
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Muncie HL. Care of the Alcoholic Patient. Fam Med 2015. [DOI: 10.1007/978-1-4939-0779-3_66-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
BACKGROUND Alcohol dependence is a major public health problem that is characterised by recidivism and a host of medical and psychosocial complications. Besides psychosocial interventions, different pharmacological interventions have been or currently are under investigation through Cochrane systematic reviews. OBJECTIVES The primary aim of the review is to assess the benefits/risks of anticonvulsants for the treatment of alcohol dependence. SEARCH METHODS We searched the Cochrane Drugs and Alcohol Group Trials Register (October 2013), PubMed (1966 to October 2013), EMBASE (1974 to October 2013) and CINAHL (1982 to October 2013). SELECTION CRITERIA Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing anticonvulsants alone or in association with other drugs and/or psychosocial interventions versus placebo, no treatment and other pharmacological or psychosocial interventions. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by The Cochrane Collaboration. MAIN RESULTS A total of 25 studies were included in the review (2641 participants). Most participants were male, with an average age of 44 years. Anticonvulsants were compared with placebo (17 studies), other medications (seven studies) and no medication (two studies). The mean duration of the trials was 17 weeks (range four to 52 weeks). The studies took place in the USA, Europe, South America, India and Thailand. Variation was reported in the characteristics of the studies, including their design and the rating instruments used. For many key outcomes, the risk of bias associated with unclear or unconcealed allocation and lack of blinding affected the quality of the evidence.Anticonvulsants versus placebo: For dropouts (16 studies, 1675 participants, risk ratio (RR) 0.94, 95% confidence interval (Cl) 0.74 to 1.19, moderate-quality evidence) and continuous abstinence (eight studies, 634 participants, RR 1.21, 95% Cl 95% 0.97 to 1.52, moderate-quality evidence), results showed no evidence of differences. Moderate-quality evidence suggested that anticonvulsants reduced drinks/drinking days (11 studies, 1126 participants, mean difference (MD) -1.49, 95% Cl -2.32 to -0.65) and heavy drinking (12 studies, 1129 participants, standardised mean difference (SMD) -0.35, 95% Cl -0.51 to -0.19). Moreover, withdrawal for medical reasons (12 studies, 1410 participants, RR 1.22, 95% Cl 0.58 to 2.56, moderate-quality evidence) showed no evidence of difference, but for specific adverse effects (nine studies, 1164 participants), two of 18 adverse event outcomes favoured placebo. The direction of results was confirmed by subgroup analyses for topiramate and partially for gabapentin and valproate.Anticonvulsants versus naltrexone: No evidence of difference was shown in dropout rates (five studies, 528 participants, RR 0.74, 95% CI 0.52 to 1.06), severe relapse rates (four studies, 427 participants, RR 0.69, 95% Cl 0.44 to 1.07) and continuous abstinence rates (five studies, 528 participants, RR 1.21, 95% Cl 0.99 to 1.49); anticonvulsants were associated with fewer heavy drinking days (three studies, 308 participants, MD -5.21, 95% Cl -8.58 to -1.83), more days to severe relapse (three studies, 244 participants, MD 11.88, 95% Cl 3.29 to 20.46) and lower withdrawal for medical reasons (three studies, 245 participants, RR 0.13, 95% Cl 0.03 to 0.58). AUTHORS' CONCLUSIONS At the current stage of research, randomised evidence supporting the clinical use of anticonvulsants to treat alcohol dependence is insufficient. Results are conditioned by heterogeneity and by the low number and quality of studies comparing anticonvulsants with other medications. The uncertainty associated with these results leaves to clinicians the need to balance possible benefits/risks of treatment with anticonvulsants versus other medications as supported by evidence of efficacy.
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Affiliation(s)
- Pier Paolo Pani
- Health District 8 (ASL 8) CagliariSocial‐Health DivisionVia Logudoro 17CagliariSardiniaItaly09127
| | - Emanuela Trogu
- Health District 8 (ASL 8) CagliariSocial‐Health DivisionVia Logudoro 17CagliariSardiniaItaly09127
| | - Matteo Pacini
- European Addiction Treatment Association (Europad)Policlinico Umberto I, University La Sapienza, RomeRomeItaly
| | - Icro Maremmani
- "Santa Chiara" University Hospital, University of Pisa, Italy"Vincent P. Dole" Dual Diagnosis Unit, Department of NeurosciencesVia Roma, 67PisaItaly56100
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Balhara YPS. A curious case of the World Health Organization's (WHO) approach on alcohol use disorders--inferences from the WHO list of essential drugs. Addiction 2013; 108:2030. [PMID: 24033368 DOI: 10.1111/add.12312] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Yatan Pal Singh Balhara
- National Drug Dependence Treatment Centre (NDDTC), All India Institute of Medical Sciences (AIIMS), New Delhi, India; Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), New Delhi, India. ,
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Abstract
BACKGROUND Cocaine dependence is a disorder for which no pharmacological treatment of proven efficacy exists, advances in the neurobiology could guide future medication development. OBJECTIVES To investigate the efficacy and acceptability of antidepressants alone or in combination with any psychosocial intervention for the treatment of cocaine dependence and problematic cocaine use. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE and CINAHL in July 2011 and researchers for unpublished trials. SELECTION CRITERIA Randomised clinical trials comparing antidepressants alone or associated with psychosocial intervention with placebo, no treatment, other pharmacological or psychosocial interventions. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. MAIN RESULTS 37 studies were included in the review (3551 participants).Antidepressants versus placebo: results for dropouts did not show evidence of difference, 31 studies, 2819 participants, RR 1.03 (Cl 95% 0.93 to 1.14). Looking at Abstinence from cocaine use, even though not statistically significant, the difference shown by the analysis in the three-weeks abstinence rate was in favour of antidepressants (eight studies, 942 participants, RR 1.22 (Cl 95% 0.99 to 1.51)). Considering only studies involving tricyclics, five studies, 367 participants, or only desipramine, four studies, 254 participants, the evidence was in favour of antidepressants. However, selecting only studies with operationally defined diagnostic criteria, statistical significance favouring antidepressants, as well as the trend for significance shown by the full sample, disappeared. Looking at safety issues, the results did not show evidence of differences (number of patients withdrawn for medical reasons, thirteen studies, 1396 participants, RR 1.39 (Cl 95% 0.91 to 2.12)). Subgroup analysis considering length of the trial, associated opioid dependence or associated psychosocial interventions as confounding factors, failed in showing consistent and statistically significant differences in favour of antidepressants.Antidepressants versus other drugs: Comparing antidepressants with dopamine agonists or with anticonvulsants, no evidence of differences was shown on dropouts and on other outcomes (abstinence from cocaine use, adverse events). AUTHORS' CONCLUSIONS At the current stage of evidence data do not support the efficacy of antidepressants in the treatment of cocaine abuse/dependence. Partially positive results obtained on secondary outcome measures, such as depression severity, do not seem to be associated with an effect on direct indicators of cocaine abuse/dependence. Antidepressants cannot be considered a mainstay of treatment for unselected cocaine abusers/dependents.
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Affiliation(s)
- Pier Paolo Pani
- Social-Health Division, Health District 8 (ASL 8) Cagliari, Via Logudoro 17, Cagliari, Sardinia, Italy, 09127
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Patel SB, Kress JP. Sedation and analgesia in the mechanically ventilated patient. Am J Respir Crit Care Med 2011; 185:486-97. [PMID: 22016443 DOI: 10.1164/rccm.201102-0273ci] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Sedation and analgesia are important components of care for the mechanically ventilated patient in the intensive care unit (ICU). An understanding of commonly used medications is essential to formulate a sedation plan for individual patients. The specific physiological changes that a critically ill patient undergoes can have direct effects on the pharmacology of drugs, potentially leading to interpatient differences in response. Objective assessments of pain, sedation, and agitation have been validated for use in the ICU for assessment and titration of medications. An evidence-based strategy for administering these drugs can lead to improvements in short- and long-term outcomes for patients. In this article, we review advances in the field of ICU sedation to provide an up-to-date perspective on management of the mechanically ventilated ICU patient.
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Affiliation(s)
- Shruti B Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Illinois, USA
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21
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Temporal and spatial patterns in the rate of alcohol withdrawal syndrome in a defined community. Alcohol 2011; 45:105-11. [PMID: 20843642 DOI: 10.1016/j.alcohol.2010.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Revised: 08/02/2010] [Accepted: 08/04/2010] [Indexed: 11/21/2022]
Abstract
There is a paucity of data about the epidemiology of alcohol withdrawal syndrome (AWS) and, particularly, with regard to temporal trends and sociodemographic factors. This study included 7,195 episodes of AWS in a defined community (Galicia, Spain) over a 11-year period. We looked for geographical correlations between AWS rate and sociodemographic factors (education and socioeconomic levels and rates of occupational activity and unemployment) within respective districts. We also investigated the inter- and intra-annual time trends for AWS. The median age of the participants was 49 years (interquartile range, 41-60 years), and 85% were men. The annual frequency of AWS episodes remained stable during the study period, with a consistent peak in episodes during the summer months and lowest frequency of episodes in winter months (P<.001). The age- and sex-adjusted geographical distribution of the AWS rate was uneven; districts with high rate tended to cluster. The mean education level was negatively correlated with AWS rate within a given district after adjusting for socioeconomic level, occupational activity rate, and unemployment rate (P<.001). In conclusion, we identified characteristic temporospatial patterns of AWS rate in this defined community. The rate of AWS tended to be higher in the summer months and lower in the winter months. The rate of AWS was higher in districts with low education levels.
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Abstract
Substance use is ubiquitous among medically ill patients. The 2008 National Survey on Drug Abuse and Health survey estimated that 20.1 million Americans aged 12 years or older (8% of the US population) had used an illicit drug during the preceding month. Some licit substances also create havoc. The survey found that slightly more than half (56%) of Americans reported being current drinkers of alcohol. A total of 6.2 million (2.5%) Americans used prescription-type psychotherapeutic drugs for nonmedical purposes and 70.9 million Americans (or 28.4%) used tobacco during the survey period. Substance abuse problems were diagnosed in up to 36% of medically hospitalized patients for whom a psychiatric consultation was requested. Given how prevalent the use of substances is among the medically ill and their potential effect on comorbid medical conditions, it is important for physicians to be mindful of their prevalence and presentation. This article covers the presenting symptoms of intoxication and withdrawal states, addresses the acute management of the most commonly encountered substances, and summarizes all others in a table.
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Affiliation(s)
- Jose R Maldonado
- Medicine & Surgery, Stanford University School of Medicine, 401 Quarry Road, Suite #2317, Stanford, CA 94305, USA.
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23
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Utilisation of a purpose-designed chart for the nursing management of acute alcohol withdrawal in the hospital setting. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/j.aenj.2010.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Silva de Lima M, Farrell M, Lima Reisser AA, Soares B. WITHDRAWN: Antidepressants for cocaine dependence. Cochrane Database Syst Rev 2010:CD002950. [PMID: 20166064 DOI: 10.1002/14651858.cd002950.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The past decade has witnessed a sustained search for an effective pharmacotherapeutic agent for the treatment of cocaine dependence. While administration of cocaine acutely increases intercellular dopamine, serotonin, and norepinephrine levels by blocking their presynaptic reuptake, chronic cocaine abuse leads to down-regulation of monoamine systems. Post-cocaine use depression and cocaine craving may be linked to this down-regulation. Antidepressant pharmacotherapy, by augmenting monoamine levels, may alleviate cocaine abstinence symptomatology, as well as relieving dysphoria and associated craving by general antidepressant action. OBJECTIVES To evaluate the efficacy and the acceptability of antidepressants for cocaine dependence SEARCH STRATEGY We searched Cochrane Drug and Alcohol Group Specialised Register (July 2007), MEDLINE (1966 to July 2007), CINAHL (1982 to July 2007), SCOPUS (July 2007); reference searching; personal communication; conference abstracts; unpublished trials, ongoing trials, relevant web-sites. SELECTION CRITERIA All randomised controlled trials and controlled clinical trials which focus on the use of any antidepressants for cocaine dependence DATA COLLECTION AND ANALYSIS The authors independently evaluated the papers, extracted data, rated methodological quality. Doubts were solved throug discussion between all the authors. MAIN RESULTS 18 studies were included in the review (1177 participants). Positive urine sample for cocaine metabolites was the main efficacy outcome, with no significant results obtained regardless of the type of antidepressant. Compared to other drugs, desipramine performed better but showing just a non significant trend with heterogeneity present as revealed by the chi-square test (8.6, df=3; p=0.04). One single trial showed imipramine performed better than placebo in terms of clinical response according to patient's self-report. A similar rate of patients remaining in treatment was found for both patients taking desipramine or placebo. Results from one single trial suggest fluoxetine patients on SSRIs are less likely to dropout. Similar results were obtained for trials where patients had additional diagnosis of opioid dependence and/or were in methadone maintenance treatment. AUTHORS' CONCLUSIONS There is no current evidence supporting the clinical use of antidepressants in the treatment of cocaine dependence. Given the high rate of dropouts in this population, clinicians may consider adding psychotherapeutic supportive measures aiming to keep patients in treatment.
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Affiliation(s)
- Mauricio Silva de Lima
- Medical, Eli Lilly & Co, Lilly House, Priestley Road, Basingstoke, Hampshire, UK, RG24 9NL
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25
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Pani PP, Trogu E, Vacca R, Amato L, Vecchi S, Davoli M. Disulfiram for the treatment of cocaine dependence. Cochrane Database Syst Rev 2010:CD007024. [PMID: 20091613 DOI: 10.1002/14651858.cd007024.pub2] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Cocaine dependence is a disorder for which no pharmacological treatment of proven efficacy exists, advances in the neurobiology could guide future medication development. OBJECTIVES To evaluate the efficacy and the acceptability of disulfiram for cocaine dependence. SEARCH STRATEGY We searched: PubMed, EMBASE, CINAHL (up to January 2008), the Cochrane Central Register of Controlled Trials (CENTRAL-The Cochrane Library, 1, 2009), reference lists of trials, main electronic sources of ongoing trials, conference proceedings. SELECTION CRITERIA Randomised and controlled clinical trials comparing disulfiram alone or associated with psychosocial intervention with no intervention, placebo, or other pharmacological intervention for the treatment of cocaine dependence. DATA COLLECTION AND ANALYSIS Three reviewers independently assessed trial quality and extracted data. MAIN RESULTS Seven studies, 492 participants, met the inclusion criteriaDisulfiram versus placebo: no statistically significant results for dropouts but a trend favouring disulfiram, two studies, 87 participants, RR 0.82 (95% CI 0.66 to 1.03). One more study, 107 participants, favouring disulfiram, was excluded from meta-analysis due high heterogeneity, RR 0.34 (95% CI 0.20 to 0.58). For cocaine use, it was not possible to pool together primary studies, results from single studies showed that, one, out of four comparisons, was in favour of disulfiram (number of weeks abstinence, 20 participants, WMD 4.50 (95% CI 2.93 to 6.07).Disulfiram versus naltrexone: no statistically significant results for dropouts but a trend favouring disulfiram, three studies, 131 participants, RR 0.67 (95% CI 0.45 to 1.01). No significant difference for cocaine use was seen in the only study that considered this outcome.Disulfiram versus no pharmacological treatment: for cocaine use: a statistically significant difference in favour of disulfiram, one study, two comparisons, 90 participants: maximum weeks of consecutive abstinence, WMD 2.10 (95% CI 0.69 to 3.51); number of subjects achieving 3 or more weeks of consecutive abstinence, RR 1.88 (95% CI 1.09 to 3.23). AUTHORS' CONCLUSIONS There is low evidence, at the present, supporting the clinical use of disulfiram for the treatment of cocaine dependence. Larger randomised investigations are needed investigating relevant outcomes and reporting data to allow comparisons of results between studies. Results from ongoing studies will be added as soon as their results will be available.
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Affiliation(s)
- Pier Paolo Pani
- Social-Health Division, Health District 8 (ASL 8) Cagliari, Cittadella della Salute, padiglione C, via Romagna 16, Cagliari, Sardinia, Italy, 09127
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26
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Jupp B, Lawrence AJ. New horizons for therapeutics in drug and alcohol abuse. Pharmacol Ther 2010; 125:138-68. [DOI: 10.1016/j.pharmthera.2009.11.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Accepted: 11/03/2009] [Indexed: 11/25/2022]
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Waal H, Bramness J. Benzodiazepiner til personer med rusmiddelproblemer? TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2010; 130:610-2. [DOI: 10.4045/tidsskr.09.0687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Abstract
In the fourth in a series of six articles on packages of care for mental disorders in low- and middle-income countries, Vivek Benegal and colleagues discuss the treatment of alcohol use disorders.
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Affiliation(s)
- Vivek Benegal
- Deaddiction Centre, National Institute of Mental Health and Neurosciences, Bangalore, India.
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Anderson P, Chisholm D, Fuhr DC. Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. Lancet 2009; 373:2234-46. [PMID: 19560605 DOI: 10.1016/s0140-6736(09)60744-3] [Citation(s) in RCA: 643] [Impact Index Per Article: 42.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This paper reviews the evidence for the effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol, in the areas of education and information, the health sector, community action, driving while under the influence of alcohol (drink-driving), availability, marketing, pricing, harm reduction, and illegally and informally produced alcohol. Systematic reviews and meta-analyses show that policies regulating the environment in which alcohol is marketed (particularly its price and availability) are effective in reducing alcohol-related harm. Enforced legislative measures to reduce drink-driving and individually directed interventions to already at-risk drinkers are also effective. However, school-based education does not reduce alcohol-related harm, although public information and education-type programmes have a role in providing information and in increasing attention and acceptance of alcohol on political and public agendas. Making alcohol more expensive and less available, and banning alcohol advertising, are highly cost-effective strategies to reduce harm. In settings with high amounts of unrecorded production and consumption, increasing the proportion of alcohol that is taxed could be a more effective pricing policy than a simple increase in tax.
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Affiliation(s)
- Peter Anderson
- School for Public Health and Primary Care, University of Maastricht, Maastricht, The Netherlands.
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Tønnesen H, Nielsen PR, Lauritzen JB, Møller AM. Smoking and alcohol intervention before surgery: evidence for best practice. Br J Anaesth 2009; 102:297-306. [PMID: 19218371 DOI: 10.1093/bja/aen401] [Citation(s) in RCA: 156] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Smoking and hazardous drinking are common and important risk factors for an increased rate of complications after surgery. The underlying pathophysiological mechanisms include organic dysfunctions that can recover with abstinence. Abstinence starting 3-8 weeks before surgery will significantly reduce the incidence of several serious postoperative complications, such as wound and cardiopulmonary complications and infections. However, this intervention must be intensive to obtain sufficient effect on surgical complications. All patients presenting for surgery should be questioned regarding smoking and hazardous drinking, and interventions appropriate for the surgical setting applied.
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Affiliation(s)
- H Tønnesen
- WHO Collaborating Centre for Evidence Based Health Promotion in Hospitals and Health Services, Copenhagen, Denmark.
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31
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Abstract
Recreational substance users are at risk for seizures by indirect mechanisms, including cerebral trauma, central nervous system infection, ischemic and hemorrhagic stroke, and metabolic derangements such as hypoglycemia, hypocalcemia, and renal failure. Drugs and ethanol can also cause seizures more directly, either as a feature of intoxication (eg, psychostimulants) or of withdrawal (eg, sedatives, including ethanol). In any patient with a seizure, clinicians should consider illicit drug or ethanol use. Seizures in known alcoholics or illicit drug users require workup to exclude treatable coexisting conditions.
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Affiliation(s)
- John C M Brust
- Columbia University College of Physicians & Surgeons, 506 Lenox Avenue, New York, NY 10037, USA.
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32
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Ritvo JI, Park C. The psychiatric management of patients with alcohol dependence. Curr Treat Options Neurol 2008. [DOI: 10.1007/s11940-007-0024-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Pani PP, Amato L, Davoli M, Vecchi S. Disulphiram for the treatment of cocaine dependence. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2008. [DOI: 10.1002/14651858.cd007024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Minozzi S, Amato L, Davoli M, Farrell M, Lima Reisser AARL, Pani PP, Silva de Lima M, Soares B, Vecchi S. Anticonvulsants for cocaine dependence. Cochrane Database Syst Rev 2008:CD006754. [PMID: 18425968 DOI: 10.1002/14651858.cd006754.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Cocaine dependence is a major public health problem that is characterized by recidivism and a host of medical and psychosocial complications. Although effective pharmacotherapy is available for alcohol and heroin dependence none exists currently for cocaine dependence despite two decades of clinical trials primarily involving antidepressant, anti convulsivant and dopaminergic medications. There has been extensive consideration of optimal pharmacological approaches to the treatment of cocaine dependence with consideration of both dopamine antagonists and agonists. Anticonvulsants have been candidates for the treatment of addiction based on the hypothesis that seizure kindling-like mechanisms contribute to addiction. OBJECTIVES To evaluate the efficacy and the acceptability of anticonvulsants for cocaine dependence SEARCH STRATEGY We searched the Cochrane Drugs and Alcohol Groups specialised register (issue 4, 2007), MEDLINE (1966 - march 2007), EMBASE (1988 - march 2007), CINAHL (1982- to march 2007) SELECTION CRITERIA All randomised controlled trials and controlled clinical trials which focus on the use of anticonvulsants medication for cocaine dependence DATA COLLECTION AND ANALYSIS Two authors independently evaluated the papers, extracted data, rated methodological quality MAIN RESULTS Fifteen studies (1066 participants) met the inclusion criteria for this review: the anticonvulsants drugs studied were carbamazepine, gabapentin, lamotrigine, phenytoin, tiagabine, topiramate, valproate. No significant differences were found for any of the efficacy measures comparing any anticonvulsants with placebo. Placebo was found to be superior to gabapentin in diminishing the number of dropouts, two studies, 81 participants, Relative Risk (RR) 3.56 (95% CI 1.07 to 11.82) and superior to phenythoin for side effects, two studies, 56 participants RR 2.12 (95% CI 1.08 to 4.17). All the other single comparisons are not statistically significant. AUTHORS' CONCLUSIONS Although caution is needed when assessing results from a limited number of small clinical trials at present there is no current evidence supporting the clinical use of anticonvulsants medications in the treatment of cocaine dependence. Aiming to answer the urgent demand of clinicians, patients, families, and the community as a whole for an adequate treatment for cocaine dependence, we need to improve the primary research in the field of addictions in order to make the best possible use out of a single study and to investigate the efficacy of other pharmacological agent.
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Affiliation(s)
- S Minozzi
- ASL RM E, Department of Epidemiology, via Pellicone 5, Fosdinovo, Italy, 54035.
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Gardner TJ, Kosten TR. Therapeutic options and challenges for substances of abuse. DIALOGUES IN CLINICAL NEUROSCIENCE 2008. [PMID: 18286802 PMCID: PMC3202509 DOI: 10.31887/dcns.2007.9.4/tgardner] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Addiction to substances continues to be a significant public health concern in the United States. The following review of current pharmacological treatments discusses a range of substances: nicotine, alcohol, cocaine, and opioids. The goal is to provide an overview of currently available and new pharmacological treatments for substance use disorders, while also addressing the pharmacothera-peutic challenges remaining. The significant advances in pharmacotherapy have had limited utilization, however. For example, naltrexone for alcoholism is infrequently prescribed, buprenorphine for opiates still has relatively few qualified prescribers, and stimulants have no Food and Drug Administration-approved pharmacotherapy. These pharmacotherapies are needed, with the rate of even the relatively uncommon abuse of opiates now rising sharply.
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Affiliation(s)
- Tracie J Gardner
- Baylor College of Medicine, Menninger Department of Psychiatry and Behavioral Sciences and Michael E. DeBakey VA Medical Center, Houston, Texas, USA.
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Celis-Rodríguez E, Besso J, Birchenall C, de la Cal M, Carrillo R, Castorena G, Ceraso D, Dueñas C, Gil F, Jiménez E, Meza J, Muñoz M, Pacheco C, Pálizas F, Pinilla D, Raffán F, Raimondi N, Rubiano S, Suárez M, Ugarte S. Guía de práctica clínica basada en la evidencia para el manejo de la sedo-analgesia en el paciente adulto críticamente enfermo. Med Intensiva 2007; 31:428-71. [DOI: 10.1016/s0210-5691(07)74853-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Minozzi M, Amato L, Pani PP, Vecchi S, Davoli M. Anticonvulsants for cocaine dependence. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2007. [DOI: 10.1002/14651858.cd006754] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
BACKGROUND Cocaine dependence is a public health problem characterized by recidivism and a host of medical and psychosocial complications. Cocaine dependence remains a disorder for which no pharmacological treatment of proven efficacy exists, although considerable advances in the neurobiology of this addiction could guide future medication development OBJECTIVES To evaluate the efficacy and the acceptability of antipsychotic medications for cocaine dependence SEARCH STRATEGY We searched the following sources: MEDLINE (1966 to October 2006), EMBASE (1980 to October 2006), CINAHL (1982 to October 2006), Cochrane Drug and Alcohol Group Specialised Register (October 2006). We also searched the reference lists of trials, the main electronic sources of ongoing trials (National Research Register, meta-Register of Controlled Trials; Clinical Trials.gov) and conference proceedings likely to contain trials relevant to the review. All searches included also non-English language literature. SELECTION CRITERIA All randomised controlled trials and controlled clinical trials with focus on the use of any antipsychotic medication for cocaine dependence DATA COLLECTION AND ANALYSIS Two authors independently evaluated the papers, extracted data, rated methodological quality MAIN RESULTS Seven small studies were included (293 participants): the antipsychotic drugs studied were risperidone, olanzapine and haloperidol. No significant differences were found for any of the efficacy measures comparing any antipsychotic with placebo. Risperidone was found to be superior to placebo in diminishing the number of dropouts, four studies, 178 participants, Relative Risk (RR) 0.77 (95% CI 0.77 to 0.98). Most of the included studies did not report useful results on important outcomes such as side effects, use of cocaine during treatment and craving. The results on olanzapine and haloperidol come from studies too small to give conclusive results. AUTHORS' CONCLUSIONS Although caution is needed when assessing results from a limited number of small clinical trials there is no current evidence, at the present , supporting the clinical use of antipsychotic medications in the treatment of cocaine dependence. Furthermore, most of the included studies did not report useful results on important outcomes such as side effects, use of cocaine during the treatment and craving. Aiming to answer the urgent demand of clinicians, patients, families, and the community as a whole for an adequate treatment for cocaine dependence, larger randomised investigations should be designed investigating relevant outcomes and reporting data to allow comparison of results between studies. Moreover some efforts should be done also to investigate the efficacy of other type medications, like anticonvulsant, currently used in clinical practice.
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Affiliation(s)
- L Amato
- ASL RM/E, Deparment of Epidemiology, Via di Santa Costanza 53, Rome, Lazio, Italy, 00198.
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Amato L, Minozzi S, Pani PP, Davoli M. Antipsychotic medications for cocaine dependence. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2007. [DOI: 10.1002/14651858.cd006306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
BACKGROUND Cocaine dependence is a common and serious condition, which has become a substantial public health problem. The past decade has witnessed a sustained search for an effective pharmacotherapeutic agent for the treatment of cocaine dependence. While administration of cocaine acutely increases intercellular dopamine, serotonin, and norepinephrine levels by blocking their presynaptic reuptake, chronic cocaine abuse leads to down-regulation of monoamine systems. Post-cocaine use depression and cocaine craving may be linked to this down-regulation. Antidepressant pharmacotherapy, by augmenting monoamine levels, may alleviate cocaine abstinence symptomatology, as well as relieving dysphoria and associated craving by general antidepressant action. OBJECTIVES To conduct a systematic review of all RCTs on the use of antidepressants for treating cocaine dependence. SEARCH STRATEGY We searched the Cochrane Controlled Trials Register (Cochrane Library, issue 4, 2000), MEDLINE (from 1966 - 2000), EMBASE (from 1980 - 2000), LILACS (from 1982 - 2000), PsycLIT (from 1974 - 2000), Biological Abstracts (1982 to 2000). Other searches:reference searching; personal communication; conference abstracts; unpublished trials from pharmaceutical industry; book chapters on treatment of cocaine dependence. SELECTION CRITERIA The inclusion criteria for all randomised controlled trials were that they should focus on the use of antidepressants on the treatment of cocaine dependence. Trials including patients with additional diagnosis such as opiate dependence were also eligible. DATA COLLECTION AND ANALYSIS The reviewers extracted the data independently and Relative Risks, weighted mean difference and number needed to treat were estimated. The reviewers assumed that people who died or dropped out had no improvement and tested the sensitivity of the final results to this assumption. MAIN RESULTS 18 studies were included in the review, with 1177 people randomised. Positive urine sample for cocaine metabolites was the main efficacy outcome, with no significant results obtained regardless of the type of antidepressant. Compared to other drugs, desipramine performed better but showing just a non significant trend with heterogeneity present as revealed by the chi-square test (8.6, df=3; p=0.04). One single trial showed imipramine performed better than placebo in terms of clinical response according to patient's self-report. A similar rate of patients remaining in treatment was found for both patients taking desipramine or placebo. Results from one single trial suggest fluoxetine patients on SSRIs are less likely to dropout. Similar results were obtained for trials where patients had additional diagnosis of opioid dependence and/or were in methadone maintenance treatment. REVIEWER'S CONCLUSIONS There is no current evidence supporting the clinical use of antidepressants in the treatment of cocaine dependence. Given the high rate of dropouts in this population, clinicians may consider adding psychotherapeutic supportive measures aiming to keep patients in treatment.
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Affiliation(s)
- M S Lima
- Department of Mental Health, Universidade Federal de Pelotas, Av. Duque de Caxias, 250, Pelotas, Rio Grande do Sul, Brazil.
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