Repeated Detoxification of Alcohol-Dependent Patients Impairs Brain Mechanisms of Behavioural Control Important in Resisting Relapse

The Continuing Challenges of Studying Parallel Behaviours in Humans and Animal Models

The use of animal models continues to be essential for carrying out research into clinical phenomena, including addiction. However, the complexity of the clinical condition inevitably means that even the best animal models are inadequate, and this may go some way to account for the apparent failures of discoveries from animal models, including the identification of potential novel therapies, to translate to the clinic. We argue here that it is overambitious and misguided in the first place to attempt to model complex, multifacetted human disorders such as addiction in animals, and especially in rodents, and that all too frequently "validity" of such models is limited to superficial similarities, referred to as "face validity", that reflect quite different underlying phenomena and biological processes from the clinical situation. Instead, a more profitable approach is to identify (a) well-defined intermediate human behavioural phenotypes that reflect defined, limited aspects of, or contributors to, the human clinical disorder, and (b) to develop animal models that are homologous with those discrete human behavioural phenotypes in terms of psychological processes, and underlying neurobiological mechanisms. Examples of past and continuing weaknesses and suggestions for more limited approaches that may allow better homology between the test animal and human condition are made.

Oral ethanol prescribing for alcohol withdrawal syndrome: initial findings and future directions following implementation within a United Kingdom National Health Service setting

INTRODUCTION

Prescribing of ethanol may be an alternative to benzodiazepines for managing alcohol withdrawal syndrome. We present our experience of oral ethanol prescribing within an acute United Kingdom National Health Service setting.

METHODS

A retrospective review of patients presenting with alcohol withdrawal who were managed with oral ethanol or benzodiazepines was performed from data collected across two acute care settings. Ethanol prescribing inclusion: high risk of delirium tremens, or a history of harmful alcohol consumption (typically ≥30 units/day; in which 1 unit = 8 grams of alcohol; one standard United States drink = 14 grams of alcohol) or known to have a history of severe alcohol withdrawal, alcohol-related seizures or delirium tremens. Inverse propensity score weighting was used to partially account for variance between the two patient populations.

RESULTS

Fifty (82 per cent male; average age 50.9 years) and 93 (84 per cent male; average age 46.5 years) patients in receipt of benzodiazepines or ethanol, respectively, were included. The likelihood of hospital admission was significantly reduced when individuals were managed with ethanol (odds ratio 0.206 (95 per cent confidence interval; 0.066-0.641), Wald chi-square P = 0.006). In those not admitted, the treatment type had no significant impact on length of stay or the number of occasions a pharmacological agent was required. In those admitted, treatment had no significant effect on length of stay.

DISCUSSION

We offer preliminary evidence to support a role of oral ethanol in the management of patients with alcohol withdrawal. We have implemented a robust and translatable guideline. Despite limitations in the data set the impact of ethanol in reducing the likelihood of admission remained significant.

CONCLUSIONS

In individuals at significant risk of severe alcohol withdrawal, prescribing ethanol as part of a comprehensive care plan, may reduce unplanned admissions. The preliminary findings presented here warrant further assessment through prospective studies.

Changes in processing speed during early abstinence from alcohol dependence

BACKGROUND

Processing speed is a task-independent construct underpinning more complex goal-related abilities. Processing speed is impaired in alcohol dependence (AD) and is linked to relapse, as are the functions it underpins. Reliable measurement of processing speed may allow tracking of AD recovery trajectories and identify patients requiring additional support.

AIMS

To assess changes in reaction time (RT) from baseline (at the start of a detoxification programme) across early abstinence.

METHODS

Vibrotactile RT was assessed in early recovery between days 3 and 7 of treatment in 66 individuals with AD (25 females; aged 19-74, 44.60 ± 10.60 years) and against 35 controls tested on one occasion (19 females; 41.00 ± 13.60), using two multivariate multiple regressions. A mixed multivariate analysis of covariance (MANCOVA) of available AD data (n = 45) assessed change in RT between timepoints and between treatment settings (outpatient vs inpatient).

RESULTS

The group (AD vs control) significantly predicted choice RT at baseline and follow-up but did not significantly predict simple RT or RT variability, which is inconsistent with previous findings. At follow-up, mental fatigue was also predicted by the group, and MANCOVA indicated that this had worsened in inpatients but improved in outpatients.

CONCLUSIONS

Recovery of RT measures so early in the treatment journey was not in line with previous research which indicates persisting deficits. The interaction between setting and timepoint indicates that despite being typically less medically complex, outpatients require ongoing support and monitoring during their recovery.

Alcohol use and interoception - A narrative review

Interoception, defined as the ability to perceive and interpret body signals, may play an important role in alcohol use disorder (AUD). Earlier studies suggested an association between interoception impairment and known risk factors for AUD (e.g., alexithymia, emotion dysregulation, impulsivity, pain). Neurobiological studies show that the neurotoxicity of alcohol affects various elements of the interoceptive system (especially the insula) at structural and functional levels, with differential short/long term impacts. Conversely, primary interoceptive impairments may promote alcohol consumption and foster the evolution towards addiction. Despite convincing evidence demonstrating that interoception impairment may be an important contributor to the development and course of AUD, only a few studies directly evaluated interoceptive abilities in AUD. The research shows that interoceptive accuracy, the objective component of interoception, is lower in AUD individuals, and is correlated with craving and emotion dysregulation. Interoceptive sensibility is in turn higher in AUD individuals compared to healthy controls. Moreover, there is evidence that therapy focused on improving the ability to sense signals from the body in addiction treatment is effective. However, important methodological limitations in interoceptive measures persist, and it is therefore necessary to further investigate the associations between interoception and AUD.

A feasibility trial of an intervention in alcohol dependence for structured preparation before detoxification versus usual care: the SPADe trial results

BACKGROUND

Individuals who are 'moderately' or 'severely' dependent consume alcohol at levels that are likely to have a severe impact on their own health and mortality, the health and behaviours of others (family members) and to have economic and social implications. Treatment guidelines suggest that treatment needs to be planned with medically assisted withdrawal (also referred to as detoxification), and aftercare support but outcomes are poor with low proportions engaging in after care and high relapse rates. An approach of structured preparation before alcohol detoxification (SPADe) puts an emphasis on introducing lifestyle changes, development of coping strategies for cravings, stress and emotions as well as introducing changes to the immediate family and social environment in advance of alcohol cessation. Such a pre-habilitation paradigm compliments the established treatment approach. The key research question was: can we design a large scale, randomised controlled trial (RCT) that will answer whether such an approach is more effective than usual care in helping individuals to maintain longer periods of alcohol abstinence?

METHODS

This is a pragmatic, parallel, two-arm, feasibility RCT comparing SPADe and usual care against usual care only in maintaining alcohol abstinence in adults with alcohol dependence receiving care in two community addiction services in London. Feasibility outcomes, exploration of primary and secondary clinical outcomes and health economic outcomes are analysed. The trial follows the guidelines of phase 2 of the Medical Research Council (MRC) for complex interventions.

RESULTS

We were able to recruit 48/50 participants during a period of 9 months. Retention in the trial for the whole period of the 12 months was 75%. Treatment compliance was overall 44%. Data completion for the primary outcome was 65%, 50% and 63% at 3, 6 and 12 months, respectively. The intervention group had more days abstinent in the previous 90 days at the 12 months (n = 54.5) versus control (n = 41.5).

CONCLUSIONS

The results of this feasibility trial indicate that with the appropriate modifications, a full multicentred trial would be possible to test the effectiveness and cost-effectiveness of a pre-habilitation approach such as the SPADe group intervention in addition to usual care against usual care only.

TRIAL REGISTRATION

Name of registry: ISRCTN; Trial Registration Number: 14621127 ; Date of Registration: 22/02/2017.

A feasibility study of an intervention for structured preparation before detoxification in alcohol dependence: the SPADe trial protocol

Background

Alcohol-related harm is currently estimated to cost the National Health Service (NHS) in England £3.5 bn a year. Of the estimated 1.6 million people with some degree of alcohol dependence, some 600,000 are believed to be moderately or severely dependent and may benefit from intensive treatment. Outcomes from medically assisted withdrawal, also referred to as detoxification, are often poor, with poor engagement in relapse prevention interventions and subsequent high relapse rates. Detoxification is costly both financially and to the individual. It has been found that people who experience multiple detoxifications show more emotional and cognitive impairments. These changes may confer upon them the inability to resolve conflict and increased sensitivity to stress thus contributing to increased vulnerability risk of relapse. The study aims to test the feasibility of using a group intervention aiming to prepare participants for long-term abstinence before, rather than after, they have medically assisted detoxification. The current study will establish key parameters that influence trial design such as recruitment, compliance with the intervention, retention, and sensitivity of alternative outcome measures, in preparation for a future randomised controlled trial (RCT). This paper presents the protocol of the feasibility study.

Methods

The study corresponds to phase 2 of the Medical Research Council (MRC) complex interventions guidelines which cover the development and feasibility testing of an intervention. The work is in three stages. The development, adaptation and implementation of the Structured Preparation before Alcohol Detoxification (SPADe) intervention (stage 1), a randomised feasibility study with economic evaluation (stage 2) and a qualitative study (stage 3). Fifty participants will be recruited from two community alcohol treatment services in England. Participants will be randomised in two arms: the treatment as usual arm (TAU), which includes planned medically assisted detoxification and aftercare and the intervention arm in which participants will receive structured group preparation before detoxification in addition to TAU. The main outcomes are duration of continuous abstinence with no incidents of lapse or relapse, percentage of days abstinent and time to relapse.

Discussion

The socioeconomic harms associated with alcohol have been well-documented, yet existing treatment options have not been able to reduce high relapse rates. This study will build on existing naturalistic studies underpinned by psychological interventions offered early and before detoxification from alcohol, which aim to reverse automatised habitual behaviours and thus may help us to understand how better to support people to remain abstinent and improve post detoxification outcomes.

Trial registration

ISRCTN, 14621127; Registered on 22 Feb 2017

Free Will, Black Swans and Addiction

The current dominant perspective on addiction as a brain disease has been challenged recently by Marc Lewis, who argued that the brain-changes related to addiction are similar to everyday changes of the brain. From this alternative perspective, addictions are bad habits that can be broken, provided that people are motivated to change. In that case, autonomous choice or "free will" can overcome bad influences from genes and or environments and brain-changes related to addiction. Even though we concur with Lewis that there are issues with the brain disease perspective, we also argue that pointing to black swans can be important, that is: there can be severe cases where addiction indeed tips over into the category of brain disease, but obviously that does not prove that every case of addiction falls into the disease category, that all swans are black. We argue that, for example, people suffering from Korsakoff's syndrome, can be described as having a brain disease, often caused by alcohol addiction. Moreover, the brain changes occurring with addiction are related to choice-behaviour (and the related notions of willed action), habit formation and insight, hence essential mental abilities to break the addiction. We argue for a more graded perspective, where both black swans (severe brain disease which makes recovery virtually impossible) and white swans (unaffected brain) are rare, and most cases of addiction come as geese in different shades of gray.

The impact of cognitive impairment and impulsivity on relapse of alcohol-dependent patients: implications for psychotherapeutic treatment

Recent models of the development of addiction propose a transition from a pleasure-driven to a heavily automatized behaviour, marked by a loss of cognitive control. This study investigated the deficits in different components of cognitive functions including behavioural inhibition in response to alcohol-related stimuli in alcohol-dependent patients (ADP) and healthy controls (HC). The aims of the study were to identify which particular cognitive functions are impaired in ADP. Furthermore, we analysed the association between cognitive deficits and relapse rates and the reversibility of cognitive deficits under abstinence in a 6-month follow-up period. Ninety-four recently detoxified ADP and 71 HC completed the cognitive tasks as well as questionnaire measures assessing drinking behaviour and personality traits. Compared with HC, ADP showed poorer performance in response initiation, response inhibition, complex-sustained attention and executive functions. Impairment in response inhibition was a significant predictor for relapse, yet the strongest predictor was the interaction between the number of previous detoxifications and response-inhibition deficits. The results of a moderation analysis showed that patients with many previous detoxifications and large deficits in response inhibition showed the highest relapse risk. These findings indicate that interventions should take into account inhibitory deficits especially in ADP with a high number of previous detoxifications.