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Yates JR. Pharmacological Treatments for Methamphetamine Use Disorder: Current Status and Future Targets. Subst Abuse Rehabil 2024; 15:125-161. [PMID: 39228432 PMCID: PMC11370775 DOI: 10.2147/sar.s431273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 08/15/2024] [Indexed: 09/05/2024] Open
Abstract
The illicit use of the psychostimulant methamphetamine (METH) is a major concern, with overdose deaths increasing substantially since the mid-2010s. One challenge to treating METH use disorder (MUD), as with other psychostimulant use disorders, is that there are no available pharmacotherapies that can reduce cravings and help individuals achieve abstinence. The purpose of the current review is to discuss the molecular targets that have been tested in assays measuring the physiological, the cognitive, and the reinforcing effects of METH in both animals and humans. Several drugs show promise as potential pharmacotherapies for MUD when tested in animals, but fail to produce long-term changes in METH use in dependent individuals (eg, modafinil, antipsychotic medications, baclofen). However, these drugs, plus medications like atomoxetine and varenicline, may be better served as treatments to ameliorate the psychotomimetic effects of METH or to reverse METH-induced cognitive deficits. Preclinical studies show that vesicular monoamine transporter 2 inhibitors, metabotropic glutamate receptor ligands, and trace amine-associated receptor agonists are efficacious in attenuating the reinforcing effects of METH; however, clinical studies are needed to determine if these drugs effectively treat MUD. In addition to screening these compounds in individuals with MUD, potential future directions include increased emphasis on sex differences in preclinical studies and utilization of pharmacogenetic approaches to determine if genetic variances are predictive of treatment outcomes. These future directions can help lead to better interventions for treating MUD.
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Affiliation(s)
- Justin R Yates
- Department of Psychological Science, Northern Kentucky University, Highland Heights, KY, USA
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2
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Li MJ, Shoptaw SJ. Clinical management of psychostimulant withdrawal: review of the evidence. Addiction 2023; 118:750-762. [PMID: 36401591 PMCID: PMC10069411 DOI: 10.1111/add.16093] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 11/02/2022] [Indexed: 11/21/2022]
Abstract
It is estimated that a majority of people who use psychostimulants, particularly methamphetamine (MA) and cocaine, experience withdrawal upon abstinence from sustained use. This review of clinical research reports the evidence regarding biomedical and behavioral treatments for psychostimulant withdrawal symptoms. It provides a framework for clinicians and scientists to increase impact on attenuating MA and cocaine withdrawal during initial and sustained abstinence. Articles reviewed included reports of controlled clinical trials (randomized or non-randomized) reporting at least one withdrawal symptom among the outcomes or specifically studying patients in withdrawal. Potential efficacy for MA withdrawal is noted for a few medications (mirtazapine, naltrexone, bupropion) and repetitive transcranial magnetic stimulation during acute (first week), early protracted (weeks 2-4) and late protracted (> 4 weeks) withdrawal phases. Topiramate shows mixed evidence of efficacy for cocaine withdrawal. In general, there is inconsistent signal for biomedical and behavioral treatments on MA and cocaine withdrawal.
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Affiliation(s)
- Michael J. Li
- Department of Family Medicine, University of California, Los Angeles, CA, USA
| | - Steven J. Shoptaw
- Department of Family Medicine, University of California, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA
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3
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Acheson LS, Williams BH, Farrell M, McKetin R, Ezard N, Siefried KJ. Pharmacological treatment for methamphetamine withdrawal: A systematic review and meta-analysis of randomised controlled trials. Drug Alcohol Rev 2023; 42:7-19. [PMID: 35862266 PMCID: PMC10083934 DOI: 10.1111/dar.13511] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/08/2022] [Accepted: 06/21/2022] [Indexed: 01/10/2023]
Abstract
ISSUES Cessation of methamphetamine use may result in a characteristic withdrawal syndrome, no medication has been approved for this indication. This systematic review aims to assess the efficacy of pharmacotherapy for methamphetamine withdrawal, the first comprehensive meta-analysis since 2008. APPROACH MEDLINE (1966-2020), CINAHL (1982-2020), PsychINFO (1806-2020) and EMBASE (1947-2020) were systematically searched. Studies were included if they were randomised controlled trials (RCT) investigating pharmacological treatments for methamphetamine withdrawal, reviewing outcomes of treatment discontinuation, mental health outcomes, withdrawal symptoms (including craving) and patient safety. The relative risk (RR) and weighted mean difference (MD) were used to meta-analyse dichotomous and continuous data respectively, with 95% confidence intervals. Risk of bias and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) assessments were conducted. KEY FINDINGS Nine RCTs of six medications (n = 242 participants) met inclusion criteria, however, only six trials of four medications (n = 186) could be meta-analysed. Mean sample size across studies was 27 participants, and 88% of participants were male. The quality of evidence in this review varies from low to very low on GRADE assessments. Amineptine may reduce discontinuation rates (RR 0.22, 95% confidence interval [CI] 0.07, 0.72, p = 0.01), and improve global state (MD -0.49, 95% CI -0.80, -0.17), compared with placebo, however, this medication is no longer approved. No other medications improved any domain when compared with placebo. Due to lack of reporting safety profiles could not be established. CONCLUSIONS There is insufficient evidence to indicate any medication is effective for the treatment of methamphetamine withdrawal. The poor quality of the evidence indicates a need for better powered, high-quality trials.
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Affiliation(s)
- Liam S Acheson
- The National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia.,Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, Australia.,The National Centre for Clinical Research on Emerging Drugs, c/o UNSW Sydney, Sydney, Australia
| | - Benjamin H Williams
- Department of Psychiatry, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, Australia
| | - Michael Farrell
- The National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Rebecca McKetin
- The National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Nadine Ezard
- The National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia.,Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, Australia.,The National Centre for Clinical Research on Emerging Drugs, c/o UNSW Sydney, Sydney, Australia.,New South Wales Drug and Alcohol Clinical Research and Improvement Network, Sydney, Australia
| | - Krista J Siefried
- The National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia.,Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, Australia.,The National Centre for Clinical Research on Emerging Drugs, c/o UNSW Sydney, Sydney, Australia
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4
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Wu MK, Satogami K, Liang CS, Stubbs B, Carvalho AF, Brunoni AR, Su KP, Tu YK, Wu YC, Chen TY, Li DJ, Lin PY, Hsu CW, Chen YW, Suen MW, Zeng BY, Takahashi S, Tseng PT, Li CT. Multiple comparison of different noninvasive brain stimulation and pharmacologic interventions in patients with methamphetamine use disorders: A network meta-analysis of randomized controlled trials. Psychiatry Clin Neurosci 2022; 76:633-643. [PMID: 35876620 DOI: 10.1111/pcn.13452] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/04/2022] [Accepted: 07/18/2022] [Indexed: 11/30/2022]
Abstract
AIM In recent decades, the prevalence of amphetamine and methamphetamine use disorders has at least doubled in some regions/countries, with accompanying high risks of drug overdose-associated mortality. Noninvasive brain stimulation (NIBS) methods may be effective treatments. However, the comparative efficacy of the NIBS protocol for amphetamine/methamphetamine use disorder (AUD/MUD) remains unknown to date. The aim of this network meta-analysis (NMA) was to compare the efficacy and acceptability of various NIBS methods/protocols for AUD/MUD management. METHODS A frequentist model-based NMA was conducted. We included randomized controlled trials (RCTs) that investigated the efficacy of NIBS and guideline-recommended pharmacologic treatments to reduce craving severity in patients with either AUD or MUD. RESULTS Twenty-two RCTs including 1888 participants met the eligibility criteria. Compared with the sham/placebo group (study = 19, subjects = 891), a combination of intermittent theta burst stimulation over the left dorsolateral prefrontal cortex (DLPFC) and continuous TBS over the left ventromedial prefrontal cortex (study = 1, subjects = 19) was associated with the largest decreases in craving severity [standardized mean difference (SMD) = -1.50; 95% confidence intervals (95%CIs) = -2.70 to -0.31]. High-frequency repetitive transcranial magnetic stimulation over the left DLPFC was associated with the largest improvements in depression and quality of sleep (study = 3, subjects = 86) (SMD = -2.48; 95%CIs = -3.25 to -1.71 and SMD = -2.43; 95%CIs = -3.38 to -1.48, respectively). The drop-out rate of most investigated treatments did not significantly differ between groups. CONCLUSION The combined TBS protocol over the prefrontal cortex was associated with the greatest improvement in craving severity. Since few studies were available for inclusion, additional large-scale randomized controlled trials are warranted.
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Affiliation(s)
- Ming-Kung Wu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kazumi Satogami
- Department of Neuropsychiatry, Wakayama Medical University, Wakayama, Japan
| | - Chih-Sung Liang
- Department of Psychiatry, Beitou Branch, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Brendon Stubbs
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - Andre F Carvalho
- Innovation in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, Geelong, Victoria, Australia
| | - Andre R Brunoni
- Service of Interdisciplinary Neuromodulation, National Institute of Biomarkers in Psychiatry, Laboratory of Neurosciences (LIM-27), Departamento e Instituto de Psiquiatria, Faculdade de Medicina da University of Sao Paulo, Sao Paulo, Brazil.,Departamento de Ciências Médicas, Faculdade de Medicina da University of Sao Paulo, Sao Paulo, Brazil
| | - Kuan-Pin Su
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Department of Psychiatry and Mind-Body Interface Laboratory (MBI-Lab), China Medical University Hospital, Taichung, Taiwan.,College of Medicine, China Medical University, Taichung, Taiwan.,An-Nan Hospital, China Medical University, Tainan, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.,Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Cheng Wu
- Department of Sports Medicine, Landseed International Hospital, Taoyuan, Taiwan
| | - Tien-Yu Chen
- Department of Psychiatry, Tri-Service General Hospital; School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Dian-Jeng Li
- Department of Addiction Science, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung City, Taiwan
| | - Pao-Yen Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Institute for Translational Research in Biomedical Sciences, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yen-Wen Chen
- Prospect Clinic for Otorhinolaryngology and Neurology, Kaohsiung, Taiwan
| | - Mein-Woei Suen
- Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan.,Gender Equality Education and Research Center, Asia University, Taichung, Taiwan.,Department of Medical Research, Asia University Hospital, Asia University, Taichung, Taiwan.,Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Bing-Yan Zeng
- Department of Internal Medicine, E-Da Dachang Hospital, Kaohsiung, Taiwan.,Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Shun Takahashi
- Department of Neuropsychiatry, Wakayama Medical University, Wakayama, Japan.,Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Japan.,Graduate School of Rehabilitation Science, Osaka Metropolitan University, Habikino, Japan.,Clinical Research and Education Center, Asakayama General Hospital, Sakai, Japan
| | - Ping-Tao Tseng
- Prospect Clinic for Otorhinolaryngology and Neurology, Kaohsiung, Taiwan.,Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan.,Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Cheng-Ta Li
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan.,Division of Psychiatry, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Brain Science and Brain Research Center, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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5
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Acheson LS, Ezard N, Lintzeris N, Dunlop A, Brett J, Rodgers C, Gill A, Christmass M, McKetin R, Farrell M, Shoptaw S, Siefried KJ. Lisdexamfetamine for the treatment of acute methamphetamine withdrawal: A pilot feasibility and safety trial. Drug Alcohol Depend 2022; 241:109692. [PMID: 36399936 DOI: 10.1016/j.drugalcdep.2022.109692] [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: 09/08/2022] [Revised: 10/28/2022] [Accepted: 10/28/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND There is no effective treatment for methamphetamine withdrawal. This study aimed to determine the feasibility and safety of a tapering dose of lisdexamfetamine for the treatment of acute methamphetamine (MA) withdrawal. METHODS Open-label, single-arm pilot study, in an inpatient drug and alcohol withdrawal unit assessing a tapering dose of oral lisdexamfetamine dimesylate commencing at 250 mg once daily, reducing by 50 mg per day to 50 mg on Day 5. Measures were assessed daily (days 0-7) with 21-day telephone follow-up. Feasibility was measured by the time taken to enrol the sample. Safety was the number of adverse events (AEs) by system organ class. Retention was the proportion to complete treatment. Other measures included the Treatment Satisfaction Questionnaire for Medication (TSQM), the Amphetamine Withdrawal Questionnaire and craving (Visual Analogue Scale). RESULTS Ten adults seeking inpatient treatment for MA withdrawal (9 male, median age 37.1 years [IQR 31.7-41.9]), diagnosed with MA use disorder were recruited. The trial was open for 126 days; enroling one participant every 12.6 days. Eight of ten participants completed treatment (Day 5). Two participants left treatment early. There were no treatment-related serious adverse events (SAEs). Forty-seven AEs were recorded, 17 (36%) of which were potentially causally related, all graded as mild severity. Acceptability of the study drug by TSQM was rated at 100% at treatment completion. Withdrawal severity and craving reduced through the admission. CONCLUSION A tapering dose regimen of lisdexamfetamine was safe and feasible for the treatment of acute methamphetamine withdrawal in an inpatient setting.
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Affiliation(s)
- Liam S Acheson
- The National Drug and Alcohol Research Centre (NDARC), the University of New South Wales, Sydney, Australia; Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, Australia; The National Centre for Clinical Research on Emerging Drugs (NCCRED), c/o the University of New South Wales, Sydney, Australia.
| | - Nadine Ezard
- The National Drug and Alcohol Research Centre (NDARC), the University of New South Wales, Sydney, Australia; Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, Australia; The National Centre for Clinical Research on Emerging Drugs (NCCRED), c/o the University of New South Wales, Sydney, Australia; New South Wales Drug and Alcohol Clinical Research and Improvement Network (DACRIN), NSW, Australia
| | - Nicholas Lintzeris
- New South Wales Drug and Alcohol Clinical Research and Improvement Network (DACRIN), NSW, Australia; The Langton Centre, South East Sydney Local Health District, Sydney, Australia; Discipline of Addiction Medicine, the University of Sydney, Sydney, Australia
| | - Adrian Dunlop
- New South Wales Drug and Alcohol Clinical Research and Improvement Network (DACRIN), NSW, Australia; Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, Australia; School of Medicine and Public Health, the University of Newcastle, Newcastle, Australia
| | - Jonathan Brett
- Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, Sydney, Australia; St. Vincent's Clinical School, the University of New South Wales, Sydney, Australia
| | - Craig Rodgers
- Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, Australia
| | - Anthony Gill
- Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, Australia
| | - Michael Christmass
- Next Step Drug and Alcohol Services, Perth, Australia; National Drug Research Institute, Curtin University, Perth, Australia
| | - Rebecca McKetin
- The National Drug and Alcohol Research Centre (NDARC), the University of New South Wales, Sydney, Australia
| | - Michael Farrell
- The National Drug and Alcohol Research Centre (NDARC), the University of New South Wales, Sydney, Australia
| | - Steve Shoptaw
- Department of Family Medicine, The University of California Los Angeles, Los Angeles, USA
| | - Krista J Siefried
- The National Drug and Alcohol Research Centre (NDARC), the University of New South Wales, Sydney, Australia; Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, Australia; The National Centre for Clinical Research on Emerging Drugs (NCCRED), c/o the University of New South Wales, Sydney, Australia
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6
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Nanni-Alvarado R, Gonzalez M, Lima C, Marín-Navarrete R, Barbosa-Méndez S, Salazar-Juárez A. Effect of Mirtazapine on Craving in Cocaine-Dependent Patients. Int J Ment Health Addict 2021. [DOI: 10.1007/s11469-021-00547-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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7
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Hickert A, Rowley B, Doyle M. Perinatal Methamphetamine Use: A Review of the Literature. Psychiatr Ann 2021. [DOI: 10.3928/00485713-20210303-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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8
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Alipour M, Jafarian M, Rastgoo R, Mokri A, Gorji A, Zarrindast MR, Lorestani F, Razaghi EM. Cabergoline in Treatment of Methamphetamine-Dependent Patients and Its Effect on Serum Level of Glial Cell-Derived Neurotrophic Factor: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial. Eur Addict Res 2021; 27:457-468. [PMID: 33857946 DOI: 10.1159/000515398] [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: 09/12/2019] [Accepted: 02/22/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Methamphetamine use disorder is an important public health problem, especially in the younger generation, and associated with various psychiatric, cognitive, social, economic, and legal issues. Cabergoline, a drug with dopaminergic properties and long half-life, has been considered for the treatment of stimulant dependence. The systemic use of cabergoline has been shown to increase glial cell-derived neurotrophic factor (GDNF) expression. OBJECTIVE In this study, we investigated the effects of cabergoline on the serum level of GDNF and its effect on abstaining from methamphetamine in individuals treated for methamphetamine use disorder. METHOD Sixty male subjects with methamphetamine use disorder were randomly assigned to 2 groups receiving cabergoline and placebo, respectively. During a 12-week follow-up, we compared the serum level of GDNF, urine test results for methamphetamine use, and depression scale between the 2 groups. RESULTS We found that serum GDNF was lower in subjects who used methamphetamine than healthy subjects (p < 0.0001). However, the serum level of GDNF was not associated with cabergoline use. The rising number of cases testing positive in the placebo group showed a trend resulting in no significant difference between cases testing positive and negative (p = 0.585) at the end of week 12. In the verum group, however, the significantly high number of cases who tested negative - sober - for substances observed in early stages (weeks 7-8) continued to remain significantly higher till the end of the study (p = 0.043), resembling an association between treatment with cabergoline and remaining sober. Although reduced during treatment, recovery from depression was not associated with cabergoline treatment. CONCLUSION The findings of this study confirmed the effect of cabergoline in reducing methamphetamine use. However, a serum level of the GDNF increase, as seen in animal studies, was not associated with cabergoline treatment of human subjects. This study was registered at the Iranian Registry of Clinical Trials (TRN:IRCT2015050422077N1, October 06, 2015, https://en.irct.ir/trial/19134).
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Affiliation(s)
- Mohammadesmaeil Alipour
- Department of Neuroscience and Addiction Studies, MD, PhD Candidate in Addiction Studies, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran.,Janbazan Medical and Engineering Research Center, Tehran, Iran
| | - Maryam Jafarian
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Rastgoo
- Department of Neuroscience and Addiction Studies, MD, PhD Candidate in Addiction Studies, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Azarakhsh Mokri
- Department of Psychiatry, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Gorji
- Epilepsy Research Center, Westfalische Wilhelms-Universität Münster, Münster, Germany
| | - Mohammad R Zarrindast
- Department of Neurosciences and Addiction Studies, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Fahimeh Lorestani
- Department of Psychology, Faculty of Humaities, Saveh Islamic Azad University, Saveh, Iran
| | - Emran M Razaghi
- Department of Psychiatry, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.,Department of Neurosciences and Addiction Studies, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran
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9
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May AC, Aupperle RL, Stewart JL. Dark Times: The Role of Negative Reinforcement in Methamphetamine Addiction. Front Psychiatry 2020; 11:114. [PMID: 32256392 PMCID: PMC7090143 DOI: 10.3389/fpsyt.2020.00114] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 02/10/2020] [Indexed: 12/01/2022] Open
Abstract
Methamphetamine use is associated with substantial adverse outcomes including poor mental and physical health, financial difficulties, and societal costs. Despite deleterious long-term consequences associated with methamphetamine, many people use drugs for short-term reduction of unpleasant physical or emotional sensations. By removing these aversive states, drug use behaviors are negatively reinforced. Abstinence from methamphetamine can then result in a return to previous aversive emotional states linked to withdrawal and craving, often contributing to an increased likelihood for relapse. This negative reinforcement cycle is hypothesized to be a motivating and maintaining factor for addiction. Thus, this review highlights the current evidence for negative reinforcement mechanisms in methamphetamine use disorder by integrating studies of subjective experience, behavior, functional magnetic resonance imaging, positron emission tomography, and event-related potentials and examining the efficacy of treatments targeting aspects of negative reinforcement. Overall, the literature demonstrates that individuals who use methamphetamine have diminished cognitive control and process emotions, loss of reward, and interoceptive information differently than non-using individuals. These differences are reflected in behavioral and subjective experiments as well as brain-based experiments which report significant differences in various frontal regions, insula, anterior cingulate cortex, and striatum. Together, the results suggest methamphetamine users have an altered experience of negative outcomes, difficulties employing effective emotion regulation, and difficulty engaging in adaptive or goal-directed decision-making. Suggestions for future research to improve our understanding of how negative reinforcement contributes to methamphetamine addiction and to develop effective interventions are provided.
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Affiliation(s)
- April C. May
- Joint Doctoral Program in Clinical Psychology, San Diego State University and University of California, San Diego, San Diego, CA, United States
| | - Robin L. Aupperle
- Laureate Institute for Brain Research, Tulsa, OK, United States
- Department of Community Medicine, University of Tulsa, Tulsa, OK, United States
| | - Jennifer L. Stewart
- Laureate Institute for Brain Research, Tulsa, OK, United States
- Department of Community Medicine, University of Tulsa, Tulsa, OK, United States
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10
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Siefried KJ, Acheson LS, Lintzeris N, Ezard N. Pharmacological Treatment of Methamphetamine/Amphetamine Dependence: A Systematic Review. CNS Drugs 2020; 34:337-365. [PMID: 32185696 PMCID: PMC7125061 DOI: 10.1007/s40263-020-00711-x] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
BACKGROUND Stimulant drugs are second only to cannabis as the most widely used class of illicit drug globally, accounting for 68 million past-year consumers. Dependence on amphetamines (AMPH) or methamphetamine (MA) is a growing global concern. Yet, there is no established pharmacotherapy for AMPH/MA dependence. A comprehensive assessment of the research literature on pharmacotherapy for AMPH/MA dependence may inform treatment guidelines and future research directions. METHODS We systematically reviewed the peer-reviewed literature via the electronic databases PubMed, EMBASE, CINAHL and SCOPUS for randomised controlled trials reported in the English language examining a pharmacological treatment for AMPH/MA dependence or use disorder. We included all studies published to 19 June 2019. The selected studies were evaluated for design; methodology; inclusion and exclusion criteria; sample size; pharmacological and (if included) psychosocial interventions; length of follow-up and follow-up schedules; outcome variables and measures; results; overall conclusions and risk of bias. Outcome measures were any reported impact of treatment related to AMPH/MA use. RESULTS Our search returned 43 studies that met our criteria, collectively enrolling 4065 participants and reporting on 23 individual pharmacotherapies, alone or in combination. Disparate outcomes and measures (n = 55 for the primary outcomes) across studies did not allow for meta-analyses. Some studies demonstrated mixed or weak positive signals (often in defined populations, e.g. men who have sex with men), with some variation in efficacy signals dependent on baseline frequency of AMPH/MA use. The most consistent positive findings have been demonstrated with stimulant agonist treatment (dexamphetamine and methylphenidate), naltrexone and topiramate. Less consistent benefits have been shown with the antidepressants bupropion and mirtazapine, the glutamatergic agent riluzole and the corticotropin releasing factor (CRF-1) antagonist pexacerfont; whilst in general, antidepressant medications (e.g. selective serotonin reuptake inhibitors [SSRIs], tricyclic antidepressants [TCAs]) have not been effective in reducing AMPH/MA use. CONCLUSIONS No pharmacotherapy yielded convincing results for the treatment of AMPH/MA dependence; mostly studies were underpowered and had low treatment completion rates. However, there were positive signals from several agents that warrant further investigation in larger scale studies; agonist therapies show promise. Common outcome measures should include change in use days. Future research must address the heterogeneity of AMPH/MA dependence (e.g. coexisting conditions, severity of disorder, differences between MA and AMPH dependence) and the role of psychosocial intervention.
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Affiliation(s)
- Krista J Siefried
- The National Centre for Clinical Research on Emerging Drugs (NCCRED), Sydney, NSW, Australia.
- St Vincent's Hospital Alcohol and Drug Service, Darlinghurst, 390 Victoria St, 2010, Sydney, NSW, Australia.
- The University of New South Wales, National Drug and Alcohol Research Centre (NDARC), Sydney, NSW, Australia.
| | - Liam S Acheson
- St Vincent's Hospital Alcohol and Drug Service, Darlinghurst, 390 Victoria St, 2010, Sydney, NSW, Australia
| | - Nicholas Lintzeris
- Division of Addiction Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, NSW, Australia
- New South Wales Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Sydney, NSW, Australia
| | - Nadine Ezard
- The National Centre for Clinical Research on Emerging Drugs (NCCRED), Sydney, NSW, Australia
- St Vincent's Hospital Alcohol and Drug Service, Darlinghurst, 390 Victoria St, 2010, Sydney, NSW, Australia
- The University of New South Wales, National Drug and Alcohol Research Centre (NDARC), Sydney, NSW, Australia
- New South Wales Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Sydney, NSW, Australia
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11
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Soares E, Pereira FC. Pharmacotherapeutic strategies for methamphetamine use disorder: mind the subgroups. Expert Opin Pharmacother 2019; 20:2273-2293. [PMID: 31671001 DOI: 10.1080/14656566.2019.1681970] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Introduction: Drug use related deaths are increasing and the lack of effective treatment for psychostimulants can be largely held responsible. Particularly, no pharmacotherapy is approved for methamphetamine (METH) use disorder despite decades of research. Only psychosocial interventions are clinically used, with limited long-term recovery and relapse.Areas covered: This review aims to select and describe the most relevant findings to date. Selected clinical trials were found in PubMed using the following keywords ('methamphetamine') and ('addiction' OR 'withdrawal' OR 'treatment' OR 'pharmacotherapy'). Randomized placebo-controlled trials enrolling treatment-seeking METH-dependent subjects and inherent secondary analysis were included.Expert opinion: Overall, end-of-treatment abstinence, reduced METH use or lower relapse rates were seen on METH dependent subgroups or attained significance only following post hoc analysis, irrespective of the medication tested. For example, light and heavy METH users seem to respond differently to pharmacotherapy. This together with the heterogeneous nature of the METH dependent population strongly suggests that some drugs herein described (e.g. mirtazapine, methylphenidate) should be further tested in clinical trials focused on subgroups. Lastly, objective measures, such as urinalysis, are mandatory to include in clinical trials and early treatment response and/or medication compliance should be carefully monitored and considered as predictors of success/failure.
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Affiliation(s)
- Edna Soares
- Institute of Pharmacology and Experimental Therapeutics/iCBR, Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Neuroscience, Vision and Brain Diseases, CNC.IBILI-University of Coimbra, Coimbra, Portugal.,Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Center for Innovative Biomedicine and Biotechnology, University of Coimbra, Coimbra, Portugal
| | - Frederico C Pereira
- Institute of Pharmacology and Experimental Therapeutics/iCBR, Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Neuroscience, Vision and Brain Diseases, CNC.IBILI-University of Coimbra, Coimbra, Portugal.,Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Center for Innovative Biomedicine and Biotechnology, University of Coimbra, Coimbra, Portugal
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Synergistic interactions between mirtazapine and prazosin prevent the induction and expression of behavioral sensitization to cocaine in rats. Physiol Behav 2017; 180:137-145. [DOI: 10.1016/j.physbeh.2017.08.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 08/21/2017] [Accepted: 08/23/2017] [Indexed: 11/22/2022]
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Mirtazapine attenuates cocaine seeking in rats. J Psychiatr Res 2017; 92:38-46. [PMID: 28391178 DOI: 10.1016/j.jpsychires.2017.03.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 03/27/2017] [Accepted: 03/31/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Relapse to cocaine use is a major problem in the clinical treatment of cocaine addiction. Antidepressants have been studied for their therapeutic potential to treat cocaine use disorder. Research has suggested that antidepressants attenuate both drug craving and the re-acquisition of drug-seeking and drug-taking behaviors. This study examined the efficacy of mirtazapine, an antidepressant/anxiolytic, in decreasing cocaine seeking in rats. METHODS We used the cocaine self-administration paradigm to assess the effects of mirtazapine on rats trained to self-administer cocaine or food under a fixed-ratio schedule. Mirtazapine (30 mg/kg, i.p.) was administered during extinction. RESULTS Mirtazapine significantly attenuated non-reinforced lever-press responses during extinction. Moreover, the mirtazapine dosed for 30 days during extinction produced sustained attenuation of lever-press responses during re-acquisition of cocaine self-administration, without changing food-seeking behavior. Our results showed that mirtazapine attenuated the re-acquisition of cocaine-seeking responses. CONCLUSION Our study pointed to the efficacy of mirtazapine in reducing the risk of drug relapse during abstinence, suggesting for its potential use as a novel pharmacological agent to treat drug abuse.
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Hellem TL. A Review of Methamphetamine Dependence and Withdrawal Treatment: A Focus on Anxiety Outcomes. J Subst Abuse Treat 2016; 71:16-22. [DOI: 10.1016/j.jsat.2016.08.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 08/04/2016] [Accepted: 08/08/2016] [Indexed: 01/16/2023]
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Chronic methamphetamine self-administration disrupts cortical control of cognition. Neurosci Biobehav Rev 2016; 69:36-48. [PMID: 27450578 DOI: 10.1016/j.neubiorev.2016.07.020] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 07/18/2016] [Accepted: 07/19/2016] [Indexed: 11/22/2022]
Abstract
Methamphetamine (meth) is one of the most abused substances worldwide. Chronic use has been associated with repeated relapse episodes that may be exacerbated by cognitive impairments during drug abstinence. Growing evidence demonstrates that meth compromises prefrontal cortex activity, resulting in persisting attentional and memory impairments. After summarizing recent studies of meth-induced cognitive dysfunction using a translationally relevant model of self-administered meth, this review emphasizes the cortical brain changes contributing to cognitive dysregulation during abstinence. Finally, we propose the use of cognitive enhancers during abstinence that may promote a drug-free state by reversing cortical dysfunction linked with prolonged meth abuse.
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Salazar-Juárez A, Barbosa-Méndez S, Jurado N, Hernández-Miramontes R, Leff P, Antón B. Mirtazapine prevents induction and expression of cocaine-induced behavioral sensitization in rats. Prog Neuropsychopharmacol Biol Psychiatry 2016; 68:15-24. [PMID: 26922897 DOI: 10.1016/j.pnpbp.2016.02.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 02/03/2016] [Accepted: 02/23/2016] [Indexed: 01/07/2023]
Abstract
Cocaine abuse is a major health problem worldwide. Treatment based on both 5-HT2A/C and 5-HT3 receptor antagonists attenuate not only the effects of cocaine abuse but also the incentive/motivational effect related to cocaine-paired cues. Mirtazapine, an antagonist of postsynaptic α2-adrenergic, 5-HT2A/C and 5HT3 receptors and inverse agonist of the 5-HT2C receptor, has been shown to effectively modify, at the preclinical and clinical levels, various behavioral alterations induced by drugs abuse. Therefore, it is important to assess whether chronic dosing of mirtazapine alters locomotor effects of cocaine as well as induction and expression of cocaine sensitization. Our results reveal that a daily mirtazapine regimen administered for 30days effectively induces a significant attenuation of cocaine-dependent locomotor activity and as well as the induction and expression of behavioral sensitization. These results suggest that mirtazapine may be used as a potentially effective therapy to attenuate induction and expression of cocaine-induced locomotor sensitization.
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Affiliation(s)
- Alberto Salazar-Juárez
- Subdirección de investigaciones Clínicas, Laboratorio de Neurobiología Molecular y Neuroquímica de las Adicciones, Instituto Nacional de Psiquiatría, México DF 14370, Mexico
| | - Susana Barbosa-Méndez
- Subdirección de investigaciones Clínicas, Laboratorio de Neurobiología Molecular y Neuroquímica de las Adicciones, Instituto Nacional de Psiquiatría, México DF 14370, Mexico
| | - Noe Jurado
- Subdirección de investigaciones Clínicas, Laboratorio de Neurobiología Molecular y Neuroquímica de las Adicciones, Instituto Nacional de Psiquiatría, México DF 14370, Mexico
| | - Ricardo Hernández-Miramontes
- Subdirección de investigaciones Clínicas, Laboratorio de Neurobiología Molecular y Neuroquímica de las Adicciones, Instituto Nacional de Psiquiatría, México DF 14370, Mexico
| | - Philippe Leff
- Subdirección de investigaciones Clínicas, Laboratorio de Neurobiología Molecular y Neuroquímica de las Adicciones, Instituto Nacional de Psiquiatría, México DF 14370, Mexico
| | - Benito Antón
- Subdirección de investigaciones Clínicas, Laboratorio de Neurobiología Molecular y Neuroquímica de las Adicciones, Instituto Nacional de Psiquiatría, México DF 14370, Mexico.
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Arora S, Vohora D. Comparative Evaluation of Partial α2 -Adrenoceptor Agonist and Pure α2 -Adrenoceptor Antagonist on the Behavioural Symptoms of Withdrawal after Chronic Alcohol Administration in Mice. Basic Clin Pharmacol Toxicol 2016; 119:202-9. [PMID: 26867012 DOI: 10.1111/bcpt.12566] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 01/28/2016] [Indexed: 12/22/2022]
Abstract
As an addictive drug, alcohol produces withdrawal symptoms if discontinued abruptly after chronic use. Clonidine (CLN), a partial α2 -adrenergic agonist, and mirtazapine (MRT), an antagonist of α2 -adrenoceptor, both clinically aid alcohol withdrawal. Considering different mechanisms of action of the two drugs, this study was designed to see how far these two mechanistically different drugs differ in their ability to decrease the severity of ethanol withdrawal syndrome. The effect of CLN and MRT on ethanol withdrawal-induced anxiety, depression and memory impairment was analysed using EPM, FST and PAR tests, respectively. Animals received distilled water, ethanol and/or either of the drugs (CLN and MRT) in different doses. Relapse to alcohol use was analysed by CPP test. Animals received ethanol as a conditioning drug and distilled water, CLN or MRT as test drug. CLN and MRT both alleviated anxiety in a dose-dependent manner. MRT (4 mg/kg) was more effective than CLN (0.1 mg/kg) in ameliorating the anxiogenic effect of alcohol withdrawal. However, CLN treatment increased depression. It significantly decreased swimming time and increased immobility time, whereas MRT treatment decreased immobility time and increased climbing and swimming time during abstinence. The effect was dose dependent for both drugs. The results of PAR test show that CLN treatment worsens working memory. Significant increase in SDE and TSZ and decrease in SDL were observed in CLN-treated animals. MRT treatment, on the other hand, improved working memory at both doses. Further, both CLN and MRT alleviated craving. A significant decrease in time spent in the ethanol-paired chamber was seen. MRT treatment at both doses showed better effect than CLN in preventing the development of preference in CPP test. These findings indicate a potential therapeutic use and better profile of mirtazapine over clonidine in improving memory, as well as in alleviating depression, anxiety and craving associated with alcohol withdrawal.
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Affiliation(s)
- Shivani Arora
- Department of Pharmacology, Faculty of Pharmacy, Jamia Hamdard University, New Delhi, India
| | - Divya Vohora
- Department of Pharmacology, Faculty of Pharmacy, Jamia Hamdard University, New Delhi, India
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Lalanne L, Lutz PE, Trojak B, Lang JP, Kieffer BL, Bacon E. Medications between psychiatric and addictive disorders. Prog Neuropsychopharmacol Biol Psychiatry 2016; 65:215-23. [PMID: 26514592 DOI: 10.1016/j.pnpbp.2015.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 10/02/2015] [Accepted: 10/25/2015] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Many epidemiological studies have revealed a frequent co-occurrence of psychiatric and substance use disorders. The term used in the literature to refer to this co-occurrence is dual diagnosis. The high prevalence of dual diagnosis has led physicians to observe the effects of medication prescribed to treat psychiatric disorders on the co-occurring substance use disorder and vice versa. The concept of medications between psychiatric and addictive disorders stems from these clinical observations, alongside which, however, it has developed from the observation that both psychiatric and substance use disorders share common neurobiological pathways and trigger common cognitive disorders. This has led researchers to develop medications on the basis of neurobiological and cognitive rationales. MATERIAL AND METHOD In our article, we review peculiar medications based on neurobiological and cognitive rationales and that have an impact in both psychiatric and addictive disorders. RESULTS We highlight how interesting these new prescriptions are for clinical observation and for the treatment of patients suffering from dual diagnosis. CONCLUSION We then go on to discuss the interest in them from the perspective of clinical practice and clinical research, in that the development of medications to treat dual diagnosis helps to further our knowledge of both psychiatric and substance use disorders.
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Affiliation(s)
- Laurence Lalanne
- Translational Medicine and Neurogenetics, Institut de Génétique et de Biologie Molé-culaire et Cellulaire, INSERM U-964, CNRS UMR-7104, Université de Strasbourg, France; CHRU de Strasbourg-INSERM1114, Department of Psychiatry, University of Strasbourg, France.
| | - Pierre-Eric Lutz
- McGill Group for Suicide Studies, Douglas Mental Health research Centre, McGill University, Montréal, Canada; Douglas Mental Health Research Centre, McGill University, Montréal, Canada.
| | - Benoit Trojak
- Department of Psychiatry and Addictology, University Hospital of Dijon, France, EA 4452, LPPM, University of Burgundy, France.
| | - Jean-Philippe Lang
- CHRU de Strasbourg-INSERM1114, Department of Psychiatry, University of Strasbourg, France.
| | - Brigitte L Kieffer
- Translational Medicine and Neurogenetics, Institut de Génétique et de Biologie Molé-culaire et Cellulaire, INSERM U-964, CNRS UMR-7104, Université de Strasbourg, France; Douglas Mental Health Research Centre, McGill University, Montréal, Canada.
| | - Elisabeth Bacon
- Inserm U-1114, Department of Psychiatry, University of Strasbourg, France.
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Is immunotherapy an opportunity for effective treatment of drug addiction? Vaccine 2015; 33:6545-51. [PMID: 26432911 DOI: 10.1016/j.vaccine.2015.09.079] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 09/22/2015] [Accepted: 09/23/2015] [Indexed: 12/31/2022]
Abstract
Immunotherapy has a great potential of becoming a new therapeutic strategy in the treatment of addiction to psychoactive drugs. It may be used to treat addiction but also to prevent neurotoxic complications of drug overdose. In preclinical studies two immunological methods have been tested; active immunization, which relies on the administration of vaccines and passive immunization, which relies on the administration of monoclonal antibodies. Until now researchers have succeeded in developing vaccines and/or antibodies against addiction to heroin, cocaine, methamphetamine, nicotine and phencyclidine. Their effectiveness has been confirmed in preclinical studies. At present, clinical studies are being conducted for vaccines against nicotine and cocaine and also anti-methamphetamine monoclonal antibody. These preclinical and clinical studies suggest that immunotherapy may be useful in the treatment of addiction and drug overdose. However, there are a few problems to be solved. One of them is controlling the level of antibodies due to variability between subjects. But even obtaining a suitable antibody titer does not guarantee the effectiveness of the vaccine. Additionally, there is a risk of intentional or unintentional overdose. As vaccines prevent passing of drugs through the blood/brain barrier and thereby prevent their positive reinforcement, some addicted patients may erroneously seek higher doses of psychoactive substances to get "high". Consequently, vaccination should be targeted at persons who have a strong motivation to free themselves from drug dependency. It seems that immunotherapy may be an opportunity for effective treatment of drug addiction if directed to adequate candidates for treatment. For other addicts, immunotherapy may be a very important element supporting psycho- and pharmacotherapy.
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Rezaei F, Emami M, Zahed S, Morabbi MJ, Farahzadi M, Akhondzadeh S. Sustained-release methylphenidate in methamphetamine dependence treatment: a double-blind and placebo-controlled trial. ACTA ACUST UNITED AC 2015; 23:2. [PMID: 25588930 PMCID: PMC4298048 DOI: 10.1186/s40199-015-0092-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 01/04/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND The objective of this randomized, double-blind, placebo-controlled study was to evaluate the efficacy of sustained-release methylphenidate (MPH-SR) in treatment of methamphetamine dependence. METHODS Fifty-six individuals who met DSM-IV-TR criteria for methamphetamine dependence participated in this 10-week trial. The participants were randomly allocated into two groups and received 18 to 54 mg/day sustained-released methylphenidate or placebo for 10 weeks. Craving was evaluated by a visual analogue craving scale every week. Urinary screening test for methamphetamine was carried out each week. The Beck Depression Inventory-II (BDI-II) was used to monitor participant depressive symptoms at baseline and bi-weekly during the treatment period. RESULTS At the end of the trial, the MPH-SR group was less methamphetamine positive compared to the placebo group and the difference was significant (p = 0.03). By the end of the study, MPH-SR group showed significantly less craving scores compared to the placebo group [MD (95% CI) = -10.28(0.88-19.18), t(54) = 2.19, p = 0.03]. There was greater improvement in the depressive symptoms scores in the intervention group compared to the placebo group [MD (95% CI) =2.03(0.31-3.75), t (54) =2.37, p = 0.02]. CONCLUSION Sustained-released methylphenidate was safe and well tolerated among active methamphetamine users and significantly reduced methamphetamine use, craving and depressive symptoms. TRIAL REGISTRATION IRCT201202281556N38.
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Affiliation(s)
- Farzin Rezaei
- Department of psychiatry, Kurdistan University of Medical Sciences, Sanandaj, Iran.
| | - Maryam Emami
- Department of psychiatry, Kurdistan University of Medical Sciences, Sanandaj, Iran.
| | - Shakiba Zahed
- Department of Health Education and Health Promotion, Faculty of Health, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Mohammad-Javad Morabbi
- Department of Neuroscience, School of Advanced Medical Technologies, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mohammadhadi Farahzadi
- Department of Neuroscience, School of Advanced Medical Technologies, Tehran University of Medical Sciences, Tehran, Iran.
| | - Shahin Akhondzadeh
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, South Kargar Street, Tehran, 13337, Iran.
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Hellem TL, Sung YH, Shi XF, Pett MA, Latendresse G, Morgan J, Huber RS, Kuykendall D, Lundberg KJ, Renshaw PF. Creatine as a Novel Treatment for Depression in Females Using Methamphetamine: A Pilot Study. J Dual Diagn 2015; 11:189-202. [PMID: 26457568 PMCID: PMC4684979 DOI: 10.1080/15504263.2015.1100471] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Depression among methamphetamine users is more prevalent in females than males, but gender-specific treatment options for this comorbidity have not been described. Reduced brain phosphocreatine levels have been shown to be lower in female methamphetamine users compared to males, and, of relevance, studies have demonstrated an association between treatment-resistant depression and reduced brain phosphocreatine concentrations. The nutritional supplement creatine monohydrate has been reported to reduce symptoms of depression in female adolescents and adults taking antidepressants, as well as to increase brain phosphocreatine in healthy volunteers. Therefore, the purpose of this pilot study was to investigate creatine monohydrate as a treatment for depression in female methamphetamine users. METHODS Fourteen females with depression and comorbid methamphetamine dependence were enrolled in an 8-week open label trial of 5 g of daily creatine monohydrate and of these 14, 11 females completed the study. Depression was measured using the Hamilton Depression Rating Scale (HAMD) and brain phosphocreatine levels were measured using phosphorus magnetic resonance spectroscopy pre- and post-creatine treatment. Secondary outcome measures included anxiety symptoms, measured with the Beck Anxiety Inventory (BAI), as well as methamphetamine use, monitored by twice weekly urine drug screens and self-reported use. RESULTS The results of a linear mixed effects repeated measures model showed significantly reduced HAMD and BAI scores as early as week 2 when compared to baseline scores. This improvement was maintained through study completion. Brain phosphocreatine concentrations were higher at the second phosphorus magnetic resonance spectroscopy scan compared to the baseline scan; Mbaseline = 0.223 (SD = 0.013) vs. Mpost-treatment = 0.233 (SD = 0.009), t (9) = 2.905, p <.01, suggesting that creatine increased phosphocreatine levels. Also, a reduction in methamphetamine positive urine drug screens of greater than 50% was observed by week 6. Finally, creatine was well tolerated and adverse events that were related to gastrointestinal symptoms and muscle cramping were determined as possibly related to creatine. CONCLUSIONS The current study suggests that creatine treatment may be a promising therapeutic approach for females with depression and comorbid methamphetamine dependence. This study is registered on clinicaltrials.gov (NCT01514630).
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Affiliation(s)
- Tracy L Hellem
- a The Brain Institute, University of Utah , Salt Lake City , Utah , USA.,b The College of Nursing, University of Utah , Salt Lake City , Utah , USA
| | - Young-Hoon Sung
- a The Brain Institute, University of Utah , Salt Lake City , Utah , USA
| | - Xian-Feng Shi
- a The Brain Institute, University of Utah , Salt Lake City , Utah , USA.,c The Department of Psychiatry , University of Utah , Salt Lake City , Utah , USA
| | - Marjorie A Pett
- b The College of Nursing, University of Utah , Salt Lake City , Utah , USA
| | - Gwen Latendresse
- b The College of Nursing, University of Utah , Salt Lake City , Utah , USA
| | - Jubel Morgan
- a The Brain Institute, University of Utah , Salt Lake City , Utah , USA.,c The Department of Psychiatry , University of Utah , Salt Lake City , Utah , USA
| | - Rebekah S Huber
- a The Brain Institute, University of Utah , Salt Lake City , Utah , USA
| | | | - Kelly J Lundberg
- c The Department of Psychiatry , University of Utah , Salt Lake City , Utah , USA
| | - Perry F Renshaw
- a The Brain Institute, University of Utah , Salt Lake City , Utah , USA.,c The Department of Psychiatry , University of Utah , Salt Lake City , Utah , USA.,d VISN 19 MIRECC , Salt Lake City , Utah , USA
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Hellem TL, Lundberg KJ, Renshaw PF. A review of treatment options for co-occurring methamphetamine use disorders and depression. J Addict Nurs 2015; 26:14-23; quiz E1. [PMID: 25761159 PMCID: PMC5510330 DOI: 10.1097/jan.0000000000000058] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Co-occurring methamphetamine use and depression interferes with treatment outcomes. Female methamphetamine users are known to have higher rates of depression than male methamphetamine users, although this is also true for the general population. There are limited treatment options for the management of depression among methamphetamine users. In this integrative review, we summarize data on treatment strategies for co-occurring depression and methamphetamine use disorders. English-language articles were identified from PsychINFO, CINAHL, PubMed, and Medline as well as from reference lists of key articles. Search terms included "methamphetamine," "depression," and "treatment." Research articles describing psychological (n = 3), pharmacological (n = 6), nutritional supplement (n = 1), and psychological combined with pharmacological (n = 3) approaches for the treatment of methamphetamine use or withdrawal and/or depression are included in this review. Psychological and combination of psychological with pharmacological approaches have not been shown to be effective in treating these co-occurring conditions. Antidepressants have been determined to be ineffective and/or to introduce side effects. Gender differences with response to treatment were examined in only one of the published studies. There is a large gap in knowledge regarding treatment of co-occurring methamphetamine use disorders and depression. Considering that female methamphetamine users experience higher rates of depression than men, a focus on gender-specific treatment approaches is warranted.
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Affiliation(s)
- Tracy L Hellem
- Tracy L. Hellem, PhD, RN, College of Nursing and The Brain Institute, University of Utah, Salt Lake City. Kelly J. Lundberg, PhD, Department of Psychiatry, University of Utah, Salt Lake City. Perry F. Renshaw, MD, PhD, MBA, The Brain Institute and Department of Psychiatry, University of Utah, and VISN 19 MIRECC, Salt Lake City
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Psychostimulant addiction treatment. Neuropharmacology 2014; 87:150-60. [PMID: 24727297 DOI: 10.1016/j.neuropharm.2014.04.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 03/14/2014] [Accepted: 04/01/2014] [Indexed: 01/29/2023]
Abstract
Treatment of psychostimulant addiction has been a major, and not fully met, challenge. For opioid addiction, there is strong evidence for the effectiveness of several medications. For psychostimulants, there is no corresponding form of agonist maintenance that has met criteria for regulatory approval or generally accepted use. Stimulant-use disorders remain prevalent and can result in both short-term and long-term adverse consequences. The mainstay of treatment remains behavioral interventions. In this paper, we discuss those interventions and some promising candidates in the search for pharmacological interventions. This article is part of the Special Issue entitled 'CNS Stimulants'.
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De La Garza R, Galloway GP, Newton T, Mendelson J, Haile C, Dib E, Hawkins RY, Chen CYA, Mahoney J, Mojsiak J, Lao G, Anderson A, Kahn R. Assessment of safety, cardiovascular and subjective effects after intravenous cocaine and lofexidine. Prog Neuropsychopharmacol Biol Psychiatry 2014; 50:44-52. [PMID: 24316175 PMCID: PMC4562471 DOI: 10.1016/j.pnpbp.2013.11.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 11/19/2013] [Accepted: 11/25/2013] [Indexed: 01/05/2023]
Abstract
The primary objective of this study was to determine the safety of lofexidine, an α2 receptor agonist, alone and concurrent with cocaine in non-treatment seeking cocaine-dependent or cocaine-abusing participants. After screening, eligible participants received double-blind, randomized infusions of saline and 20mg of cocaine on Day 1, and saline and 40mg of cocaine on Day 2. Subjects were randomized and started receiving daily administration of placebo (N=4) or lofexidine on Day 3 and continued on this schedule until Day 7. Two dosing regimens for lofexedine were investigated: 0.8 QID (N=3) and 0.2mg QID (N=11). On Days 6 and 7, subjects received double-blind infusions of saline and 20mg of cocaine on Day 6, and saline and 40mg of cocaine on Day 7. The data reveal a notable incidence of hemodynamic-related AEs over the course of the study. Two of the three participants at the 0.8mg dose level discontinued, and five of 11 participants at the 0.2mg dose level were withdrawn (or voluntarily discontinued) after hemodynamic AEs. Subjective effects and cardiovascular data were derived from all participants who were eligible to receive infusions (i.e., did not meet stopping criteria) on Days 6 and 7 (6 received lofexidine 0.2mg, QID and 4 received placebo, QID). As expected, cocaine significantly increased heart rate and blood pressure, as well as several positive subjective effects. There was a trend for lofexidine to decrease cocaine-induced cardiovascular changes and cocaine-induced ratings for "any drug effect", "good effects", and "desire cocaine", but sample size issues limit the conclusions that can be drawn. Despite the trends to reduce cocaine-induced subjective effects, cardiovascular AEs may limit future utility of lofexidine as a treatment for this population.
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Affiliation(s)
- R. De La Garza
- Baylor College of Medicine, Menninger Department of Psychiatry and Behavioral Sciences, Houston, TX
| | - G. P. Galloway
- California Pacific Medical Center Research Institute, San Francisco, CA
| | - T.F. Newton
- Baylor College of Medicine, Menninger Department of Psychiatry and Behavioral Sciences, Houston, TX
| | - J. Mendelson
- California Pacific Medical Center Research Institute, San Francisco, CA
| | - C.N. Haile
- Baylor College of Medicine, Menninger Department of Psychiatry and Behavioral Sciences, Houston, TX
| | - E. Dib
- California Pacific Medical Center Research Institute, San Francisco, CA
| | - R. Y. Hawkins
- Baylor College of Medicine, Menninger Department of Psychiatry and Behavioral Sciences, Houston, TX
| | - C-Y A. Chen
- California Pacific Medical Center Research Institute, San Francisco, CA
| | - J.J. Mahoney
- Baylor College of Medicine, Menninger Department of Psychiatry and Behavioral Sciences, Houston, TX
| | - J. Mojsiak
- National Institute on Drug Abuse, NIH, Bethesda, MD
| | - G. Lao
- National Institute on Drug Abuse, NIH, Bethesda, MD
| | - A. Anderson
- National Institute on Drug Abuse, NIH, Bethesda, MD
| | - R. Kahn
- National Institute on Drug Abuse, NIH, Bethesda, MD
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Alam A, Voronovich Z, Carley JA. A review of therapeutic uses of mirtazapine in psychiatric and medical conditions. Prim Care Companion CNS Disord 2013; 15:13r01525. [PMID: 24511451 DOI: 10.4088/pcc.13r01525] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 07/09/2013] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE To review the literature examining the use of mirtazapine with an emphasis on its therapeutic benefits for psychiatric patients with comorbid medical conditions. DATA SOURCES MEDLINE, PsycINFO, Global Health, and AGRICOLA were searched using the terms mirtazapine OR Remeron. Limits were English language, human, year 1980-2012, treatment and prevention, and therapy. STUDY SELECTION Two hundred ninety-three articles were identified. DATA EXTRACTION Identified articles were reviewed with a focus on indications and therapeutic benefits in patients with medical comorbidities. RESULTS Mirtazapine is an effective antidepressant with unique mechanisms of action. It is characterized by a relatively rapid onset of action, high response and remission rates, a favorable side-effect profile, and several unique therapeutic benefits over other antidepressants. Mirtazapine has also shown promise in treating some medical disorders, including neurologic conditions, and ameliorating some of the associated debilitating symptoms of weight loss, insomnia, and postoperative nausea and vomiting. CONCLUSIONS Mirtazapine offers clinicians multiple therapeutic advantages especially when treating patients with comorbid medical illness.
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Affiliation(s)
- Abdulkader Alam
- Departments of Psychiatry and Medicine (Dr Alam), University of Pittsburgh School of Medicine (Ms Voronovich), Pittsburgh, Pennsylvania; and University of Alabama School of Medicine, Birmingham (Dr Carley)
| | - Zoya Voronovich
- Departments of Psychiatry and Medicine (Dr Alam), University of Pittsburgh School of Medicine (Ms Voronovich), Pittsburgh, Pennsylvania; and University of Alabama School of Medicine, Birmingham (Dr Carley)
| | - Joseph A Carley
- Departments of Psychiatry and Medicine (Dr Alam), University of Pittsburgh School of Medicine (Ms Voronovich), Pittsburgh, Pennsylvania; and University of Alabama School of Medicine, Birmingham (Dr Carley)
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Miles SW, Sheridan J, Russell B, Kydd R, Wheeler A, Walters C, Gamble G, Hardley P, Jensen M, Kuoppasalmi K, Tuomola P, Föhr J, Kuikanmäki O, Vorma H, Salokangas R, Mikkonen A, Kallio M, Kauhanen J, Kiviniemi V, Tiihonen J. Extended-release methylphenidate for treatment of amphetamine/methamphetamine dependence: a randomized, double-blind, placebo-controlled trial. Addiction 2013; 108:1279-86. [PMID: 23297867 DOI: 10.1111/add.12109] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Revised: 07/19/2012] [Accepted: 12/26/2012] [Indexed: 11/30/2022]
Abstract
AIMS To assess the efficacy of methylphenidate as a substitution therapy for amphetamine/methamphetamine dependence in Finland and New Zealand. DESIGN Parallel-group, double-blind, randomized placebo-controlled trial. SETTING Out-patient care. PARTICIPANTS Amphetamine-/methamphetamine-dependent, aged 16-65 years. MEASUREMENTS The primary outcome measure was presence/absence of amphetamine/methamphetamine in urine samples collected twice weekly. Secondary measures included treatment adherence, alterations in craving scores and self-reported use. Primary analysis was by intention-to-treat (ITT). The study drug, methylphenidate (as Concerta(®) ), was up-titrated over 2 weeks to a maximum dose of 54 mg daily and continued for a further 20 weeks. Doses were given under daily supervision at the clinics. FINDINGS Seventy-nine participants were randomized (40 methylphenidate; 39 placebo); 76 received allocated treatment and 27 completed the trial. ITT analysis (n = 78) showed no statistically significant difference in the percentage of positive urines between the methylphenidate and placebo arms (odds ratio: 0.95, 95% confidence interval: 0.83-1.08). However, there was a significant difference (P < 0.05) between the active and placebo arms in retention, the placebo arm displaying a significantly lower retention from 6 weeks that persisted until the end of the trial. CONCLUSIONS The trial failed to replicate earlier findings suggesting that methylphenidate was superior to placebo. The low retention rate confounded the ability to draw firm conclusions about efficacy. The higher retention rate was observed in the methylphenidate arm. Any replication of this work would need to consider alternatives to the rigid clinic attendance criteria, and consider an increased dose.
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Affiliation(s)
- S Wayne Miles
- Waitemata District Health Board, Auckland, New Zealand.
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Brensilver M, Heinzerling KG, Shoptaw S. Pharmacotherapy of amphetamine-type stimulant dependence: an update. Drug Alcohol Rev 2013; 32:449-60. [PMID: 23617468 DOI: 10.1111/dar.12048] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 04/01/2013] [Indexed: 01/14/2023]
Abstract
ISSUES Methamphetamine- or amphetamine-type stimulants are the second most frequently used illicit drug worldwide, second only to cannabis. Behavioural treatments are efficacious, but their impact is limited underscoring the need for other treatment options, notably, pharmacotherapy. APPROACH A review of randomised controlled trials of pharmacotherapies for methamphetamine- or amphetamine-type stimulants was performed using PubMed and Google Scholar databases. Evidence for efficacy of medications is reported. KEY FINDINGS Clinical trials have yielded no broadly effective pharmacotherapy. Promising signals have been observed for methylphenidate, naltrexone, bupropion and mirtazapine in subgroups of patients in reducing stimulant use (e.g. patients with less severe dependence at baseline and men who have sex with men), though none has produced an unambiguous, replicable signal of efficacy. IMPLICATIONS Problems in Phase II trials, including high dropout rates, missing data and a lack of agreement on outcomes, complicate efforts to find a broadly effective pharmacotherapy for amphetamine-type stimulant disorders. Efforts to address these problems include calls for better validation of pharmacological target exposure, receptor binding and functional modulation. As well, there is a need for agreement in using findings from preclinical and early phases of the medication development process for selecting better pharmacotherapy candidates. CONCLUSION After over 20 years of efforts worldwide to develop a broadly effective medication for dependence on methamphetamine- or amphetamine-type stimulants, no candidate has emerged. This highlights the need for new compounds, consistent and stringent research methods, better integration between preclinical and clinical stages of medication development, and improved collaboration between government, industry and researchers.
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Affiliation(s)
- Matthew Brensilver
- Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, USA
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Chronic treatment with curcumin enhances methamphetamine locomotor sensitization and cue-induced reinstatement of methamphetamine self-administration. Pharmacol Biochem Behav 2012; 102:555-61. [DOI: 10.1016/j.pbb.2012.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 06/06/2012] [Accepted: 06/14/2012] [Indexed: 11/17/2022]
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Graves SM, Rafeyan R, Watts J, Napier TC. Mirtazapine, and mirtazapine-like compounds as possible pharmacotherapy for substance abuse disorders: evidence from the bench and the bedside. Pharmacol Ther 2012; 136:343-53. [PMID: 22960395 DOI: 10.1016/j.pharmthera.2012.08.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 08/16/2012] [Indexed: 10/27/2022]
Abstract
Understanding substance use disorders (SUDs) and the problems associated with abstinence has grown in recent years. Nonetheless, highly efficacious treatment targeting relapse prevention has remained elusive, and there remains no FDA-approved pharmacotherapy for psychostimulant dependence. Preclinical and clinical investigations assessing the utility of classical antidepressants, which block monoamine reuptake, show mixed and often contradictory results. Mirtazapine (Remeron®) is a unique FDA-approved antidepressant, with negligible affinity for reuptake proteins, indirectly augments monoamine transmission presumably through antagonist activity at multiple receptors including the norepinephrine (NE)(α2), and serotonin (5-HT)(2A/C) receptors. Historically, mirtazapine was also considered to be a 5-HT(2C) antagonist, but recent evidence indicates that mirtazapine is an inverse agonist at this receptor subtype. Suggesting a promising role for mixed-action serotonergic drugs for addiction pharmacotherapy, mirtazapine attenuates psychostimulant-induced behaviors in several rodent models of substance abuse, and antagonizes methamphetamine-induced biochemical and electrophysiological alterations in rats. Preclinical findings are confirmed through published case studies documenting successful outcomes with mirtazapine therapy across a number of SUDs. To date, a large scale clinical trial assessing the utility of mirtazapine in substance abuse pharmacotherapy has yet to be conducted. However, as reviewed here, accumulating preclinical and clinical evidence argues that mirtazapine, or compounds that emulate aspects of its pharmacological profile, may prove useful in helping treat addictions.
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Affiliation(s)
- Steven M Graves
- Center for Compulsive Behavior and Addiction, Rush University Medical Center, Chicago, IL, USA
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30
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Lingford-Hughes AR, Welch S, Peters L, Nutt DJ. BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP. J Psychopharmacol 2012; 26:899-952. [PMID: 22628390 DOI: 10.1177/0269881112444324] [Citation(s) in RCA: 154] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The British Association for Psychopharmacology guidelines for the treatment of substance abuse, harmful use, addiction and comorbidity with psychiatric disorders primarily focus on their pharmacological management. They are based explicitly on the available evidence and presented as recommendations to aid clinical decision making for practitioners alongside a detailed review of the evidence. A consensus meeting, involving experts in the treatment of these disorders, reviewed key areas and considered the strength of the evidence and clinical implications. The guidelines were drawn up after feedback from participants. The guidelines primarily cover the pharmacological management of withdrawal, short- and long-term substitution, maintenance of abstinence and prevention of complications, where appropriate, for substance abuse or harmful use or addiction as well management in pregnancy, comorbidity with psychiatric disorders and in younger and older people.
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Lee N, Pennay A, Hester R, McKetin R, Nielsen S, Ferris J. A pilot randomised controlled trial of modafinil during acute methamphetamine withdrawal: feasibility, tolerability and clinical outcomes. Drug Alcohol Rev 2012; 32:88-95. [PMID: 22630616 DOI: 10.1111/j.1465-3362.2012.00473.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 05/03/2012] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND AIMS There are no medications approved for the treatment of methamphetamine withdrawal. Wake-promoting agent modafinil has recently been proposed as a viable option. This paper reports on the results of a pilot study that tested the feasibility of modafinil in an inpatient withdrawal setting during acute methamphetamine withdrawal. DESIGN AND METHODS In a double-blind, randomised, placebo-controlled study, 19 methamphetamine dependent participants received modafinil (n = 9) or placebo (n = 10) daily for 7 days (200 mg for the first 5 days and 100 mg on days 6 and 7). Primary outcomes were retention in treatment and severity of withdrawal symptoms. Secondary outcomes were methamphetamine craving, sleep and physiological outcomes. RESULTS There were no significant differences between groups on retention in treatment, withdrawal severity, craving, sleep or physiological outcomes. There were no adverse events or side-effects reported. CONCLUSIONS Modafinil was found to be tolerable and well accepted by methamphetamine users and feasible for short-term inpatient withdrawal, but the sample was too small to detect treatment effects. Larger trials are needed to establish efficacy.
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Affiliation(s)
- Nicole Lee
- Turning Point Alcohol and Drug Centre, Melbourne, Australia
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Voigt RM, Napier TC. Context-dependent effects of a single administration of mirtazapine on the expression of methamphetamine-induced conditioned place preference. Front Behav Neurosci 2012; 5:92. [PMID: 22347852 PMCID: PMC3276317 DOI: 10.3389/fnbeh.2011.00092] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Accepted: 12/27/2011] [Indexed: 01/13/2023] Open
Abstract
Re-exposure to cues repeatedly associated with methamphetamine (Meth) can trigger Meth-seeking and relapse in the abstinent abuser. Weakening the conditioned Meth-associated memory during cue re-exposure may provide a means for relapse-reduction pharmacotherapy. Accordingly, we sought to determine if the atypical antidepressant mirtazapine disrupted the persistence of Meth-induced conditioned place preference (CPP) when administered in conjunction with re-exposure to contextual conditioning cues, and if this effect was altered by Meth being present during cue re-exposure. First, we evaluated the effect of mirtazapine on the maintenance of Meth-induced CPP during re-exposure to either the saline- or Meth-paired chamber 12 days after conditioning. Meth-conditioned rats subsequently administered mirtazapine expressed CPP independent of re-exposure to the saline- or Meth-paired chamber; but the magnitude of CPP was significantly less for mirtazapine-treated rats re-exposed to the Meth-paired chamber. Next, we evaluated the effect of mirtazapine on a "reinforced re-exposure" to the Meth-paired context. Administration of mirtazapine vehicle and Meth, prior to re-exposure to the Meth-paired chamber did not disrupt the ability of rats to demonstrate CPP 15 days after conditioning; however, CPP was disrupted when rats were administered mirtazapine and Meth prior to re-exposure to the Meth-paired chamber. These results indicate that the capacity of mirtazapine to diminish Meth-induced CPP is promoted if mirtazapine treatment is coupled with Meth administration in the Meth-associated context and thus appears to be the consequence of disrupting processes necessary to reconsolidate CPP following activation of drug-associated memories.
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Affiliation(s)
- Robin M Voigt
- Department of Pharmacology, Center for Compulsive Behavior and Addiction, Rush University Medical Center Chicago, IL, USA
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Afshar M, Knapp CM, Sarid-Segal O, Devine E, Colaneri LS, Tozier L, Waters ME, Putnam MA, Ciraulo DA. The efficacy of mirtazapine in the treatment of cocaine dependence with comorbid depression. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2012; 38:181-6. [PMID: 22221171 DOI: 10.3109/00952990.2011.644002] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Prior findings concerning the use of mirtazapine in the treatment of a variety of substance use disorders and its antagonistic actions at the serotonin 5-HT(2A) receptor suggest that this drug may have efficacy in the treatment of cocaine dependence in the presence of a depressive disorder. METHODS Depressed cocaine-dependent subjects received either mirtazapine (target dose 45 mg daily) or placebo for 12 weeks. Urine concentrations of benzoylecgonine and self-report were used to assess cocaine consumption. Depression and sleep quality were evaluated using the Hamilton Depression Rating Scale (HAM-D) and the Pittsburgh Sleep Quality Index, respectively. RESULTS Cocaine consumption during the treatment period did not differ significantly between the mirtazapine (n = 11) and placebo (n = 13) groups in this study. In week 4 sleep latency was significantly lower in the active medication than in the placebo group. Positive effects of mirtazapine treatment on early insomnia were suggested by an item analysis of the HAM-D. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE The results of this study suggest that mirtazapine is superior to placebo in improving sleep in patients with comorbid depression and cocaine dependence, but is not more effective than placebo in reducing cocaine use.
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Affiliation(s)
- Maryam Afshar
- Department of Psychiatry, Boston Medical Center, Boston University School of Medicine, MA 02118, USA.
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Colfax GN, Santos GM, Das M, Santos DM, Matheson T, Gasper J, Shoptaw S, Vittinghoff E. Mirtazapine to reduce methamphetamine use: a randomized controlled trial. ACTA ACUST UNITED AC 2011; 68:1168-75. [PMID: 22065532 DOI: 10.1001/archgenpsychiatry.2011.124] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT No approved pharmacologic treatments for methamphetamine dependence exist. Methamphetamine use is associated with high morbidity and is a major cofactor in the human immunodeficiency virus epidemic among men who have sex with men (MSM). OBJECTIVE To determine whether mirtazapine would reduce methamphetamine use among MSM who are actively using methamphetamine. DESIGN Double-blind, randomized, controlled, 12-week trial of mirtazapine vs placebo conducted from September 5, 2007, to March 4, 2010. SETTING San Francisco Department of Public Health. PARTICIPANTS Participants were actively using, methamphetamine-dependent, sexually active MSM seen weekly for urine sample collection and substance use counseling. INTERVENTIONS Random assignment to daily oral mirtazapine (30 mg) or placebo; both arms included 30-minute weekly substance use counseling. MAIN OUTCOME MEASURES The primary study outcome was reduction in methamphetamine-positive urine test results. Secondary outcomes were study medication adherence (by self-report and medication event monitoring systems) and sexual risk behavior. RESULTS Sixty MSM were randomized, 85% of follow-up visits were completed, and 56 participants (93%) completed the final visit. In the primary intent-to-treat analysis, participants assigned to the mirtazapine group had fewer methamphetamine-positive urine test results compared with participants assigned to the placebo group (relative risk, 0.57; 95% CI, 0.35-0.93, P = .02). Urine positivity decreased from 67% (20 of 30 participants) to 63% (17 of 27) in the placebo arm and from 73% (22 of 30) to 44% (12 of 27) in the mirtazapine arm. The number needed to treat to achieve a negative weekly urine test result was 3.1. Adherence was 48.5% by medication event monitoring systems and 74.7% by self-report; adherence measures were not significantly different between arms (medication event monitoring systems, P = .82; self-report, P = .92). Most sexual risk behaviors decreased significantly more among participants taking mirtazapine compared with those taking placebo (number of male partners with whom methamphetamine was used, P = .009; number of male partners, P = .04; episodes of anal sex with serodiscordant partners, P = .003; episodes of unprotected anal sex with serodiscordant partners, P = .003; episodes of insertive anal sex with serodiscordant partners, P = .001). There were no serious adverse events related to study drug or significant differences in adverse events by arm (P ≥ .99). CONCLUSION The addition of mirtazapine to substance use counseling decreased methamphetamine use among active users and was associated with decreases in sexual risk despite low to moderate medication adherence. Trial Registration clinicalTrials.gov Identifier NCT00497081.
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Affiliation(s)
- Grant N Colfax
- San Francisco Department of Public Health, San Francisco, CA 94102, USA.
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Brackins T, Brahm NC, Kissack JC. Treatments for methamphetamine abuse: a literature review for the clinician. J Pharm Pract 2011; 24:541-50. [PMID: 22095579 DOI: 10.1177/0897190011426557] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Methamphetamine (METH) use and dependence is a serious public health concern with implications across multiple areas from societal impact to burden on psychiatric and medical resources. An estimated 8% of admissions to substance abuse treatment programs are related to stimulants with METH/amphetamine abuse. To date, effective pharmacotherapy options to enhance abstinence have not been identified. The objective of this article is to critically review the literature of METH treatment options. Preclinical research and human research with compounds not yet available commercially in the United States will not be included. A literature review was conducted for research on pharmacological treatments for METH use and addiction. Trial information on the use of sertraline, bupropion, mirtazapine, modafinil, dextroamphetamine, ondansetron, risperidone, aripiprazole, baclofen, and gabapentin was reviewed. Aripiprazole trials appeared in the reviewed literature more frequently than the other medications. Based on the findings of this review, no single medication demonstrated consistent efficacy and each trial contained a variety of methodological limitations.
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Affiliation(s)
- Todd Brackins
- Pharmacy Practice, Harding University College of Pharmacy, Searcy, AR 72149, USA.
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Zorick T, Sugar CA, Hellemann G, Shoptaw S, London ED. Poor response to sertraline in methamphetamine dependence is associated with sustained craving for methamphetamine. Drug Alcohol Depend 2011; 118:500-3. [PMID: 21592681 PMCID: PMC3181284 DOI: 10.1016/j.drugalcdep.2011.04.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Revised: 04/07/2011] [Accepted: 04/16/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Depression is common among individuals with methamphetamine (MA) use disorders. As agents that enhance serotonergic function are frequently used to treat depression, one might predict that they would be useful medications for MA dependence. However, clinical trials of serotonergic agents for MA addiction have been unsuccessful. OBJECTIVE To identify factors that distinguish MA-dependent research participants who increased MA self-administration while receiving treatment with the selective serotonin reuptake inhibitor (SSRI) sertraline from other groups of participants. METHOD Using a dataset from a 12-week randomized, placebo-controlled trial of sertraline (100mg daily) for MA addiction, we identified participants who had completed at least 8 weeks of the trial (n=61 sertraline, n=68 placebo). We compared the proportions of MA-positive urine tests for weeks 8-12 of the trial for these subjects to their pre-randomization baseline, and identified those subjects who increased MA use during treatment. Using classification trees, we then assessed all data collected during the study to identify factors associated with increasing MA use during treatment with sertraline, compared to placebo. RESULTS More subjects in the sertraline condition increased MA use during treatment (n=13) than in the placebo condition (n=5; p=0.03). Classification trees identified multiple factors from both pre-treatment and in-treatment data that were associated with increased MA use during treatment. Only elevated in-treatment craving for MA specifically characterized subjects in the sertraline group who increased their MA use. CONCLUSIONS Some MA-abusing individuals treated with SSRIs have sustained craving with an increased propensity to relapse during treatment despite psychosocial treatment interventions.
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Affiliation(s)
- Todd Zorick
- Department of Psychiatry, Greater Los Angeles Veterans Administration Healthcare System, Los Angeles, CA 90073, USA.
| | - Catherine A. Sugar
- Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, Los Angeles, CA 90095, Department of Biostatistics, University of California at Los Angeles, Los Angeles, CA 90095
| | - Gerhard Hellemann
- Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, Los Angeles, CA 90095
| | - Steve Shoptaw
- Department of Family Medicine, University of California at Los Angeles, Los Angeles, CA 90095
| | - Edythe D. London
- Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, Los Angeles, CA 90095, Department of Molecular and Medical Pharmacology, University of California at Los Angeles, Los Angeles, CA 90095, Brain Research Institute, University of California at Los Angeles, Los Angeles, CA 90095
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Voigt RM, Mickiewicz AL, Napier TC. Repeated mirtazapine nullifies the maintenance of previously established methamphetamine-induced conditioned place preference in rats. Behav Brain Res 2011; 225:91-6. [PMID: 21771613 DOI: 10.1016/j.bbr.2011.07.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Revised: 06/30/2011] [Accepted: 07/05/2011] [Indexed: 11/30/2022]
Abstract
The atypical antidepressant mirtazapine enhances monoaminergic transmission; thus, mirtazapine therapy may counter the hypo-activation of monoamine systems associated with withdrawal from methamphetamine abuse. Human addiction therapy will likely require chronic administration that is given after brain and behavioral maladaptations are established. To emulate this scenario in rats, we ascertained if acute or repeated mirtazapine treatments could antagonize previously established consequences of repeated methamphetamine. Methamphetamine-induced conditioned place preference (CPP) was used, wherein methamphetamine (1mg/kg, i.p.) was administered in a unique environmental context once-daily for three days interposed by saline injections in an alternate context. Subsequently, mirtazapine (5mg/kg, i.p.) was administered in the home cage either as 10 once-daily injections or a single injection. The expression of CPP was determined in drug-free rats three days after the last mirtazapine injection. Expression of methamphetamine-induced CPP was inhibited by 10 home cage administrations of mirtazapine but not by a single injection of mirtazapine. These findings reveal that mirtazapine can inhibit the maintenance of methamphetamine-induced CPP and that treatment duration and/or treatment timing contributes to this effect of mirtazapine.
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Affiliation(s)
- Robin M Voigt
- Department of Pharmacology & Experimental Therapeutics, Loyola University Chicago Medical Center, Maywood, IL, United States.
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PENNAY AMYE, LEE NICOLEK. Putting the call out for more research: The poor evidence base for treating methamphetamine withdrawal. Drug Alcohol Rev 2010; 30:216-22. [DOI: 10.1111/j.1465-3362.2010.00240.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Heinzerling KG, Swanson AN, Kim S, Cederblom L, Moe A, Ling W, Steven S. Randomized, double-blind, placebo-controlled trial of modafinil for the treatment of methamphetamine dependence. Drug Alcohol Depend 2010; 109:20-9. [PMID: 20092966 PMCID: PMC2875545 DOI: 10.1016/j.drugalcdep.2009.11.023] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Revised: 11/18/2009] [Accepted: 11/21/2009] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare modafinil to placebo for reducing methamphetamine (MA) use, improving retention, and reducing depressive symptoms and MA cravings. Rates of adverse events and cigarette smoking with modafinil versus placebo were also compared. METHODS Following a 2-week, non-medication lead-in period, 71 treatment-seeking MA-dependent participants were randomly assigned to modafinil (400mg once daily; N=34) or placebo (once daily; N=37) for 12 weeks under double-blind conditions. Participants attended clinic thrice-weekly to provide urine samples analyzed for MA-metabolite, to complete research assessments, and to receive contingency management and weekly cognitive behavioral therapy (CBT) sessions. RESULTS There were no statistically significant effects for modafinil on MA use, retention, depressive symptoms, or MA cravings in pre-planned analyses. Outcomes for retention and MA use favored modafinil in a post hoc analysis among participants with low CBT attendance and among participants with baseline high-frequency of MA use (MA use on >18 of past 30 days), but did not reach statistical significance in these small subgroups. Modafinil was safe and well tolerated and did not increase cigarette smoking. CONCLUSIONS Modafinil was no more effective than placebo at 400mg daily in a general sample of MA users. A post hoc analysis showing a trend favoring modafinil among subgroups with baseline high-frequency MA use and low CBT attendance suggests that further evaluation of modafinil in MA users is warranted.
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Affiliation(s)
- Keith G. Heinzerling
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA,UCLA Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90025, USA,Corresponding author: Keith G. Heinzerling, Department of Family Medicine, David Geffen School of Medicine at UCLA, 10880 Wilshire Blvd., Suite 1800, Los Angeles, CA 90095; phone: +1 310 749 0619; fax: +1 310 794 2808;
| | - Aimee-Noelle Swanson
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Soeun Kim
- Department of Biostatistics, David Geffen School of Medicine at UCLA, Los Angeles, CA 90024, USA
| | - Lisa Cederblom
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | | | - Walter Ling
- UCLA Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90025, USA,Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA 90024, USA
| | - Shoptaw Steven
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA,UCLA Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90025, USA,Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA 90024, USA
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Karila L, Weinstein A, Aubin HJ, Benyamina A, Reynaud M, Batki SL. Pharmacological approaches to methamphetamine dependence: a focused review. Br J Clin Pharmacol 2010; 69:578-92. [PMID: 20565449 PMCID: PMC2883750 DOI: 10.1111/j.1365-2125.2010.03639.x] [Citation(s) in RCA: 156] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2009] [Accepted: 12/08/2009] [Indexed: 11/27/2022] Open
Abstract
Methamphetamine dependence is a serious worldwide public health problem with major medical, psychiatric, socioeconomic and legal consequences. Various neuronal mechanisms implicated in methamphetamine dependence have suggested several pharmacological approaches. A literature search from a range of electronic databases (PubMed, EMBASE, PsycInfo, the NIDA research monograph index and the reference list of clinicaltrials.gov) was conducted for the period from January 1985 to October 2009. There were no restrictions on the identification or inclusion of studies in terms of publication status, language and design type. A variety of medications have failed to show efficacy in clinical trials, including a dopamine partial agonist (aripiprazole), GABAergic agents (gabapentin) and serotonergic agents (SSRI, ondansetron, mirtazapine). Three double-blind placebo-controlled trials using modafinil, bupropion and naltrexone have shown positive results in reducing amphetamine or methamphetamine use. Two studies employing agonist replacement medications, one with d-amphetamine and the other with methylphenidate, have also shown promise. Despite the lack of success in most studies to date, increasing efforts are being made to develop medications for the treatment of methamphetamine dependence and several promising agents are targets of further research.
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Affiliation(s)
- Laurent Karila
- Addiction Research and Treatment Center, Paul Brousse Hospital, Paris XI University, AP-HP, CEA- INSERM U1000, Villejuif, France.
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D'Souza MS, Markou A. Neural substrates of psychostimulant withdrawal-induced anhedonia. Curr Top Behav Neurosci 2010; 3:119-178. [PMID: 21161752 DOI: 10.1007/7854_2009_20] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Psychostimulant drugs have powerful reinforcing and hedonic properties and are frequently abused. Cessation of psychostimulant administration results in a withdrawal syndrome characterized by anhedonia (i.e., an inability to experience pleasure). In humans, psychostimulant withdrawal-induced anhedonia can be debilitating and has been hypothesized to play an important role in relapse to drug use. Hence, understanding the neural substrates involved in psychostimulant withdrawal-induced anhedonia is essential. In this review, we first summarize the theoretical perspectives of psychostimulant withdrawal-induced anhedonia. Experimental procedures and measures used to assess anhedonia in experimental animals are also discussed. The review then focuses on neural substrates hypothesized to play an important role in anhedonia experienced after termination of psychostimulant administration, such as with cocaine, amphetamine-like drugs, and nicotine. Both neural substrates that have been extensively investigated and some that need further evaluation with respect to psychostimulant withdrawal-induced anhedonia are reviewed. In the context of reviewing the various neurosubstrates of psychostimulant withdrawal, we also discuss pharmacological medications that have been used to treat psychostimulant withdrawal in humans. This literature review indicates that great progress has been made in understanding the neural substrates of anhedonia associated with psychostimulant withdrawal. These advances in our understanding of the neurobiology of anhedonia may also shed light on the neurobiology of nondrug-induced anhedonia, such as that seen as a core symptom of depression and a negative symptom of schizophrenia.
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Affiliation(s)
- Manoranjan S D'Souza
- Department of Psychiatry, University of California, San Diego, La Jolla, CA 92093, USA
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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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Edens E, Massa A, Petrakis I. Novel pharmacological approaches to drug abuse treatment. Curr Top Behav Neurosci 2010; 3:343-86. [PMID: 21161760 DOI: 10.1007/7854_2009_29] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The field of pharmacologic addiction treatment is expanding rapidly. While there are currently several FDA-approved medications for nicotine, alcohol, and opiate dependence, research into novel pharmacological approaches for these and additional substances is legion. Each drug of abuse, while sharing a common final neural pathway of increasing dopaminergic tone, has unique and individual characteristics that are important in developing improved and varied treatments. In this chapter, we discuss such research and present the neurobiological underpinnings of these explorations. In general, addiction treatment is focused on four areas: (1) reducing withdrawal discomfort, (2) diminishing cravings, (3) blocking rewarding effects of the drug, and (4) treating comorbidities, such as depression or ADHD. We present current ideas in pharmacologic research for nicotine, alcohol, cannabis, stimulants, and opiates.
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Affiliation(s)
- Ellen Edens
- West Haven Veterans Administration Medical Center, West Haven, CT 06516, USA
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Abstract
BACKGROUND Few studies examined treatments for amphetamine withdrawal, although it is a common problem among amphetamine users. Its symptoms, in particular intense craving, may be a critical factor leading to relapse to amphetamine use. In clinical practice, medications for cocaine withdrawal are commonly used to manage amphetamine withdrawal although the pharmacodynamic and pharmacokinetic properties of these two illicit substances are different. OBJECTIVES To assess the effectiveness of pharmacological alone or in combination with psychosocial treatment for amphetamine withdrawals on discontinuation rates, global state, withdrawal symptoms, craving, and other outcomes. SEARCH STRATEGY MEDLINE (1966 - 2008), CINAHL (1982 - 2008), PsycINFO (1806 - 2008), CENTRAL (Cochrane Library 2008 issue 2), references of obtained articles. SELECTION CRITERIA All randomised controlled and clinical trials evaluating pharmacological and or psychosocial treatments (alone or combined) for people with amphetamine withdrawal symptoms. DATA COLLECTION AND ANALYSIS Two authors evaluated and extracted data independently. The data were extracted from intention-to-treat analyses. The Relative Risk (RR) with the 95% confidence interval (95% CI) was used to assess dichotomous outcomes. The Weighted Mean Difference (WMD) with 95% CI was used to assess continuous outcomes. MAIN RESULTS Four randomised controlled trials (involving 125 participants) met the inclusion criteria for the review. Two studies found that amineptine significantly reduced discontinuation rates and improved overall clinical presentation, but did not reduce withdrawal symptoms or craving compared to placebo. The benefits of mirtazapine over placebo for reducing amphetamine withdrawal symptoms were not as clear. One study suggested that mirtazapine may reduce hyperarousal and anxiety symptoms associated with amphetamine withdrawal. A more recent study failed to find any benefit of mirtazapine over placebo on retention or on amphetamine withdrawal symptoms. AUTHORS' CONCLUSIONS No medication is effective for treatment of amphetamine withdrawal. Amineptine showed reduction in discontinuation rates and improvement in clinical presentation compared to placebo, but had no effect on reducing withdrawal symptoms or craving. In spite of these limited benefits, amineptine is not available for use due to concerns over abuse liability when using the drug. The benefits of mirtazapine as a withdrawal agent are less clear based on findings from two randomised controlled trials: one report showed improvements in amphetamine withdrawal symptoms over placebo; a second report showed no differences in withdrawal symptoms compared to placebo. Further potential treatment studies should examine medications that increase central nervous system activity involving dopamine, norepinephrine and/or serotonin neurotransmitters, including mirtazapine.
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Affiliation(s)
- Steven J Shoptaw
- Department of Family Medicine, University of California, 10880 Wilshire Boulevard, Suite 540, Los Angeles, CA 90024, USA.
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Shearer J, Darke S, Rodgers C, Slade T, van Beek I, Lewis J, Brady D, McKetin R, Mattick RP, Wodak A. A double-blind, placebo-controlled trial of modafinil (200 mg/day) for methamphetamine dependence. Addiction 2009; 104:224-33. [PMID: 19149817 DOI: 10.1111/j.1360-0443.2008.02437.x] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To examine the safety and efficacy of modafinil (200 mg/day) compared to placebo in the treatment of methamphetamine dependence and to examine predictors of post-treatment outcome. PARTICIPANTS AND DESIGN Eighty methamphetamine-dependent subjects in Sydney, Australia were allocated randomly to modafinil (200 mg/day) (n = 38) or placebo (n = 42) under double-blind conditions for 10 weeks with a further 12 weeks post-treatment follow-up. MEASURES Comprehensive drug use data (urine specimens and self-report) and other health and psychosocial data were collected weekly during treatment and research interviews at baseline, week 10 and week 22. RESULTS Treatment retention and medication adherence were equivalent between groups. There were no differences in methamphetamine abstinence, craving or severity of dependence. Medication-compliant subjects tended to provide more methamphetamine-negative urine samples over the 10-week treatment period (P = 0.07). Outcomes were better for methamphetamine-dependent subjects with no other substance dependence and those who accessed counselling. There were statistically significant reductions in systolic blood pressure (P = 0.03) and weight gain (P = 0.05) in modafinil-compliant subjects compared to placebo. There were no medication-related serious adverse events. Adverse events were generally mild and consistent with known pharmacological effects. CONCLUSIONS Modafinil demonstrated promise in reducing methamphetamine use in selected methamphetamine-dependent patients. The study findings support definitive trials of modafinil in larger multi-site trials.
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Affiliation(s)
- James Shearer
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
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Degenhardt L, Baker A, Maher L. Methamphetamine: geographic areas and populations at risk, and emerging evidence for effective interventions. Drug Alcohol Rev 2008; 27:217-9. [PMID: 18368601 DOI: 10.1080/09595230801956538] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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