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Aubin HJ, Berlin I, Guiraud J, Bruhwyler J, Batel P, Perney P, Trojak B, Bendimerad P, Guillou M, Bisch M, Grall-Bronnec M, Labarrière D, Delsart D, Questel F, Moirand R, Bernard P, Trovero F, Pham HP, Tassin JP, Puech A. Prazosin and cyproheptadine in combination in the treatment of alcohol use disorder: A randomized, double-blind, placebo-controlled trial. Addiction 2024; 119:1211-1223. [PMID: 38597214 DOI: 10.1111/add.16484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 02/23/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND AND AIMS Pre-clinical studies suggest that the simultaneous blockade of the α1b and 5HT2A receptors may be effective in reducing alcohol consumption. This study aimed to assess the efficacy and safety of prazosin (α1b blocker) and cyproheptadine (5HT2A blocker) combination in decreasing total alcohol consumption (TAC) in alcohol use disorder (AUD). DESIGN, SETTING AND PARTICIPANTS This was a double-blind, parallel group, placebo-controlled, Phase 2, randomized clinical trial conducted in 32 addiction treatment centres in France. A total of 108 men and 46 women with severe AUD took part. INTERVENTION Participants were randomly assigned to one of the following 3-month treatments: (1) low-dose group (LDG) receiving 8 mg cyproheptadine and 5 mg prazosin extended-release (ER) formulation daily; (2) high-dose group (HDG) receiving 12 mg cyproheptadine and 10 mg prazosin ER daily; and (3) placebo group (PG) receiving placebo of cyproheptadine and prazosin ER. A total of 154 patients were randomized: 54 in the PG, 54 in the LDG and 46 in the HDG. MEASUREMENTS The primary outcome was TAC change from baseline to month 3. FINDINGS A significant main treatment effect in the change in TAC was found in the intent-to-treat population (P = 0.039). The HDG and LDG showed a benefit in the change in TAC from baseline to month 3 compared with PG: -23.6 g/day, P = 0.016, Cohen's d = -0.44; -18.4 g/day, P = 0.048 (Bonferroni correction P < 0.025), Cohen's d = -0.36. In a subgroup of very high-risk drinking-level participants (> 100 g/day of pure alcohol for men and > 60 g/day for women), the difference between the HDG and the PG in the primary outcome was -29.8 g/day (P = 0.031, Cohen's d = -0.51). The high and low doses were well-tolerated with a similar safety profile. CONCLUSIONS A randomized controlled trial of treatment of severe alcohol use disorder with a cyproheptadine-prazosin combination for 3 months reduced drinking by more than 23 g per day compared with placebo. A higher dose combination was associated with a larger magnitude of drinking reduction than a lower dose combination while showing similar safety profile.
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Affiliation(s)
| | - Ivan Berlin
- Hopital Pitie-Salpetriere, Sorbonne Université, Paris, France
| | - Julien Guiraud
- University of Amsterdam, Amsterdam, the Netherlands
- Vergio, Clichy, France
| | | | | | - Pascal Perney
- Hôpital Carémeau, Nîmes, Université Montpellier 1, Villejuif, France
| | - Benoît Trojak
- Centre hospitalier Universitaire Dijon Bourgogne, Université Bourgogne Franche-Comté, Besançon, France
| | - Patrick Bendimerad
- Addiction Department, Groupe Hospitalier Littoral Atlantique, La Rochelle, France
| | - Morgane Guillou
- ER 7479 SPURBO, Université Bretagne Occidentale, Brest, France
| | - Michaël Bisch
- Centre Psychothérapique de Nancy, Addiction Medicine department, Laxou, France
| | - Marie Grall-Bronnec
- Addictology and Liaison Psychiatry Department, Nantes University Hospital, Nantes and Tours Universities, Nantes, France
| | | | | | - Frank Questel
- Université Paris Diderot, GH Lariboisière-Saint-Louis-Fernand Widal, Paris, France
| | - Romain Moirand
- Université Rennes, Rennes, Institut NUMECAN (Nutrition Metabolisms and Cancer), UF Addictologie, Rennes, France
| | | | | | | | - Jean-Pol Tassin
- Inserm, Sorbonne-Université, Laboratoire Neuroscience Paris-Seine, Paris, France
| | - Alain Puech
- Kinnov-Therapeutics, Orléans, France
- Inserm, Sorbonne-Université, Laboratoire Neuroscience Paris-Seine, Paris, France
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Park SW, Choi H, Na EH, Oh HS, Roh SW, Lee SK. Effectiveness of the Korean-Patient Placement Criteria for Alcohol Use Disorders: A Prospective Exploratory Study. Psychiatry Investig 2024; 21:792-802. [PMID: 39089705 PMCID: PMC11298261 DOI: 10.30773/pi.2023.0314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/19/2023] [Accepted: 05/16/2024] [Indexed: 08/04/2024] Open
Abstract
OBJECTIVE Various patient placement criteria (PPC) have been developed to address alcohol use disorder (AUD), which has a high relapse rate and imposes substantial socioeconomic costs. Although research has shown PPC to be an effective tool, evidence supporting the Korean-PPC (K-PPC) is insufficient. This paper investigated whether treatment matching with the K-PPC was effective, based on variables related to AUD. METHODS In total, 524 participants were evaluated using the 6 dimensions of the K-PPC and levels of care (LoC) were recommended based on the results. Participants whose treatment matched with the recommended LoC were classified into the matched group, and those whose treatment did not match were classified into the mismatched group. Subsequently, treatment was planned according to the determined LoC, and a total of 3 follow-up evaluations were conducted at 1 month, 3 months, and 6 months. RESULTS There was no significant difference in the follow-up rate between the K-PPC matched group and the mismatched group. Of the variables measured by the 6 dimensions of the K-PPC, alcohol-related variables, depression, insight, and biomedical outcomes showed the most significant results (especially alcohol-related variables) from the baseline evaluation to the 6-month follow-up. In addition, the average adherence to the treatment program in the 6-month period was found to be higher in the matched group than in the mismatched group. CONCLUSION The K-PPC could be effective for placing patients and providing treatment by matching patient characteristics. Enhancing treatment program retention can also have a positive effect on clinical outcomes.
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Affiliation(s)
- Sang-Wook Park
- Department of Psychiatry, National Cancer Center, Goyang, Republic of Korea
| | - Hayeong Choi
- Department of Psychiatry, Hallym University, Chuncheon Sacred Heart Hospital, Chuncheon, Republic of Korea
| | - Eui Hyeon Na
- Department of Neuropsychiatry, Presbyterian Medical Center, Jeonju, Republic of Korea
| | - Hong Seok Oh
- Department of Psychiatry, Konyang University College of Medicine, Konyang University Hospital, Daejeon, Republic of Korea
| | - Sung Won Roh
- Department of Psychiatry, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Sang Kyu Lee
- Department of Psychiatry, Hallym University, Chuncheon Sacred Heart Hospital, Chuncheon, Republic of Korea
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Daniel J, Dumortier J, Del Bello A, Gamon L, Molinari N, Faure S, Meszaros M, Ursic-Bedoya J, Meunier L, Monet C, Navarro F, Boillot O, Pageaux GP, Donnadieu-Rigole H. Integrating an addiction team into the management of patients transplanted for alcohol-associated liver disease reduces the risk of severe relapse. JHEP Rep 2023; 5:100832. [PMID: 37681206 PMCID: PMC10480527 DOI: 10.1016/j.jhepr.2023.100832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/24/2023] [Accepted: 06/14/2023] [Indexed: 09/09/2023] Open
Abstract
Background & Aims Liver transplantation (LT) is a last resort treatment for patients at high risk of mortality from end-stage liver disease. Over the past years, alcohol-associated liver disease has become the most frequent indication for LT in the world. The outcomes of LT for alcohol-associated liver disease are good, but return to alcohol use is detrimental for medium-term survival because of cancer development, cardiovascular events, and recurrent alcohol-associated cirrhosis. Several strategies have been developed to prevent return to alcohol use during the pre- or post-LT period, but there are no specific recommendations. Therefore, the main objective of this study was to investigate if the integration of an addiction team in a LT unit affected the rate of severe alcohol relapse after LT. The secondary objectives were to assess the effects of addiction follow up on cardiovascular events, cancer, and overall survival. Methods This study was a retrospective comparison between centres with or without addiction monitoring. Results The study included 611 patients of which 79.4% were male with a mean age of 55.4 years at the time of LT, 190 were managed by an integrated addiction team. The overall alcohol relapse rate was 28.9% and the rate of severe relapse was 13.0%. Patients with addiction follow-up had significantly less frequent severe alcohol relapse than those in the control group (p = 0.0218). Addiction follow up (odds ratio = 0.19; p = 0.001) and age at LT (odds ratio = 1.23; p = 0.02) remained significantly associated with post-LT cardiovascular events. Conclusions Our study confirms the benefits of integrating an addiction team to reduce return to alcohol use after LT. Clinical Trials registration This study is registered at ClinicalTrials.gov (NCT04964687). Impact and implications The main indication for liver transplantation is alcohol-associated cirrhosis. There are currently no specific recommendations on the addiction monitoring of transplant candidates, although severe return to alcohol use after liver transplantation has a negative impact on long-term survival of patients. In this study, we explored the impact of a systematic addiction intervention on the return to alcohol use rates. In our transplantation centre, we demonstrated the interest of an addiction follow up to limit the severe alcohol relapses rate. This information should be further investigated in prospective studies to validate these data.
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Affiliation(s)
- Jules Daniel
- Hepatology and Liver Transplantation Department, Saint Eloi Hospital, University Hospital of Montpellier, Montpellier, France
| | - Jérôme Dumortier
- Fédération des Spécialités Digestives, Hôpital Edouard Herriot, Hospices Civils de Lyon et Université Claude Bernard, Lyon, France
| | - Arnaud Del Bello
- Nephrology and Organ Transplant Department, CHU de Toulouse, Toulouse, France
| | - Lucie Gamon
- Medical Information Department, La Colombière Hospital, University Hospital of Montpellier, Montpellier, France
| | - Nicolas Molinari
- Medical Information Department, La Colombière Hospital, University Hospital of Montpellier, Montpellier, France
- Medical University of Montpellier (UM1), Montpellier, France
| | - Stéphanie Faure
- Hepatology and Liver Transplantation Department, Saint Eloi Hospital, University Hospital of Montpellier, Montpellier, France
| | - Magdalena Meszaros
- Hepatology and Liver Transplantation Department, Saint Eloi Hospital, University Hospital of Montpellier, Montpellier, France
| | - José Ursic-Bedoya
- Hepatology and Liver Transplantation Department, Saint Eloi Hospital, University Hospital of Montpellier, Montpellier, France
| | - Lucy Meunier
- Hepatology and Liver Transplantation Department, Saint Eloi Hospital, University Hospital of Montpellier, Montpellier, France
| | - Clément Monet
- Department of Anesthesia and Intensive Care Unit, University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, Montpellier, France
| | - Francis Navarro
- Medical University of Montpellier (UM1), Montpellier, France
- Department of Digestive Surgery, University Hospital of Montpellier, St-Eloi Hospital, Montpellier, France
| | - Olivier Boillot
- Fédération des Spécialités Digestives, Hôpital Edouard Herriot, Hospices Civils de Lyon et Université Claude Bernard, Lyon, France
| | - Georges-Philippe Pageaux
- Hepatology and Liver Transplantation Department, Saint Eloi Hospital, University Hospital of Montpellier, Montpellier, France
- Medical University of Montpellier (UM1), Montpellier, France
| | - Hélène Donnadieu-Rigole
- Medical University of Montpellier (UM1), Montpellier, France
- Addictions Department, Saint Eloi Hospital, University Hospital of Montpellier, Montpellier, France
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Donoghue K, Boniface S, Brobbin E, Byford S, Coleman R, Coulton S, Day E, Dhital R, Farid A, Hermann L, Jordan A, Kimergård A, Koutsou ML, Lingford-Hughes A, Marsden J, Neale J, O'Neill A, Phillips T, Shearer J, Sinclair J, Smith J, Strang J, Weinman J, Whittlesea C, Widyaratna K, Drummond C. Adjunctive Medication Management and Contingency Management to enhance adherence to acamprosate for alcohol dependence: the ADAM trial RCT. Health Technol Assess 2023; 27:1-88. [PMID: 37924307 PMCID: PMC10641712 DOI: 10.3310/dqkl6124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2023] Open
Abstract
Background Acamprosate is an effective and cost-effective medication for alcohol relapse prevention but poor adherence can limit its full benefit. Effective interventions to support adherence to acamprosate are therefore needed. Objectives To determine the effectiveness of Medication Management, with and without Contingency Management, compared to Standard Support alone in enhancing adherence to acamprosate and the impact of adherence to acamprosate on abstinence and reduced alcohol consumption. Design Multicentre, three-arm, parallel-group, randomised controlled clinical trial. Setting Specialist alcohol treatment services in five regions of England (South East London, Central and North West London, Wessex, Yorkshire and Humber and West Midlands). Participants Adults (aged 18 years or more), an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis of alcohol dependence, abstinent from alcohol at baseline assessment, in receipt of a prescription for acamprosate. Interventions (1) Standard Support, (2) Standard Support with adjunctive Medication Management provided by pharmacists via a clinical contact centre (12 sessions over 6 months), (3) Standard Support with adjunctive Medication Management plus Contingency Management that consisted of vouchers (up to £120) to reinforce participation in Medication Management. Consenting participants were randomised in a 2 : 1 : 1 ratio to one of the three groups using a stratified random permuted block method using a remote system. Participants and researchers were not blind to treatment allocation. Main outcome measures Primary outcome: self-reported percentage of medication taken in the previous 28 days at 6 months post randomisation. Economic outcome: EuroQol-5 Dimensions, a five-level version, used to calculate quality-adjusted life-years, with costs estimated using the Adult Service Use Schedule. Results Of the 1459 potential participants approached, 1019 (70%) were assessed and 739 (73 consented to participate in the study, 372 (50%) were allocated to Standard Support, 182 (25%) to Standard Support with Medication Management and 185 (25%) to Standard Support and Medication Management with Contingency Management. Data were available for 518 (70%) of participants at 6-month follow-up, 255 (68.5%) allocated to Standard Support, 122 (67.0%) to Standard Support and Medication Management and 141 (76.2%) to Standard Support and Medication Management with Contingency Management. The mean difference of per cent adherence to acamprosate was higher for those who received Standard Support and Medication Management with Contingency Management (10.6%, 95% confidence interval 19.6% to 1.6%) compared to Standard Support alone, at the primary end point (6-month follow-up). There was no significant difference in per cent days adherent when comparing Standard Support and Medication Management with Standard Support alone 3.1% (95% confidence interval 12.8% to -6.5%) or comparing Standard Support and Medication Management with Standard Support and Medication Management with Contingency Management 7.9% (95% confidence interval 18.7% to -2.8%). The primary economic analysis at 6 months found that Standard Support and Medication Management with Contingency Management was cost-effective compared to Standard Support alone, achieving small gains in quality-adjusted life-years at a lower cost per participant. Cost-effectiveness was not observed for adjunctive Medication Management compared to Standard Support alone. There were no serious adverse events related to the trial interventions reported. Limitations The trial's primary outcome measure changed substantially due to data collection difficulties and therefore relied on a measure of self-reported adherence. A lower than anticipated follow-up rate at 12 months may have lowered the statistical power to detect differences in the secondary analyses, although the primary analysis was not impacted. Conclusions Medication Management enhanced with Contingency Management is beneficial to patients for supporting them to take acamprosate. Future work Given our findings in relation to Contingency Management enhancing Medication Management adherence, future trials should be developed to explore its effectiveness and cost-effectiveness with other alcohol interventions where there is evidence of poor adherence. Trial registration This trial is registered as ISRCTN17083622 https://doi.org/10.1186/ISRCTN17083622. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 22. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Kim Donoghue
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
- National Addictions Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience King's College London, London, UK
| | - Sadie Boniface
- National Addictions Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience King's College London, London, UK
- Institute of Alcohol Studies, London, UK
| | - Eileen Brobbin
- National Addictions Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience King's College London, London, UK
| | - Sarah Byford
- Institute of Psychiatry, Psychology and Neuroscience, King's Health Economics, King's College London, London UK
| | - Rachel Coleman
- Faculty of Health Sciences, Institute for Clinical and Applied Health Research (ICAHR), University of Hull, Hull, UK
| | - Simon Coulton
- Centre for Health Services Studies, University of Kent, Canterbury, Kent, UK
| | - Edward Day
- Institute for Mental Health, University of Birmingham, Birmingham, UK
| | - Ranjita Dhital
- National Addictions Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience King's College London, London, UK
- Arts and Sciences Department, University College London, London, UK
| | - Anum Farid
- National Addictions Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience King's College London, London, UK
- What Works for Children's Social Care, London, UK
| | - Laura Hermann
- National Addictions Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience King's College London, London, UK
- Faculty of Health Sciences, Institute for Clinical and Applied Health Research (ICAHR), University of Hull, Hull, UK
| | - Amy Jordan
- National Addictions Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience King's College London, London, UK
- Black Country Healthcare NHS Foundation Trust, West Bromwich, UK
| | - Andreas Kimergård
- National Addictions Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience King's College London, London, UK
| | | | - Anne Lingford-Hughes
- Division of Psychiatry, Department of Brain Sciences, Imperial College London, London, UK
| | - John Marsden
- National Addictions Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Joanne Neale
- National Addictions Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience King's College London, London, UK
| | - Aimee O'Neill
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Thomas Phillips
- Faculty of Health Sciences, Institute for Clinical and Applied Health Research (ICAHR), University of Hull, Hull, UK
| | - James Shearer
- Institute of Psychiatry, Psychology and Neuroscience, King's Health Economics, King's College London, London UK
| | - Julia Sinclair
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Joanna Smith
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - John Strang
- National Addictions Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - John Weinman
- School of Cancer & Pharmaceutical Sciences, King's College London, London, UK
| | - Cate Whittlesea
- Research Department of Practice and Policy, UCL School of Pharmacy, University College London, London, UK
| | - Kideshini Widyaratna
- Institute of Psychiatry Psychology and Neuroscience, Department of Psychology, King's College London, London, UK
| | - Colin Drummond
- National Addictions Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
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Maddern XJ, Walker LC, Campbell EJ, Arunogiri S, Haber PS, Morley K, Manning V, Millan EZ, McNally GP, Lubman DI, Lawrence AJ. Can we enhance the clinical efficacy of cognitive and psychological approaches to treat substance use disorders through understanding their neurobiological mechanisms? Neurosci Biobehav Rev 2022; 142:104899. [PMID: 36183863 DOI: 10.1016/j.neubiorev.2022.104899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 11/19/2022]
Abstract
Despite decades of research in the field of addiction, relapse rates for substance use disorders remain high. Consequently, there has been growing focus on providing evidence-based treatments for substance use disorders, resulting in the increased development and use of cognitive and psychological interventions. Such treatment approaches, including contingency management, community-reinforcement approach, and cognitive bias modification, have shown promising clinical efficacy in reducing substance use and promoting abstinence during treatment. However, these interventions are still somewhat limited in achieving sustained periods of abstinence post-treatment. The neurobiological mechanisms underpinning these treatment approaches remain largely unknown and under-studied, in part, due to a lack of translational animal models. The adoption of a reverse translational approach may assist in development of more representative models that can facilitate elucidation of the mechanisms behind these clinically relevant interventions. This review examines our current understanding of addiction neurobiology from clinical, preclinical research and existing animal models, and considers how the efficacy of such behavioral-oriented interventions alone, or in combination with pharmacotherapy, may be enhanced to improve treatment outcomes.
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Affiliation(s)
- Xavier J Maddern
- Florey Institute of Neuroscience and Mental Health, Parkville, VIC 3010, Australia; Florey Department of Neuroscience and Mental Health, University of Melbourne, VIC 3010, Australia.
| | - Leigh C Walker
- Florey Institute of Neuroscience and Mental Health, Parkville, VIC 3010, Australia; Florey Department of Neuroscience and Mental Health, University of Melbourne, VIC 3010, Australia
| | - Erin J Campbell
- Florey Institute of Neuroscience and Mental Health, Parkville, VIC 3010, Australia; Florey Department of Neuroscience and Mental Health, University of Melbourne, VIC 3010, Australia; School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia; Brain Neuromodulation Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Shalini Arunogiri
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Australia; Turning Point, Eastern Health, Melbourne, Australia
| | - Paul S Haber
- Edith Collins Centre, Drug Health Services, Sydney Local Health District, Camperdown, Australia; Sydney Medical School, University of Sydney, NSW, Australia
| | - Kirsten Morley
- Sydney Medical School, University of Sydney, NSW, Australia
| | - Victoria Manning
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Australia; Turning Point, Eastern Health, Melbourne, Australia
| | | | | | - Dan I Lubman
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Australia; Turning Point, Eastern Health, Melbourne, Australia
| | - Andrew J Lawrence
- Florey Institute of Neuroscience and Mental Health, Parkville, VIC 3010, Australia; Florey Department of Neuroscience and Mental Health, University of Melbourne, VIC 3010, Australia.
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van Amsterdam J, Blanken P, Spijkerman R, van den Brink W, Hendriks V. The Added Value of Pharmacotherapy to Cognitive Behavior Therapy And Vice Versa in the Treatment of Alcohol Use Disorders: A Systematic Review. Alcohol Alcohol 2022; 57:768-775. [PMID: 36085572 DOI: 10.1093/alcalc/agac043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/31/2022] [Accepted: 08/10/2022] [Indexed: 11/13/2022] Open
Abstract
AIM To explore whether combined interventions i.e. psychotherapeutic plus psychosocial interventions are more effective than monotherapies in the treatment of alcohol use disorders. METHODS Systematic review of the results of randomized controlled trials that compared combined therapies with monotherapies (either pharmacotherapy or psychotherapy). RESULTS The search resulted in 28 eligible studies. Data from these RCTs showed that 10 out of 19 RCTs (53%) demonstrated an added value of combined therapy (psychotherapy + pharmacotherapy) compared to psychotherapy only, whereas only three out of nine RCTs (33%) comparing combined therapy with pharmacotherapy showed a possible added value for combined therapy. CONCLUSIONS Pharmacotherapy is effective to treat AUD with or without psychotherapy and that psychotherapy can best be offered in combination with pharmacotherapy.
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Affiliation(s)
- Jan van Amsterdam
- Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Research Program Compulsivity, Impulsivity & Attention, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Peter Blanken
- Parnassia Addiction Research Centre (PARC), Parnassia Psychiatric Institute, Zoutkeetsingel 40, 2512 HN, The Hague, The Netherlands
| | - Renske Spijkerman
- Parnassia Addiction Research Centre (PARC), Parnassia Psychiatric Institute, Zoutkeetsingel 40, 2512 HN, The Hague, The Netherlands
| | - Wim van den Brink
- Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Research Program Compulsivity, Impulsivity & Attention, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Vincent Hendriks
- Parnassia Addiction Research Centre (PARC), Parnassia Psychiatric Institute, Zoutkeetsingel 40, 2512 HN, The Hague, The Netherlands.,Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
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7
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Hashimoto N, Habu H, Takao S, Sakamoto S, Okahisa Y, Matsuo K, Takaki M, Kishi Y, Yamada N. Clinical moderators of response to nalmefene in a randomized-controlled trial for alcohol dependence: An exploratory analysis. Drug Alcohol Depend 2022; 233:109365. [PMID: 35228081 DOI: 10.1016/j.drugalcdep.2022.109365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Nalmefene is the only medication marketed to reduce the consumption of alcohol in patients with alcohol dependence, but it remains unclear which patients could most benefit from it. This study aimed to identify clinical moderators that affect treatment response to nalmefene in patients with alcohol dependence. METHODS In a multicenter, randomized, controlled, double-blind, phase 3 study of nalmefene on Japanese patients with alcohol dependence, the relationship between the reduction of heavy drinking days (HDD) and total alcohol consumption (TAC) at 12 and 24 weeks of treatment and baseline variables of the participants were analyzed in a linear regression and multiple adjusted analysis. RESULTS Age < 65, no family history of problem drinking, age at onset of problem drinking ≥ 25, and not currently smoking were possible positive moderators. Nalmefene showed a significant HDD reduction in patients with age < 65 or no family history of problem drinking, and a significant TAC reduction in patients with age at onset of problem drinking ≥ 25 or who were not currently smoking. After multiple adjusted analyses, age < 65 (p = .028), no family history of problem drinking (p = .047), and age at onset of problem drinking ≥ 25 (p = .030) were statistically significant. Not currently smoking (p = .071) was marginally significant. In combination, these moderators indicated synergistic effects. CONCLUSIONS Alcohol-dependent patients with favorable prognostic factors such as non-smoking status, no family history of problem drinking, and a late-onset of problem drinking selectively benefit from nalmefene. Further research is needed to validate these exploratory results.
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Affiliation(s)
- Nozomu Hashimoto
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan; Okayama Psychiatric Medical Center, Japan
| | - Hiroshi Habu
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Soshi Takao
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Shinji Sakamoto
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Yuko Okahisa
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Keitaro Matsuo
- Division of Cancer Epidemiology and Prevention, Aichi Cancer Center Research Institute, Japan
| | - Manabu Takaki
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan.
| | | | - Norihito Yamada
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
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Rieser NM, Herdener M, Preller KH. Psychedelic-Assisted Therapy for Substance Use Disorders and Potential Mechanisms of Action. Curr Top Behav Neurosci 2022; 56:187-211. [PMID: 34910289 DOI: 10.1007/7854_2021_284] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Substance use disorders (SUD) represent a significant public health issue with a high need for novel and efficacious treatment options. In light of this high unmet need, recent results reporting beneficial outcomes of psychedelic-assisted therapy in SUD are particularly relevant. However, several questions remain with regard to this treatment approach. The clinical mechanisms of action of psychedelic substances in the treatment of SUD are not well understood. Closing this knowledge gap is critical to inform and optimize the psychotherapeutic embedding of the acute substance administration. In this chapter, we discuss potential mechanisms that have implications on psychotherapeutic approaches including induced neuroplasticity, alterations in brain network connectivity, reward and emotion processing, social connectedness, insight, and mystical experiences. Furthermore, we outline considerations and approaches that leverage these mechanisms in order to optimize the therapeutic embedding by maximizing synergy between substance effects and psychotherapy. Understanding the mechanisms of action, developing psychotherapeutic approaches accordingly, and evaluating their synergistic efficacy in scientific studies will be critical to advance the framework of psychedelic-assisted therapy for addiction, create evidence-based approaches, and achieve the best treatment outcome for patients with SUD.
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Affiliation(s)
- Nathalie M Rieser
- Pharmaco-Neuroimaging and Cognitive-Emotional Processing, Department of Psychiatry, Psychotherapy and Psychosomatics, University of Zurich, Psychiatric University Hospital Zurich, Zurich, Switzerland.
| | - Marcus Herdener
- Center for Addictive Disorders, Department of Psychiatry, Psychotherapy and Psychosomatics, University of Zurich, Psychiatric University Hospital Zurich, Zurich, Switzerland
| | - Katrin H Preller
- Pharmaco-Neuroimaging and Cognitive-Emotional Processing, Department of Psychiatry, Psychotherapy and Psychosomatics, University of Zurich, Psychiatric University Hospital Zurich, Zurich, Switzerland
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Shahrabadi S, Jalali A, Jalali R, Salari N. Validation of Texas Christian University Psychosocial Functioning and Motivation Scales in Iranian Persons Who Use Drugs. Curr Drug Res Rev 2020; 13:49-58. [PMID: 33023463 DOI: 10.2174/2589977512666201006150415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 06/04/2020] [Accepted: 07/02/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The psychosocial functioning and motivation scales of the Texas Cristian University (TCU) were translated and validated for the Persons Who Use Drugs (PWUDs). METHODS This study was carried out as a methodological research. The scales were translated forward and backward and then, the PWUDs in Kermanshah-based (west of Iran) substance abuse treatment centers in 2019 filled out the scales. Participants included 250 individuals who were selected by convenience sampling method. A demographics form and psychosocial functioning and motivation scales were used to collect data. For data analysis, content validity, face validity, testretest, internal consistency, and construct validity were applied by using exploratory analysis methods in SPSS (v.20) and confirmatory factor analysis in LISREL software. RESULTS Exploratory Factor Analysis (EFA) results were obtained by using the main component analysis and Varimax rotation of three factors (psychological function, social function, treatment motivation). Extracted factors, along with the eigenvalues, attributed variance percentage, and cumulative attributed variances by each factor, by 68.56%, showed a total variance of the questionnaire. Moreover, the fitness indexes of the Confirmatory Factor Analysis (CFA) of psychological function, social function, and treatment motivation were 0.059, 0.075 and 0.072, respectively. Therefore, the questionnaire fitness was at an acceptable level. The test-retest reliability coefficient was 0.875, and the Cronbachs alpha coefficient for all the components was higher than 0.71. CONCLUSION The results showed that psychosocial functioning, motivation scales have good psychometric properties, and they can be used in research and treatment fields.
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Affiliation(s)
- Sana Shahrabadi
- Deptartment of Psychiatric Nursing, School of Nursing and Midwifery, Students Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Amir Jalali
- Substance Abuse Prevention Research Center, Research Institute for Health, Kermanshah University of Medical Sciences Kermanshah, Iran
| | - Rostam Jalali
- Deptartment of Nursing, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Nader Salari
- Deptartment of Biostatistics Department, School of Nursing & Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Higuchi S, Takahashi M, Murai Y, Tsuneyoshi K, Nakamura I, Meulien D, Miyata H. Long-term safety and efficacy of nalmefene in Japanese patients with alcohol dependence. Psychiatry Clin Neurosci 2020; 74:431-438. [PMID: 32359104 PMCID: PMC7496902 DOI: 10.1111/pcn.13017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/16/2020] [Accepted: 04/27/2020] [Indexed: 12/01/2022]
Abstract
AIM The safety and efficacy of nalmefene in Japanese patients with high or very high World Health Organization drinking risk level of alcohol dependence were assessed in a multicenter, randomized, double-blind, placebo-controlled, phase 3 (lead-in) study. Here, the long-term safety and efficacy of nalmefene in an open-label extension of the lead-in study are presented. METHODS Patients who completed the 24-week lead-in study were eligible for the extension study, where they were treated with nalmefene 20 mg as needed for 24 weeks. The long-term safety and efficacy of nalmefene 20 mg during the total 48-week period were evaluated. Treatment-emergent adverse events during the study period were recorded and change from baseline in the number of heavy drinking days and total alcohol consumption were calculated. RESULTS Overall, long-term nalmefene 20 mg was well tolerated; the main treatment-emergent adverse events reported in ≥5% of patients included nasopharyngitis (37.2%), nausea (36.5%), somnolence (21.2%), dizziness (16.8%), malaise (14.6%), and vomiting (12.4%). The number of heavy drinking days and total alcohol consumption decreased from baseline to 48 weeks (mixed model for repeated measures, least squares mean ± standard error, -15.09 ± 0.77 days/month and -53.20 ± 2.29 g/day, respectively) during the study. CONCLUSION This long-term evaluation in Japanese patients with high or very high drinking risk levels of alcohol dependence indicated that nalmefene was safe, well tolerated, and efficacious.
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Affiliation(s)
- Susumu Higuchi
- National Hospital Organization, Kurihama Medical and Addiction Center, Yokosuka, Japan
| | - Masayoshi Takahashi
- Department of Clinical Management, Clinical Development Headquarters, Otsuka Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Yoshiyuki Murai
- Department of Clinical Management, Clinical Development Headquarters, Otsuka Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Kana Tsuneyoshi
- Department of Biometrics, Clinical Development Headquarters, Otsuka Pharmaceutical Co., Ltd., Osaka, Japan
| | - Izuru Nakamura
- Medical Affairs, Otsuka Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Didier Meulien
- Clinical Research and Development, H. Lundbeck A/S, Valby, Denmark
| | - Hisatsugu Miyata
- Department of Psychiatry, Jikei University School of Medicine, Tokyo, Japan
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Ray LA, Meredith LR, Kiluk BD, Walthers J, Carroll KM, Magill M. Combined Pharmacotherapy and Cognitive Behavioral Therapy for Adults With Alcohol or Substance Use Disorders: A Systematic Review and Meta-analysis. JAMA Netw Open 2020; 3:e208279. [PMID: 32558914 PMCID: PMC7305524 DOI: 10.1001/jamanetworkopen.2020.8279] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Substance use disorders (SUDs) represent a pressing public health concern. Combined behavioral and pharmacological interventions are considered best practices for addiction. Cognitive behavioral therapy (CBT) is a first-line intervention, yet the superiority of CBT compared with other behavioral treatments when combined with pharmacotherapy remains unclear. An understanding of the effects of combined CBT and pharmacotherapy will inform best-practice guidelines for treatment of SUD. OBJECTIVE To conduct a meta-analysis of the published literature on combined CBT and pharmacotherapy for adult alcohol use disorder (AUD) or other SUDs. DATA SOURCES PubMed, Cochrane Register, MEDLINE, PsychINFO, and Embase databases from January 1, 1990, through July 31, 2019, were searched. Keywords were specified in 3 categories: treatment type, outcome type, and study design. Collected data were analyzed through September 30, 2019. STUDY SELECTION Two independent raters reviewed abstracts and full-text articles. English language articles describing randomized clinical trials examining CBT in combination with pharmacotherapy for AUD and SUD were included. DATA EXTRACTION AND SYNTHESIS Inverse-variance weighted, random-effects estimates of effect size were pooled into 3 clinically informative subgroups: (1) CBT plus pharmacotherapy compared with usual care plus pharmacotherapy, (2) CBT plus pharmacotherapy compared with another specific therapy plus pharmacotherapy, and (3) CBT added to usual care and pharmacotherapy compared with usual care and pharmacotherapy alone. Sensitivity analyses included assessment of study quality, pooled effect size heterogeneity, publication bias, and primary substance moderator effects. MAIN OUTCOMES AND MEASURES Substance use frequency and quantity outcomes after treatment and during follow-up were examined. RESULTS The sample included 62 effect sizes from 30 unique randomized clinical trials that examined CBT in combination with some form of pharmacotherapy for AUD and SUD. The primary substances targeted in the clinical trial sample were alcohol (15 [50%]), followed by cocaine (7 [23%]) and opioids (6 [20%]). The mean (SD) age of the patient sample was 39 (6) years, with a mean (SD) of 28% (12%) female participants per study. The following pharmacotherapies were used: naltrexone hydrochloride and/or acamprosate calcium (26 of 62 effect sizes [42%]), methadone hydrochloride or combined buprenorphine hydrochloride and naltrexone (11 of 62 [18%]), disulfiram (5 of 62 [8%]), and another pharmacotherapy or mixture of pharmacotherapies (20 of 62 [32%]). Random-effects pooled estimates showed a benefit associated with combined CBT and pharmacotherapy over usual care (g range, 0.18-0.28; k = 9). However, CBT did not perform better than another specific therapy, and evidence for the addition of CBT as an add-on to combined usual care and pharmacotherapy was mixed. Moderator analysis showed variability in effect direction and magnitude by primary drug target. CONCLUSIONS AND RELEVANCE The present study supports the efficacy of combined CBT and pharmacotherapy compared with usual care and pharmacotherapy. Cognitive behavioral therapy did not perform better than another evidence-based modality (eg, motivational enhancement therapy, contingency management) in this context or as an add-on to combined usual care and pharmacotherapy. These findings suggest that best practices in addiction treatment should include pharmacotherapy plus CBT or another evidence-based therapy, rather than usual clinical management or nonspecific counseling services.
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Affiliation(s)
- Lara A. Ray
- Department of Psychology, University of California, Los Angeles
| | | | | | - Justin Walthers
- Center for Alcohol and Addiction Studies, Brown University, Providence, Rhode Island
| | | | - Molly Magill
- Center for Alcohol and Addiction Studies, Brown University, Providence, Rhode Island
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Tadori Y. [Pharmacological profile and clinical findings of nalmefene (Selincro ®) for reducing alcohol consumption in patients with alcohol dependence]. Nihon Yakurigaku Zasshi 2020; 155:113-119. [PMID: 32115477 DOI: 10.1254/fpj.19136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Nalmefene (Selincro®), an opioid receptor modulator, is approved in Japan, the European Union, and other countries for reducing alcohol consumption in patients with alcohol dependence. This article reviews the efficacy and safety of as-needed use of nalmefene in the treatment of alcohol dependence, as well as summarizing its pharmacological properties. Ethanol increases the release of endogenous opioids, such as β-endorphin, a μ-opioid receptor agonist; and dynorphin, a κ-opioid receptor agonist. Preclinical data suggest that nalmefene acts as an antagonist at the μ-opioid receptor and a partial agonist at the κ-opioid receptor, and reduces ethanol self-administration in ethanol-dependent and ethanol-non-dependent rats. Nalmefene counters alcohol-induced dysregulation of the β-endorphin/μ-opioid receptor and the dynorphin/κ-opioid receptor systems. In a multicenter, randomized, double-blind, phase 3 study of as-needed use of nalmefene combined with psychosocial support in alcohol-dependent Japanese patients with at least high drinking risk level, compared with placebo, nalmefene 10 mg and 20 mg significantly reduced the number of heavy drinking days and total alcohol consumption at week 12. In the 24-week treatment period, treatment-emergent adverse events occurred in ≥5% of patients in either the nalmefene 10 mg or 20 mg group and at least twice as often as in the placebo group were nausea, dizziness, somnolence, vomiting, insomnia, decreased appetite, constipation, malaise, and palpitations. Most adverse events were mild or moderate in severity. In conclusion, as-needed use of nalmefene provides a new concept for the treatment of alcohol dependence: namely, "reduction of alcohol intake".
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Kraus SW, Etuk R, Potenza MN. Current pharmacotherapy for gambling disorder: a systematic review. Expert Opin Pharmacother 2020; 21:287-296. [PMID: 31928246 DOI: 10.1080/14656566.2019.1702969] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: Gambling disorder is classified as an addictive disorder and is associated with significant distress and impairment in personal, social, occupational or other important areas of functioning. Although no pharmacotherapy has a formal indication for gambling disorder, data suggest potential benefits of specific medications.Area covered: This systematic review evaluated findings from 19 randomized controlled trials testing pharmacotherapies for the treatment of gambling disorder.Expert opinion: Few randomized controlled trials have studied pharmacotherapies for gambling disorder. Though results are limited, opioid antagonists like naltrexone showed promise in the pharmacological treatment of gambling disorder. Pharmacotherapy combined with psychotherapy treatments for gambling disorder may provide better rates of patient retention in comparison to pharmacology-only treatments, though further research is needed in this area. Future studies should address gaps relating to considerations of racial, ethnic, gender and other individual differences in clinical studies. Because gambling disorder often co-occurs with other psychiatric disorders, additional research is needed to test treatments for dually diagnosed patients.
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Affiliation(s)
- Shane W Kraus
- Department of Psychology, University of Nevada, Las Vegas, NV, USA
| | - Repairer Etuk
- Department of Psychology, University of Nevada, Las Vegas, NV, USA
| | - Marc N Potenza
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA.,Department of Neuroscience, Yale University School of Medicine, New Haven, CT, USA.,Yale Child Study Center, Yale University School of Medicine, New Haven, CT, USA.,The Connecticut Council on Problem Gambling, Wethersfield, CT, USA.,The Connecticut Mental Health Center, New Haven, CT, USA
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López-Pelayo H, Zuluaga P, Caballeria E, Van den Brink W, Mann K, Gual A. Safety of nalmefene for the treatment of alcohol use disorder: an update. Expert Opin Drug Saf 2019; 19:9-17. [PMID: 31868031 DOI: 10.1080/14740338.2020.1707802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Reduced drinking has been debated as a treatment goal for heavy drinking alcohol-dependent patients, in whom treatment based on abstinence is not always an option. Nalmefene was the first drug approved by the European Medicines Agency (2013) with the indication of reduced drinking in high drinking risk level alcohol-dependent patients. Six years after its introduction in Europe, data from clinical experience can be compared with those from preclinical studies and pivotal registration studies to evaluate what nalmefene has added to the treatment of AUD.Areas covered: Systematic review of efficacy and safety data of nalmefene use in humans from preclinical, phase III and phase IV studies, including systematic reviews, meta-analyses, cost-effectiveness analyses, and other secondary analyses.Expert opinion: Nalmefene introduces a paradigm change in the treatment of AUD that makes it appealing to patients that are reluctant to embrace abstinence, and facilitate patient-centered care in heavy users. However, information regarding safety data in special populations (e.g., patients with alcohol-related diseases, pregnancy, psychiatric disease), and direct comparisons with other potential drugs for alcohol reduction are further needed. Despite the promising role of nalmefene, there are still some factors that limit its wide prescription further than in specialized settings.
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Affiliation(s)
- Hugo López-Pelayo
- Grup Recerca Addiccions Clínic (GRAC-GRE), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic Barcelona, Barcelona, Spain
| | - Paola Zuluaga
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Elsa Caballeria
- Grup Recerca Addiccions Clínic (GRAC-GRE), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic Barcelona, Barcelona, Spain
| | - Wim Van den Brink
- Department of Psychiatry, Amsterdam University Medical Centres, Location AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Karl Mann
- Central Institute of Mental Health, University of Heidelberg, Mannheim, Germany
| | - Antoni Gual
- Grup Recerca Addiccions Clínic (GRAC-GRE), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic Barcelona, Barcelona, Spain
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Miyata H, Takahashi M, Murai Y, Tsuneyoshi K, Hayashi T, Meulien D, Sørensen P, Higuchi S. Nalmefene in alcohol-dependent patients with a high drinking risk: Randomized controlled trial. Psychiatry Clin Neurosci 2019; 73:697-706. [PMID: 31298784 PMCID: PMC6899457 DOI: 10.1111/pcn.12914] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 06/18/2019] [Accepted: 07/05/2019] [Indexed: 12/19/2022]
Abstract
AIMS Reducing alcohol consumption is one treatment approach for alcohol-dependent patients. This study compared nalmefene 20 mg and 10 mg with placebo, combined with psychosocial support, in alcohol-dependent Japanese patients with a high or very high drinking risk level (DRL). METHODS This was a multicenter, randomized, double-blind, phase 3 study conducted in alcohol-dependent patients with a high or very high DRL. Patients were randomized to 24 weeks of treatment with as-needed nalmefene 20 mg, 10 mg, or placebo with psychosocial support. The primary endpoint was change in heavy drinking days (HDD) from baseline to week 12. A key secondary endpoint was the change in total alcohol consumption (TAC) from baseline to week 12. RESULTS At week 12, 234, 206, and 154 patients who received placebo, nalmefene 20 mg, and 10 mg were included in the primary endpoint analysis. Compared with placebo, nalmefene was associated with significant reductions in HDD at week 12 (difference in 20 mg group, -4.34 days/month; 95% confidence interval [CI]: -6.05 to -2.62; P < 0.0001; difference in 10 mg group, -4.18 days/month; 95%CI: -6.05 to -2.32; P < 0.0001), as well as a significant reduction in TAC at week 12 (P < 0.0001). The incidence of treatment-emergent adverse events was 87.9%, 84.8%, and 79.2% in the groups receiving nalmefene 20 mg, 10 mg, and placebo, respectively. These events were mostly of mild or moderate severity. CONCLUSIONS Nalmefene 20 mg or 10 mg effectively reduced alcohol consumption and was well tolerated in alcohol-dependent patients with a high or very high DRL.
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Affiliation(s)
- Hisatsugu Miyata
- Department of Psychiatry, Jikei University School of Medicine, Tokyo, Japan
| | - Masayoshi Takahashi
- Department of Clinical Management, Clinical Development Headquarters, Otsuka Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Yoshiyuki Murai
- Department of Clinical Management, Clinical Development Headquarters, Otsuka Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Kana Tsuneyoshi
- Department of Biometrics, Clinical Development Headquarters, Otsuka Pharmaceutical Co., Ltd., Osaka, Japan
| | - Takako Hayashi
- Medical Affairs, Otsuka Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Didier Meulien
- Clinical Research and Development - Neurology, H. Lundbeck SAS, Issy-les-Moulineaux, Paris, France
| | | | - Susumu Higuchi
- National Hospital Organization, Kurihama Medical and Addiction Center, Japan
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Castrén S, Mäkelä N, Haikola J, Salonen AH, Crystal R, Scheinin M, Alho H. Treating gambling disorder with as needed administration of intranasal naloxone: a pilot study to evaluate acceptability, feasibility and outcomes. BMJ Open 2019; 9:e023728. [PMID: 31439593 PMCID: PMC6707653 DOI: 10.1136/bmjopen-2018-023728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND AIM There is growing interest in the use of medication-assisted treatments for gambling disorder (GD). Opioid receptor antagonists are hypothesised to blunt the craving associated with gambling. This study was designed to assess the feasibility of using an intranasal naloxone spray to treat GD. DESIGN An 8-week, open-label, uncontrolled pilot study. SETTING A single study site in the capital region of Finland. SUBJECTS Twenty problem gamblers (nine men) were randomised into two groups. Group A (n=10) took one dose into one nostril (2 mg naloxone), as needed, with a maximum of 4 doses/day (max. 8 mg/day). Group B (n=10) took one dose into each nostril (4 mg naloxone) as needed, with a maximum of 4 doses/day (max. 16 mg/day). INTERVENTION Naloxone hydrochloride nasal spray. MEASURES Acceptability and feasibility of the intervention were assessed. Use of study medication, adverse events, gambling frequency and gambling expenditure were recorded in a mobile diary. Problem gambling: South Oaks Gambling Screen (SOGS), depressive symptoms: Beck Depression Inventory (BDI) and alcohol use: Alcohol Use Disorders Identification Test were recorded. RESULTS Study completion rate was 90%. Acceptability and feasibility scores were high. Group B used intranasal naloxone more frequently than group A, and consequently used more naloxone. No serious adverse events were reported. The postintervention SOGS scores were lower (median=4 (IQR=3.75) versus preintervention scores (median=12 (IQR=4.75)). Depressive symptoms were reduced during the trial (preintervention BDI median=9, IQR=9 vs postintervention BDI median=6, IQR=6). CONCLUSIONS The acceptability and feasibility of using intranasal naloxone were high, and no serious adverse events were reported. Preliminary results suggest mixed results in terms of gambling behaviour (ie, reduced frequency but not expenditure) and decreased depressive symptoms. TRIAL REGISTRATION NUMBER EudraCT2016-001828-56.
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Affiliation(s)
- Sari Castrén
- Department of Public Health Solutions, Terveyden ja hyvinvoinnin laitos, Helsinki, Finland
- Faculty of Social Science, Department of Psychology and Speech Language Pathology, Turun Yliopisto, Turku, Finland
| | - Niklas Mäkelä
- Alcohol, Drugs and Addictions Unit, Terveyden ja hyvinvoinnin laitos, Helsinki, Finland
- Clinicum, University of Helsinki, Helsinki, Finland
| | - Janne Haikola
- Faculty of Natural Sciences, University of Tampere, Tampere, Finland
| | - Anne H Salonen
- Alcohol, Drugs and Addictions Unit, Terveyden ja hyvinvoinnin laitos, Helsinki, Finland
- Ita-Suomen yliopisto Terveystieteiden tiedekunta, Kuopio, Finland
| | | | - Mika Scheinin
- Institute of Biomedicine, University of Turku, Turku, Finland
| | - Hannu Alho
- Alcohol, Drugs and Addictions Unit, Terveyden ja hyvinvoinnin laitos, Helsinki, Finland
- Abdominal Center, University and University of Helsinki, Helsinki, Finland
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Brown LA, Jerud A, Asnaani A, Petersen J, Zang Y, Foa EB. Changes in posttraumatic stress disorder (PTSD) and depressive symptoms over the course of prolonged exposure. J Consult Clin Psychol 2019; 86:452-463. [PMID: 29683702 DOI: 10.1037/ccp0000292] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Prior studies of prolonged exposure therapy (PE) suggested that reduction of posttraumatic stress disorder (PTSD) precedes reduction in depression, yet no research has collapsed data across multiple studies to examine whether the directionality of reduction remains consistent in larger and diagnostically diverse samples. Thus, the objective of this study is to conduct an evaluation of bidirectional associations between PTSD and depression in PE. METHOD Participants (n = 216) from three randomized controlled trials of PE alone, PE + alcohol use disorder treatment, and PE + nicotine use disorder treatment completed weekly PTSD and depression severity measures. First, we analyzed the directional relationship between PTSD and depression over time in 2 single models to separately examine the effects of PTSD on depression and vice versa. Second, we analyzed a combined model to examine the simultaneous effects of reduction in PTSD on reduction in depression over and above the effects of reduction in depression on reduction in PTSD, and vice versa. RESULTS Two single models suggested that reductions in PTSD lead to reductions in depression and vice versa. The combined models suggested that both directions of change are important and reciprocal. The strength of predictive power from PTSD to depression, and vice versa, is approximately equal. Most significant prediction of PTSD from depression and vice versa occurred early in treatment. CONCLUSION The relationship between reductions in PTSD and depression during PE is transactional. Regardless of whether PTSD or depression decreases first, reduction in the other symptom cluster is likely to follow. (PsycINFO Database Record
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A relationship between the aldosterone-mineralocorticoid receptor pathway and alcohol drinking: preliminary translational findings across rats, monkeys and humans. Mol Psychiatry 2018; 23:1466-1473. [PMID: 28461696 PMCID: PMC5668213 DOI: 10.1038/mp.2017.97] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 02/15/2017] [Accepted: 03/16/2017] [Indexed: 12/17/2022]
Abstract
Aldosterone regulates electrolyte and fluid homeostasis through binding to the mineralocorticoid receptors (MRs). Previous work provides evidence for a role of aldosterone in alcohol use disorders (AUDs). We tested the hypothesis that high functional activity of the mineralocorticoid endocrine pathway contributes to vulnerability for AUDs. In Study 1, we investigated the relationship between plasma aldosterone levels, ethanol self-administration and the expression of CYP11B2 and MR (NR3C2) genes in the prefrontal cortex area (PFC) and central nucleus of the amygdala (CeA) in monkeys. Aldosterone significantly increased after 6- and 12-month ethanol self-administration. NR3C2 expression in the CeA was negatively correlated to average ethanol intake during the 12 months. In Study 2, we measured Nr3c2 mRNA levels in the PFC and CeA of dependent and nondependent rats and the correlates with ethanol drinking during acute withdrawal. Low Nr3c2 expression levels in the CeA were significantly associated with increased anxiety-like behavior and compulsive-like drinking in dependent rats. In Study 3, the relationship between plasma aldosterone levels, alcohol drinking and craving was investigated in alcohol-dependent patients. Non-abstinent patients had significantly higher aldosterone levels than abstinent patients. Aldosterone levels positively correlated with the number of drinks consumed, craving and anxiety scores. These findings support a relationship between ethanol drinking and the aldosterone/MR pathway in three different species.
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Thirty- Versus Ten-Day Diazepam Treatment for Alcohol Detoxification and a Comparison of Drinking Patterns, Craving, and Anxiety for up to 12 Weeks: A "Proof-of-Concept" Open-Label Randomized Controlled Trial. J Clin Psychopharmacol 2017; 37:722-728. [PMID: 28984747 DOI: 10.1097/jcp.0000000000000786] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE The aim of this study was to evaluate whether a prolonged detoxification treatment could decrease the relapse rate at 3 months after alcohol cessation in alcohol-dependent individuals through decreasing the levels of postdetoxification craving and anxiety. METHODS Twenty-six adult patients with alcohol dependence (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) who began an outpatient alcohol cessation program with an initial drinking goal of abstinence were enrolled in a 3-month, parallel, randomized (1:1 ratio), controlled, open-label, pilot trial. Participants were randomized to receive a detoxification treatment of diazepam with a duration of 30 (n = 12) or 10 days (n = 14). All participants received BRENDA-based psychotherapy during follow-up. RESULTS No significant between-group difference in relapse to any drinking was found at 3 months (P = 0.20). However, relapse to any heavy drinking at 3 months and regular drinking or heavy drinking during follow-up were significantly lower in the 30-day diazepam group (P = 0.009, P = 0.049, and P = 0.004, respectively). These differences were corroborated by significant differences in the alcohol-specific biological marker carbohydrate deficient transferrin at 3 months. Participants in the 30-day diazepam group also displayed significantly lower scores for alcohol craving (P = 0.007), self-reported anxiety (P = 0.024), and clinician-assessed anxiety (P = 0.002) throughout the follow-up. No serious adverse event was reported during the study. CONCLUSION This study provides an evidence-based rationale for a double-blind, randomized, placebo-controlled trial to confirm the efficacy of such a procedure on short-term and mid-/long-term drinking outcomes after alcohol cessation in alcohol-dependent individuals.
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Drewes AM, Bouwense SAW, Campbell CM, Ceyhan GO, Delhaye M, Demir IE, Garg PK, van Goor H, Halloran C, Isaji S, Neoptolemos JP, Olesen SS, Palermo T, Pasricha PJ, Sheel A, Shimosegawa T, Szigethy E, Whitcomb DC, Yadav D. Guidelines for the understanding and management of pain in chronic pancreatitis. Pancreatology 2017; 17:720-731. [PMID: 28734722 DOI: 10.1016/j.pan.2017.07.006] [Citation(s) in RCA: 171] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 06/26/2017] [Accepted: 07/11/2017] [Indexed: 12/11/2022]
Abstract
Abdominal pain is the foremost complication of chronic pancreatitis (CP). Pain can be related to recurrent or chronic inflammation, local complications or neurogenic mechanisms with corresponding changes in the nervous systems. Both pain intensity and the frequency of pain attacks have been shown to reduce quality of life in patients with CP. Assessment of pain follows the guidelines for other types of chronic pain, where the multidimensional nature of symptom presentation is taken into consideration. Quantitative sensory testing may be used to characterize pain, but is currently used in a research setting in advanced laboratories. For pain relief, current guidelines recommend a simple stepwise escalation of analgesic drugs with increasing potency until pain relief is obtained. Abstinence from alcohol and smoking should be strongly advised. Pancreatic enzyme therapy and antioxidants may be helpful as initial treatment. Endoscopic treatment can be used in patients with evidence of ductal obstruction and may be combined with extracorporeal shock wave lithothripsy. The best candidates are those with distal obstruction of the main pancreatic duct and in early stage of disease. Behavioral interventions should be part of the multidisciplinary approach to chronic pain management particularly when psychological impact is experienced. Surgery should be considered early and after a maximum of five endoscopic interventions. The type of surgery depends on morphological changes of the pancreas. Long-term effects are variable, but high success rates have been reported in open studies and when compared with endoscopic treatment. Finally, neurolytical interventions and neuromodulation can be considered in difficult patients.
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Affiliation(s)
- Asbjørn M Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Denmark.
| | - Stefan A W Bouwense
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Claudia M Campbell
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Güralp O Ceyhan
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Myriam Delhaye
- Department of Gastroenterology, Erasme University Hospital, Brussels, Belgium
| | - Ihsan Ekin Demir
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Pramod K Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Shuiji Isaji
- Department of Surgery, Mie University Graduate School of Medicine, Japan
| | - John P Neoptolemos
- Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - Søren S Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Denmark
| | - Tonya Palermo
- Seattle Children's Hospital Research Institute, Washington School of Medicine, USA
| | - Pankaj Jay Pasricha
- Center for Neurogastroenterology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Andrea Sheel
- Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - Tooru Shimosegawa
- Department of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Eva Szigethy
- Visceral Inflammation and Pain Center, Division of Gastroenterology, University of Pittsburgh and UPMC, Pittsburgh, PA, USA
| | - David C Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, USA
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Nalmefene in Alcohol Use Disorder Subjects with Psychiatric Comorbidity: A Naturalistic Study. Adv Ther 2017; 34:1636-1649. [PMID: 28540656 DOI: 10.1007/s12325-017-0546-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Nalmefene is the first drug to be approved for reducing alcohol consumption in alcohol use disorder (AUD) patients at high drinking risk. In real-world settings, there is a high prevalence of concurrent psychiatric disorders in AUD subjects, with associated increased morbidity and worse prognosis. This study evaluated the use of nalmefene in AUD patients with stabilized psychiatric comorbidity previously treated unsuccessfully for alcohol dependence, and assessed craving reduction and safety. METHODS Sixty-five AUD outpatients treated with as-needed 18 mg nalmefene for 24 weeks were included. Primary outcome measures were: changes in heavy drinking days (HDDs) and total alcohol consumption (TAC, g/day). Secondary outcome measures were: changes in drinking risk level and craving (obsessive-compulsive drinking scale and visual analogue scale for craving). RESULTS Forty-two AUD subjects (64.6%) had one or more stabilized psychiatric comorbidity. There was a significant reduction in HDDs, TAC and craving measures (p < 0.001), with no differences between subjects with and without psychiatric comorbidity. Nalmefene was safe and well tolerated in all patients. CONCLUSION As-needed nalmefene reduced drinking and craving in AUD subjects with and without psychiatric comorbidity. These findings suggest that nalmefene is a valid therapeutic option in real-world clinical settings, where comorbid conditions are common, and has the potential to engage AUD patients who may otherwise not have sought help. FUNDING Lundbeck Italia S.P.A.
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Reynaud M, Aubin HJ, Trinquet F, Zakine B, Dano C, Dematteis M, Trojak B, Paille F, Detilleux M. A Randomized, Placebo-Controlled Study of High-Dose Baclofen in Alcohol-Dependent Patients—The ALPADIR Study. Alcohol Alcohol 2017; 52:439-446. [DOI: 10.1093/alcalc/agx030] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 05/02/2017] [Indexed: 11/12/2022] Open
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Zang Y, Yu J, Chazin D, Asnaani A, Zandberg LJ, Foa EB. Changes in coping behavior in a randomized controlled trial of concurrent treatment for PTSD and alcohol dependence. Behav Res Ther 2016; 90:9-15. [PMID: 27930926 DOI: 10.1016/j.brat.2016.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 11/15/2016] [Accepted: 11/22/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The current study examines changes in coping among 165 adults meeting DSM-IV criteria for co-morbid posttraumatic stress disorder (PTSD) and alcohol dependence (AD). METHOD Participants were randomized to receive naltrexone or placebo, with or without prolonged exposure (PE). All participants received supportive counseling focused on alcohol use (BRENDA). Assessments of coping, PTSD, and AD were conducted at pre-treatment, mid-treatment, post-treatment, 3-month follow-up, and 6-month follow-up. RESULTS Participants exhibited significant decreases in both avoidant coping and adaptive coping from pre-treatment to 6-month follow-up across all groups. Participants who received PE showed faster decreases in avoidant coping during this period than participants who did not receive PE. PTSD symptom reduction was associated with changes in both avoidant and adaptive coping across groups. Improvement in PTSD symptoms was related to a faster rate of reduction in avoidant coping in the PE groups compared to those receiving BRENDA alone. CONCLUSIONS The current results suggest that concurrent treatment for co-morbid PTSD-AD decreases avoidant and adaptive coping, and participants who show greater reductions in PTSD symptoms also show greater changes in coping style. Consistent with theorized mechanisms of change in PE, the addition of PE to supportive counseling for AD was associated with a greater reduction of avoidant coping than supportive counseling alone.
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Affiliation(s)
- Yinyin Zang
- University of Pennsylvania, Philadelphia, PA, USA.
| | - Jessica Yu
- Rutgers, The State University of New Jersey, Piscataway, NJ, USA
| | | | - Anu Asnaani
- University of Pennsylvania, Philadelphia, PA, USA
| | | | - Edna B Foa
- University of Pennsylvania, Philadelphia, PA, USA
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Fitzgerald N, Angus K, Elders A, de Andrade M, Raistrick D, Heather N, McCambridge J. Weak evidence on nalmefene creates dilemmas for clinicians and poses questions for regulators and researchers. Addiction 2016; 111:1477-87. [PMID: 27262594 PMCID: PMC5089629 DOI: 10.1111/add.13438] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 12/15/2015] [Accepted: 04/21/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIMS Nalmefene has been approved in Europe for the treatment of alcohol dependence and subsequently recommended by the UK National Institute for Health and Care Excellence (NICE). This study examines critically the evidence base underpinning both decisions and the issues arising. METHODS Published studies of nalmefene were identified through a systematic search, with documents from the European Medicines Agency, the NICE appraisal and public clinical trial registries also examined to identify methodological issues. RESULTS Efficacy data used to support the licensing of nalmefene suffer from risk of bias due to lack of specification of a priori outcome measures and sensitivity analyses, use of post-hoc sample refinement and the use of inappropriate comparators. Despite this, evidence for the efficacy of nalmefene in reducing alcohol consumption in those with alcohol dependence is, at best, modest, and of uncertain significance to individual patients. The relevance of existing trial data to routine primary care practice is doubtful. CONCLUSIONS Problems with the registration, design, analysis and reporting of clinical trials of nalmefene did not prevent it being licensed and recommended for treating alcohol dependence. This creates dilemmas for primary care clinicians and commissioning organisations where nalmefene has been heavily promoted, and poses wider questions about the effectiveness of the medicines regulation system and how to develop the alcohol treatment evidence base.
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Affiliation(s)
- Niamh Fitzgerald
- Institute for Social Marketing, UK Centre for Tobacco Alcohol StudiesUniversity of StirlingScotlandUK
| | - Kathryn Angus
- Institute for Social Marketing, UK Centre for Tobacco Alcohol StudiesUniversity of StirlingScotlandUK
| | | | - Marisa de Andrade
- School of Health in Social ScienceUniversity of EdinburghEdinburghScotlandUK
| | | | - Nick Heather
- Department of Psychology, Faculty of Health and Life SciencesNorthumbria UniversityNewcastle upon TyneUK
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Laramée P, Millier A, Rahhali N, Cristeau O, Aballéa S, François C, Chalem Y, Toumi M, Rehm J. A Trial-Based Predictive Microsimulation Assessing the Public Health Benefits of Nalmefene and Psychosocial Support for the Reduction of Alcohol Consumption in Alcohol Dependence. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2016; 14:493-505. [PMID: 27283839 DOI: 10.1007/s40258-016-0248-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Alcohol dependence causes considerable harm to patients. Treatment with nalmefene, aiming to reduce consumption rather than maintain complete abstinence, has been licensed based on trials demonstrating a reduction in total alcohol consumption and heavy drinking days. Relating these trial outcomes to harmful events avoided is important to demonstrate the clinical relevance of nalmefene treatment. METHODS A predictive microsimulation model was developed to compare nalmefene plus brief psychosocial intervention (BRENDA) versus placebo plus BRENDA for the treatment of patients with alcohol dependence and a high or very high drinking risk level based on three pooled clinical trials. The model simulated patterns and level of alcohol consumption, day-by-day, for 12 months, to estimate the occurrence of alcohol-attributable diseases, injuries and deaths; assessing the clinical relevance of reducing alcohol consumption with treatment. RESULTS The microsimulation model predicted that, in a cohort of 100,000 patients, 971 (95 % confidence interval [CI] 904-1038) alcohol-attributable diseases and injuries and 133 (95 % CI 117-150) deaths would be avoided with nalmefene versus placebo. This level of benefit has been considered clinically relevant by the European Medicines Agency. CONCLUSIONS This microsimulation model supports the clinical relevance of the reduction in alcohol consumption, and has estimated the extent of the public health benefit of treatment with nalmefene in patients with alcohol dependence and a high or very high drinking risk level.
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Affiliation(s)
- Philippe Laramée
- Social and Epidemiological Research Department, Centre for Addiction and Mental Health, Toronto, M5S 2S1, Canada.
| | - Aurélie Millier
- Health Economics and Outcomes Research, Creativ-Ceutical, 75008, Paris, France
| | - Nora Rahhali
- Global Analytics, Lundbeck SAS, 92445, Issy-les-Moulineaux Cedex, France
| | - Olivier Cristeau
- Health Economics and Outcomes Research, Creativ-Ceutical, 75008, Paris, France
| | - Samuel Aballéa
- Health Economics and Outcomes Research, Creativ-Ceutical, 75008, Paris, France
| | - Clément François
- Global Outcomes Research, Lundbeck SAS, 92445, Issy-les-Moulineaux Cedex, France
| | - Ylana Chalem
- Global Outcomes Research, Lundbeck SAS, 92445, Issy-les-Moulineaux Cedex, France
| | - Mondher Toumi
- Laboratoire de Santé Publique, Faculté de Médecine, Université de la Méditerranée, 13385, Marseille, France
| | - Jürgen Rehm
- Social and Epidemiological Research Department, Centre for Addiction and Mental Health, Toronto, M5S 2S1, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, M5T 3M7, Canada
- Klinische Psychologie und Psychotherapie, TU Dresden, 01187, Dresden, Germany
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Laramée P, Millier A, Brodtkorb TH, Rahhali N, Cristeau O, Aballéa S, Montgomery S, Steeves S, Toumi M, Rehm J. A Comparison of Markov and Discrete-Time Microsimulation Approaches: Simulating the Avoidance of Alcohol-Attributable Harmful Events from Reduction of Alcohol Consumption Through Treatment of Alcohol Dependence. Clin Drug Investig 2016; 36:945-956. [DOI: 10.1007/s40261-016-0442-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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McLean CP, Su YJ, Foa EB. Mechanisms of symptom reduction in a combined treatment for comorbid posttraumatic stress disorder and alcohol dependence. J Consult Clin Psychol 2016; 83:655-61. [PMID: 26009787 DOI: 10.1037/ccp0000024] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To examine the mechanisms of prolonged exposure (PE) and naltrexone (NAL) that underlie symptom reduction among individuals with comorbid posttraumatic stress disorder (PTSD) and alcohol dependence (AD). We hypothesized that (a) reduction in negative cognitions mediates PTSD improvement during PE; (b) reduction in alcohol craving mediates reduction in drinking frequency during NAL treatment; and (c) PTSD improvement mediates reduction in craving and alcohol use during PE. METHOD Participants were 159 individuals meeting the DSM-IV diagnosis of PTSD and AD randomly assigned to 1 of 4 conditions: PE + NAL, PE + placebo (PBO), supportive counseling (SC) + NAL; and SC + PBO. All participants received supportive counseling. RESULTS Lagged multilevel mediational analyses indicated that (a) a reciprocal relationship between cognitive change and PTSD improvement was observed in PE + NAL, PE + PBO, and SC + NAL, but not in SC + PBO; (b) reduction in craving significantly mediated subsequent decrease in alcohol use in PE + NAL and SC + PBO, but not in PE + PBO and SC + NAL; and (c) PTSD improvement significantly mediated subsequent reduction of craving in PE + PBO, and mediated decrease in alcohol use in PE + NAL. CONCLUSIONS The efficacy of combining PE and NAL for reducing alcohol use among those with comorbid PTSD/AD seems to be through reduction in both PTSD symptoms and craving. These findings shed light on the mechanism of PE and highlight the central role of PTSD in the maintenance of alcohol craving and use in patients with comorbid PTSD/AD.
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Affiliation(s)
| | - Yi-Jen Su
- Graduate Institute of Behavioral Sciences
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Zandberg LJ, Rosenfield D, Alpert E, McLean CP, Foa EB. Predictors of dropout in concurrent treatment of posttraumatic stress disorder and alcohol dependence: Rate of improvement matters. Behav Res Ther 2016; 80:1-9. [PMID: 26972745 PMCID: PMC4828304 DOI: 10.1016/j.brat.2016.02.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 02/24/2016] [Accepted: 02/25/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The present study examined predictors and moderators of dropout among 165 adults meeting DSM-IV criteria for posttraumatic stress disorder (PTSD) and alcohol dependence (AD). Participants were randomized to 24 weeks of naltrexone (NAL), NAL and prolonged exposure (PE), pill placebo, or pill placebo and PE. All participants received supportive AD counseling (the BRENDA manualized model). METHOD Logistic regression using the Fournier approach was conducted to investigate baseline predictors of dropout across the entire study sample. Rates of PTSD and AD symptom improvement were included to evaluate the impact of symptom change on dropout. RESULTS Trauma type and rates of PTSD and AD improvement significantly predicted dropout, accounting for 76% of the variance in dropout. Accidents and "other" trauma were associated with the highest dropout, and physical assault was associated with the lowest dropout. For participants with low baseline PTSD severity, faster PTSD improvement predicted higher dropout. For those with high baseline severity, both very fast and very slow rates of PTSD improvement were associated with higher dropout. Faster rates of drinking improvement predicted higher dropout among participants who received PE. CONCLUSIONS The current study highlights the influence of symptom trajectory on dropout risk. Clinicians may improve retention in PTSD-AD treatments by monitoring symptom change at regular intervals, and eliciting patient feedback on these changes.
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Affiliation(s)
- Laurie J Zandberg
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA.
| | - David Rosenfield
- Department of Psychology, Southern Methodist University, Dallas, TX, USA
| | - Elizabeth Alpert
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Carmen P McLean
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Edna B Foa
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
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Kaczkurkin AN, Asnaani A, Alpert E, Foa EB. The impact of treatment condition and the lagged effects of PTSD symptom severity and alcohol use on changes in alcohol craving. Behav Res Ther 2016; 79:7-14. [PMID: 26905901 DOI: 10.1016/j.brat.2016.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 02/03/2016] [Accepted: 02/10/2016] [Indexed: 11/19/2022]
Abstract
Given the high rates of comorbidity between posttraumatic stress disorder (PTSD) and substance use disorder (SUD), we investigated an integrated treatment for these disorders. Individuals with comorbid PTSD and alcohol dependence were randomized to receive naltrexone or placebo, with or without prolonged exposure (PE). All participants also received BRENDA (supportive counseling). The naltrexone plus PE group showed a greater decline in alcohol craving symptoms than those in the placebo with no PE group. The PE plus placebo and the naltrexone without PE groups did not differ significantly from the placebo with no PE group in terms of alcohol craving. No treatment group differences were found for percentage of drinking days. Alcohol craving was moderated by PTSD severity, with those with higher PTSD symptoms showing faster decreases in alcohol craving. Both PTSD and alcohol use had a lagged effect on alcohol craving, with changes in PTSD symptoms and percentage of days drinking being associated with subsequent changes in craving. These results support the relationship between greater PTSD symptoms leading to greater alcohol craving and suggest that reducing PTSD symptoms may be beneficial to reducing craving in those with co-occurring PTSD/SUD.
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Affiliation(s)
| | - Anu Asnaani
- University of Pennsylvania, Philadelphia, PA 19104, USA
| | | | - Edna B Foa
- University of Pennsylvania, Philadelphia, PA 19104, USA
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Brodtkorb TH, Bell M, Irving AH, Laramée P. The Cost Effectiveness of Nalmefene for Reduction of Alcohol Consumption in Alcohol-Dependent Patients with High or Very High Drinking-Risk Levels from a UK Societal Perspective. CNS Drugs 2016; 30:163-77. [PMID: 26879458 DOI: 10.1007/s40263-016-0310-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM To evaluate costs and health outcomes of nalmefene plus psychosocial support, compared with psychosocial intervention alone, for reducing alcohol consumption in alcohol-dependent patients, specifically focusing on societal costs related to productivity losses and crime. METHODS A Markov model was constructed to model costs and health outcomes of the treatments over 5 years. Analyses were conducted for nalmefene's licensed population: adults with both alcohol dependence and high or very high drinking-risk levels (DRLs) who do not require immediate detoxification and who have high or very high DRLs after initial assessment. The main outcome measure was cost per quality-adjusted life-year (QALY) gained as assessed from a UK societal perspective. Alcohol-attributable productivity loss, crime and health events occurring at different levels of alcohol consumption were taken from published risk-relation studies. Health-related and societal costs were drawn from public data and the literature. Data on the treatment effect, as well as baseline characteristics of the modelled population and utilities, came from three pivotal phase 3 trials of nalmefene. RESULTS Nalmefene plus psychosocial support was dominant compared with psychosocial intervention alone, resulting in QALYs gained and reduced societal costs. Sensitivity analyses showed that this conclusion was robust. Nalmefene plus psychosocial support led to per-patient reduced costs of £3324 and £2483, due to reduced productivity losses and crime events, respectively. CONCLUSION Nalmefene is cost effective from a UK societal perspective, resulting in greater QALY gains and lower costs compared with psychosocial support alone. Nalmefene demonstrates considerable public benefits by reducing alcohol-attributable productivity losses and crime events in adults with both alcohol dependence and high or very high DRLs who do not require immediate detoxification and who have high or very high DRLs after initial assessment.
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Affiliation(s)
| | - Melissa Bell
- RTI Health Solutions, The Pavilion, Towers Business Park, Wilmslow Road, Didsbury, Manchester, M20 6AR, UK
| | - Adam H Irving
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, NSW, Australia
| | - Philippe Laramée
- Social and Epidemiological Research Program, Centre for Addiction and Mental Health, Toronto, M5S 2S1, Canada
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Laramée P, Bell M, Irving A, Brodtkorb TH. The Cost-Effectiveness of the Integration of Nalmefene within the UK Healthcare System Treatment Pathway for Alcohol Dependence. Alcohol Alcohol 2016; 51:283-90. [PMID: 26825639 DOI: 10.1093/alcalc/agv140] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 12/18/2015] [Indexed: 11/13/2022] Open
Abstract
AIMS To assess the cost-effectiveness of integrating nalmefene within the treatment pathway for alcohol dependence recommended by the National Institute for Health and Care Excellence in the UK. METHODS A Markov model, taking a UK NHS perspective, followed a cohort with alcohol dependence and high/very high drinking risk levels (HVHDRLs), who do not require immediate detoxification and who continue at HVHDRLs after initial assessment, for 5 years. Costs and quality-adjusted life years (QALYs) from treatment with nalmefene plus psychosocial support versus psychosocial support alone were modelled. The consequent incidence of alcohol-attributable harmful events and disease progression, with the possibility of requiring other options or recurrent treatment, were captured. RESULTS Nalmefene plus psychosocial support dominated psychosocial support alone, with lower costs and increased QALYs after 5 years. Savings are driven by the higher response to nalmefene, and the subsequent lower cost accumulation for alternatives. CONCLUSIONS Nalmefene represents a highly cost-effective treatment option in this population. The analysis shows that integrating nalmefene within the current UK clinical treatment pathway for alcohol dependence could reduce the economic burden on the NHS by limiting harmful events and disease progression.
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Affiliation(s)
- Philippe Laramée
- Social and Epidemiological Research Program, Centre for Addiction and Mental Health, Toronto, M5S 2S1, Canada
| | | | - Adam Irving
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, NSW, Australia
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Zandberg LJ, Rosenfield D, McLean CP, Powers MB, Asnaani A, Foa EB. Concurrent treatment of posttraumatic stress disorder and alcohol dependence: Predictors and moderators of outcome. J Consult Clin Psychol 2016; 84:43-56. [PMID: 26460570 PMCID: PMC4695374 DOI: 10.1037/ccp0000052] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The present study examined predictors and moderators of treatment response among 165 adults meeting Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria for comorbid posttraumatic stress disorder (PTSD) and alcohol dependence (AD), who were randomized to 24 weeks of Naltrexone (NAL), NAL and prolonged exposure (PE), pill placebo, or pill placebo and PE. All participants received supportive counseling for alcohol use. METHOD Six domains of predictors or moderators (23 variables) were evaluated using measures of PTSD (Posttraumatic Stress Symptom Scale Interview) and AD (days drinking from the timeline follow-back interview) collected every 4 weeks throughout treatment. Multilevel modeling with the Fournier approach was used to evaluate predictors and moderators of rates of symptom improvement and posttreatment outcomes. RESULTS Combat trauma, sexual assault trauma, and higher baseline anxiety sensitivity predicted slower improvement and poorer PTSD outcome. Combat trauma, White race, and higher baseline drinking severity predicted poorer drinking outcome. PTSD severity moderated the efficacy of PE on PTSD outcomes, such that the benefit of PE over no-PE was greater for participants with higher baseline PTSD severity. Baseline depressive severity moderated the efficacy of PE on drinking outcomes, whereby the benefit of PE over no-PE was greater for participants with higher depressive symptoms. NAL effects were most beneficial for those with the longest duration of AD. CONCLUSION These results suggest that concurrent, trauma-focused treatment should be recommended for PTSD-AD patients who present with moderate or severe baseline PTSD and depressive symptoms. Future research should examine the mechanisms underlying poorer outcome among identified subgroups of PTSD-AD patients.
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Affiliation(s)
| | - David Rosenfield
- Department of Psychology, Southern Methodist University, Dallas, TX
| | - Carmen P. McLean
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
| | - Mark B. Powers
- Department of Psychology, University of Texas at Austin, Austin, TX
| | - Anu Asnaani
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
| | - Edna B. Foa
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
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Roerecke M, Sørensen P, Laramée P, Rahhali N, Rehm J. Clinical relevance of nalmefene versus placebo in alcohol treatment: reduction in mortality risk. J Psychopharmacol 2015; 29:1152-8. [PMID: 26349557 PMCID: PMC4623485 DOI: 10.1177/0269881115602487] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Reduction of long-term mortality risk, an important clinical outcome for people in alcohol dependence treatment, can rarely be established in randomized controlled trials (RCTs). We calculated the reduction in all-cause mortality risk using data from short-term (6 and 12 months) double-blind RCTs comparing as-needed nalmefene treatment to placebo, and mortality risks from meta-analyses on all-cause-mortality risk by reduction of drinking in people with alcohol dependence. A reduction in drinking in the RCTs was defined by shifts in drinking risk levels established by the European Medicines Agency. Results showed that the reduction of drinking in the nalmefene group was associated with a reduction in mortality risk by 8% (95% CI: 2%, 13%) when compared to the placebo group. Sensitivity analyses confirmed a significant effect. Thus comparing the difference between nalmefene and placebo in reduction in drinking levels with results on all-cause mortality risk from meta-analyses indicated a clinically relevant reduction in mortality risk. Given the high mortality risk of people with alcohol dependence, abstinence or a reduction in drinking have been shown to reduce mortality risk and should be considered treatment goals.
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Affiliation(s)
- Michael Roerecke
- Social and Epidemiological Research Department, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada Dalla Lana School of Public Health (DLSPH), University of Toronto, Toronto, ON, Canada
| | | | - Philippe Laramée
- Lundbeck SAS, Issy-les-Moulineaux, France,Université Claude Bernard Lyon I, Villeurbanne, France
| | | | - Jürgen Rehm
- Social and Epidemiological Research Department, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada,Dalla Lana School of Public Health (DLSPH), University of Toronto, Toronto, ON, Canada,Institute of Medical Science, University of Toronto, Toronto, ON, Canada,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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François C, Rahhali N, Chalem Y, Sørensen P, Luquiens A, Aubin HJ. The Effects of as-Needed Nalmefene on Patient-Reported Outcomes and Quality of Life in Relation to a Reduction in Alcohol Consumption in Alcohol-Dependent Patients. PLoS One 2015; 10:e0129289. [PMID: 26053024 PMCID: PMC4460126 DOI: 10.1371/journal.pone.0129289] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 05/06/2015] [Indexed: 11/15/2022] Open
Abstract
Background The objective of this article was to investigate the effect of as-needed nalmefene on health-related quality of life (HRQoL) in patients with alcohol dependence, and to relate changes in drinking behavior and status to HRQoL outcomes. Methods This post hoc analysis was conducted on a pooled subgroup of patients with at least a high drinking risk level (men: >60 g/day; women: >40 g/day) who participated in one of two randomized controlled 6-month studies, ESENSE 1 and ESENSE 2. Patients received nalmefene 18 mg or placebo on an as-needed basis, in addition to a motivational and adherence-enhancing intervention (BRENDA). At baseline and after 12 and 24 weeks questionnaires for the Medical Outcomes Study (MOS) 36-item Short-Form Health Survey (SF-36), European Quality of life-5 Dimensions (EQ-5D) and the Drinker Inventory of Consequences (DrInC-2R) were completed. Results The pooled population consisted of 667 patients (nalmefene: 335; placebo: 332), with no notable between-group differences in baseline patient demographics/characteristics. At week 24, nalmefene had a superior effect compared to placebo in improving SF-36 mental component summary scores (mean difference [95% CI], p-value: 3.09 [1.29, 4.89]; p=0.0008), SF-36 physical component summary scores (1.23 [0.15, 2.31]; p=0.026), EQ-5D utility index scores (0.03 [0.00, 0.06]; p=0.045), EQ-5D health state scores (3.46 [0.75, 6.17]; p=0.012), and DrInC-2R scores (-3.22 [-6.12, 0.33]; p=0.029). The improvements in SF-36 mental component summary scores at week 24, and the DrInC-2R total score change from baseline to week 24, were significantly correlated to reductions in heavy drinking days and total alcohol consumption at week 24. Conclusions As-needed nalmefene significantly improved almost all patient-reported HRQoL measures included in SF-36 and EQ-5D compared with placebo. These HRQoL gains were significantly correlated to reduced drinking behavior, as determined by reductions in heavy drinking days and total alcohol consumption.
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Affiliation(s)
| | - Nora Rahhali
- H. Lundbeck A/S, Issy les Moulineaux Cedex, France
| | - Ylana Chalem
- H. Lundbeck A/S, Issy les Moulineaux Cedex, France
| | | | - Amandine Luquiens
- Assistance Publique-Hôpitaux de Paris, Hôpital Paul Brousse, INSERM U669, Villejuif Cedex, France
| | - Henri-Jean Aubin
- Assistance Publique-Hôpitaux de Paris, Hôpital Paul Brousse, INSERM U669, Villejuif Cedex, France
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Nuijten M, Blanken P, van den Brink W, Hendriks V. Modafinil in the treatment of crack-cocaine dependence in the Netherlands: Results of an open-label randomised controlled feasibility trial. J Psychopharmacol 2015; 29:678-87. [PMID: 25922424 DOI: 10.1177/0269881115582151] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Crack-cocaine dependence is a serious disorder with no approved pharmacological treatment. Modafinil is a promising medication with increased cocaine abstinence and reduced craving in some previous studies. In the present study, we examined the acceptance, safety and potential benefits of modafinil as an add-on treatment to cognitive behavioural therapy (CBT) in crack-cocaine dependent patients. METHODS Sixty-five crack-cocaine dependent outpatients participated in an open-label, randomised feasibility trial. Patients were randomised to receive either 12-week individual CBT plus 400 mg/day modafinil or 12-week individual CBT only. The primary outcome measure was CBT treatment retention. Secondary outcomes included modafinil adherence, tolerability and safety, use of cocaine and other substances, cocaine craving, health, social functioning and patient satisfaction. RESULTS Modafinil adherence was low, with only 10% treatment completers. Intent-to-treat analyses showed that modafinil did not improve CBT treatment retention or any of the secondary cocaine-related outcomes. Both groups showed similar, large reductions in cocaine use during the study treatment. Post hoc exploratory analyses within the CBT plus modafinil group showed significantly larger baseline to week 12 reductions in cocaine use days in high (⩾ 8 weeks) modafinil adherent patients. CONCLUSIONS Acceptance and benefits of modafinil were not demonstrated in the present study. Since reduction in cocaine use was observed in high modafinil adherent patients, further research in the treatment of cocaine dependence, in which modafinil adherence is optimised, is warranted.
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Affiliation(s)
- Mascha Nuijten
- Parnassia Addiction Research Centre (PARC, Brijder Addiction Treatment), The Hague, the Netherlands
| | - Peter Blanken
- Parnassia Addiction Research Centre (PARC, Brijder Addiction Treatment), The Hague, the Netherlands
| | - Wim van den Brink
- Amsterdam Institute for Addiction Research, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Vincent Hendriks
- Parnassia Addiction Research Centre (PARC, Brijder Addiction Treatment), The Hague, the Netherlands
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Ponizovsky AM, Rosca P, Aronovich E, Weizman A, Grinshpoon A. Baclofen as Add-On to Standard Psychosocial Treatment for Alcohol Dependence: a Randomized, Double-Blind, Placebo-Controlled Trial With 1Year Follow-Up. J Subst Abuse Treat 2015; 52:24-30. [DOI: 10.1016/j.jsat.2014.11.007] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 11/18/2014] [Accepted: 11/24/2014] [Indexed: 11/30/2022]
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Kamal RM, Schellekens A, De Jong CAJ, Dijkstra BAG. Baclofen as relapse prevention in the treatment of Gamma- Hydroxybutyrate (GHB) dependence: an open label study. BMC Psychiatry 2015; 15:91. [PMID: 25927622 PMCID: PMC4424532 DOI: 10.1186/s12888-015-0471-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 04/08/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND GHB dependence is a growing health problem in several western countries, especially the Netherlands. Attempts to stop using GHB are often followed by relapse shortly after successful detoxification. Craving for GHB use and co-morbid psychiatric symptom levels are thought to be the major factors contributing to the high relapse rates. Given its pharmacological profile, baclofen might prove an effective anti-craving agent for patients with GHB dependence. The aim of the current study is to assess the potential of baclofen as an anti-craving agent relapse prevention intervention in GHB dependent patients. METHODS/DESIGN In an open label non-randomized trial treatment with baclofen to a maximum of 60 mg/day will be compared with treatment as usual (TAU) in recently detoxified GHB dependent patients (n = 80). The primary outcome measure will be the level of GHB use. Secondary outcome measures are craving levels, psychiatric symptom levels and quality of life. Questionnaires will be administered during 12 weeks of baclofen treatment and at follow-up (six months after the start of treatment). DISCUSSION It is hypothesized that baclofen treatment compared to TAU will be associated with significantly reduced GHB use. In addition, we hypothesize that baclofen treatment will be associated with decreased craving and anxiety levels, and higher quality of life. If results are in line with our hypotheses, further studies on the efficacy of baclofen using placebo controlled designs and long term follow-up are warranted. TRIAL REGISTRATION The Netherlands Trial Register with number NTR4528 . Registered 19 April 2014.
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Affiliation(s)
- Rama M Kamal
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Hogedwarsstraat 3, PO Box 243, Vught, 5260 AE, the Netherlands. .,Novadic-Kentron Addiction Care network, Vught, the Netherlands.
| | - Arnt Schellekens
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Hogedwarsstraat 3, PO Box 243, Vught, 5260 AE, the Netherlands.
| | - Cornelis AJ De Jong
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Hogedwarsstraat 3, PO Box 243, Vught, 5260 AE the Netherlands
| | - Boukje AG Dijkstra
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Hogedwarsstraat 3, PO Box 243, Vught, 5260 AE the Netherlands
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van den Brink W, Strang J, Gual A, Sørensen P, Jensen TJ, Mann K. Safety and tolerability of as-needed nalmefene in the treatment of alcohol dependence: results from the Phase III clinical programme. Expert Opin Drug Saf 2015; 14:495-504. [PMID: 25652768 DOI: 10.1517/14740338.2015.1011619] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To investigate safety and tolerability of nalmefene for reduction of alcohol consumption in alcohol-dependent patients. METHODS Pooled data from three randomized, placebo-controlled studies (two 6-month; one 12-month) of 18 mg nalmefene (as-needed use) in alcohol-dependent patients looking at the total population (placebo n = 824, nalmefene n = 1123) and patients with high/very high drinking risk levels at screening and randomization (target population: placebo n = 374, nalmefene n = 450). RESULTS In the study, 62.7% of patients on placebo and 74.7% on nalmefene in the total population had treatment-emergent adverse events (TEAEs). Fourty-seven (5.9%) on placebo and 149 (13.0%) on nalmefene dropped out due to TEAEs. Thirty-five (4.4%) on placebo and 57 (5.0%) on nalmefene had serious adverse events. Tolerability and safety were similar in the target population and total population. Most frequent TEAEs were transient, mainly occurring at treatment initiation. There was no difference in tolerability and safety if nalmefene was taken daily or intermittently; no signal of increased risk of suicide-related behavior with nalmefene. The higher incidence of psychiatric events in the nalmefene group was mainly due to the TEAE of confusional state. CONCLUSIONS Although there was a higher incidence of TEAEs and TEAEs leading to dropout, nalmefene was well-tolerated and no major safety issues were identified.
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Affiliation(s)
- Wim van den Brink
- University of Amsterdam, Academic Medical Center, Psychiatry , Meibergdreef 5, Gerrit vd Veenstraat 84-hs, Amsterdam, 1077el , Netherlands
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Aubin HJ, Reimer J, Nutt DJ, Bladström A, Torup L, François C, Chick J. Clinical relevance of as-needed treatment with nalmefene in alcohol-dependent patients. Eur Addict Res 2015; 21:160-168. [PMID: 25832297 DOI: 10.1159/000371547] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 12/13/2014] [Indexed: 11/19/2022]
Abstract
Nalmefene is the first drug approved for reduction of alcohol consumption. The aim of this study was to evaluate the clinical relevance of treatment with nalmefene in alcohol-dependent patients with a high drinking risk level from two randomised placebo-controlled 6-month studies (NCT00811720 and NCT00812461). Response criteria were based on alcohol consumption, Clinical Global Impression, and Short Form Health Survey mental component summary scores at month 6, analysed using logistic regression. The proportion of responders was higher in the nalmefene group than in the placebo group with odds ratios significantly in favour of nalmefene for all responder criteria; numbers-needed-to-treat ranged from 6 to 10. Significant differences from placebo in clinician-rated and patient-reported outcomes, and liver enzymes further supported the clinical relevance of the treatment effect. In conclusion, this study supports the clinical relevance of nalmefene treatment in patients with alcohol dependence. Nalmefene may help to reduce the alcohol-related burden and the large treatment gap, with currently less than 10% of alcohol-dependent patients in Europe receiving treatment.
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Bendimerad P, Blecha L. [Benefits in reducing alcohol consumption: how nalmefene can help]. Encephale 2014; 40:495-500. [PMID: 25454365 DOI: 10.1016/j.encep.2014.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 10/13/2014] [Indexed: 02/04/2023]
Abstract
Alcohol consumption represents a significant factor for mortality in the world: 6.3% in men and 1.1% in women. Alcohol use disorder is also very common: 5.4% in men, 1.5% in women. Despite its high frequency and the seriousness of this disorder, only 8% of all alcohol-dependents are ever treated. Recent meta-analyses have shown that if we can increase current figures by 40%, we could decrease alcohol-related morality rates by 13% in men and 9% in women. Thus, it is important to motivate both physicians and patients to participate in treatment in alcohol use disorder. Recent epidemiological data from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) are currently challenging the notion of alcohol use disorder as a fixed entity. Among a cohort of 4422 subjects initially diagnosed as having alcohol dependency, only 25% of these could still be diagnosed as alcohol-dependent one year later. Among the others, 27% were in partial remission, 12% had risk use, 18% low risk use and 18% were abstinent. Stable remission rates were observed in 30% of these subjects at 5 years. This study also argues in favour of the newer dimensional approach elaborated in the DSM 5. One potentially interesting treatment option is oriented toward reducing alcohol intake. In a study by Rehm and Roerecke (2013), they modelled the impact of reduced consumption in a typical alcoholic patient who drinks 8 glasses of alcohol per day (92 g of pure alcohol). If he decreases his alcohol intake by just one glass per day (12 g of alcohol per day), his one-year mortality risk falls from 180/100,000 to 120/100,000; if he decreases his intake by two glasses per day (24 g), this risk falls to 95/100,000, roughly half his baseline risk. These observations have resulted in integrating reduced consumption as an option into the treatment guidelines of several national institutions such as the National Institute for Clinical Excellence (NICE, UK), European Medicines Agency, as well as the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Decreasing stigmatisation of alcohol use disorder through public service announcements, in addition to more flexible physician attitudes concerning personal alcohol intake objectives may be key in getting increased numbers of patients into treatment programmes. In one study in Great Britain, 50% of patients in treatment for alcohol use disorder would prefer an initial objective of reduced consumption. A recent addition to the pharmacotherapy arsenal is nalmefene, which has been recently released as a medication to aid in reducing alcohol consumption. It is a strong μ and δ opioid receptor antagonist and a partial κ opioid receptor agonist. Opioid receptor antagonism is associated with reduced reward in relation to alcohol use, thus helping patients in reducing their consumption. Patients are instructed to take one nalmefene tablet two hours prior to each drinking occasion. Nalmefene therapy is to be accompanied by a specific psychosocial programme called BRENDA. BRENDA consists of a biopsychosocial evaluation, restitution of the evaluation to the patient, an empathetic approach that responds to patient needs, offering direct advice and adjusting goals and treatment programmes as the patient makes progress. Nalmefene has been associated with decreased heavy drinking days in two clinical trials. Overall, the treatment is well tolerated; adverse effects are fairly mild and short-lived. In conclusion, an approach that integrates reduced alcohol consumption makes sense from both a public and personal standpoint. Medications such as nalmefene have shown efficacy in association with a biopsychosocial approach to help patients attain their personal objectives with respect to alcohol use.
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Affiliation(s)
- P Bendimerad
- Groupe hospitalier La Rochelle Ré Aunis, 208, rue Marius-Lacroix, 17000 La Rochelle, France.
| | - L Blecha
- Centre enseignement recherche traitement des addictions, pôle neurosciences, tête et cou, hôpitaux universitaires Paris-Sud, AP-HP, avenue Paul-Vaillant-Couturier, 94800 Villejuif, France
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Laramée P, Brodtkorb TH, Rahhali N, Knight C, Barbosa C, François C, Toumi M, Daeppen JB, Rehm J. The cost-effectiveness and public health benefit of nalmefene added to psychosocial support for the reduction of alcohol consumption in alcohol-dependent patients with high/very high drinking risk levels: a Markov model. BMJ Open 2014; 4:e005376. [PMID: 25227627 PMCID: PMC4166142 DOI: 10.1136/bmjopen-2014-005376] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 08/14/2014] [Accepted: 08/18/2014] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To determine whether nalmefene combined with psychosocial support is cost-effective compared with psychosocial support alone for reducing alcohol consumption in alcohol-dependent patients with high/very high drinking risk levels (DRLs) as defined by the WHO, and to evaluate the public health benefit of reducing harmful alcohol-attributable diseases, injuries and deaths. DESIGN Decision modelling using Markov chains compared costs and effects over 5 years. SETTING The analysis was from the perspective of the National Health Service (NHS) in England and Wales. PARTICIPANTS The model considered the licensed population for nalmefene, specifically adults with both alcohol dependence and high/very high DRLs, who do not require immediate detoxification and who continue to have high/very high DRLs after initial assessment. DATA SOURCES We modelled treatment effect using data from three clinical trials for nalmefene (ESENSE 1 (NCT00811720), ESENSE 2 (NCT00812461) and SENSE (NCT00811941)). Baseline characteristics of the model population, treatment resource utilisation and utilities were from these trials. We estimated the number of alcohol-attributable events occurring at different levels of alcohol consumption based on published epidemiological risk-relation studies. Health-related costs were from UK sources. MAIN OUTCOME MEASURES We measured incremental cost per quality-adjusted life year (QALY) gained and number of alcohol-attributable harmful events avoided. RESULTS Nalmefene in combination with psychosocial support had an incremental cost-effectiveness ratio (ICER) of £5204 per QALY gained, and was therefore cost-effective at the £20,000 per QALY gained decision threshold. Sensitivity analyses showed that the conclusion was robust. Nalmefene plus psychosocial support led to the avoidance of 7179 alcohol-attributable diseases/injuries and 309 deaths per 100,000 patients compared to psychosocial support alone over the course of 5 years. CONCLUSIONS Nalmefene can be seen as a cost-effective treatment for alcohol dependence, with substantial public health benefits. TRIAL REGISTRATION NUMBERS This cost-effectiveness analysis was developed based on data from three randomised clinical trials: ESENSE 1 (NCT00811720), ESENSE 2 (NCT00812461) and SENSE (NCT00811941).
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Affiliation(s)
- Philippe Laramée
- Université Claude Bernard Lyon I, Villeurbanne, France Lundbeck S.A.S., Issy-les-Moulineaux Cedex, France
| | | | - Nora Rahhali
- Lundbeck S.A.S., Issy-les-Moulineaux Cedex, France
| | - Chris Knight
- BresMed Health Solutions, Sheffield, South Yorkshire, UK
| | - Carolina Barbosa
- Behavioral Health Economics Program, RTI International, Chicago,Illinois, USA
| | | | - Mondher Toumi
- Université Claude Bernard Lyon I, Villeurbanne, France
| | - Jean-Bernard Daeppen
- Alcohol Treatment Centre, Lausanne University Hospital/CHUV, Lausanne, Switzerland
| | - Jürgen Rehm
- Social and Epidemiological Research Department, Centre for Addiction and Mental Health, Toronto, Canada Dalla Lana School of Public Health, University of Toronto, Canada Klinische Psychologie und Psychotherapie, TU Dresden, Germany
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Abstract
Reduction of alcohol consumption is not yet a widely accepted treatment objective for alcohol-dependent patients, as abstinence is often considered to be the only possible objective in this situation. However, various studies have demonstrated the value of proposing these two options to such patients. Firstly, reduction of alcohol consumption very significantly reduces the risk of alcohol-related damage, and also modifies the patient’s and the doctor’s perception of the disease, resulting in improved access to care and better patient adherence with the proposed treatment objective and consequently better clinical results. Recent studies have shown that some medicinal products can help patients reduce their alcohol consumption. One such product, nalmefene, has been granted European marketing authorization and is now being released onto the market in various countries. The ESENSE 1 and 2 studies in alcohol-dependent patients showed that, in combination with BRENDA, a psychosocial intervention focusing on reinforcement of motivation and treatment adherence, nalmefene significantly reduced the number of heavy drinking days and mean daily total alcohol consumption versus placebo. This reduction was more marked in the marketing authorization target population, ie, patients with a high or very high drinking risk level according to World Health Organization criteria. Another original feature of this molecule is that it can be used as needed if the patient perceives a risk of drinking, which is a more flexible approach and more likely to ensure the patient’s active involvement in the treatment of his/her disease. This molecule opens up interesting and original therapeutic prospects in the treatment of alcohol dependence.
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Affiliation(s)
- François Paille
- Department of Addiction Treatment, University Hospital, Vandoeuvre-lès-Nancy, France
| | - Hervé Martini
- Department of Addiction Treatment, University Hospital, Vandoeuvre-lès-Nancy, France
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van den Brink W, Sørensen P, Torup L, Mann K, Gual A. Long-term efficacy, tolerability and safety of nalmefene as-needed in patients with alcohol dependence: A 1-year, randomised controlled study. J Psychopharmacol 2014; 28:733-44. [PMID: 24671340 DOI: 10.1177/0269881114527362] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study evaluated the long-term efficacy and safety of nalmefene treatment in reducing alcohol consumption. We randomised (1:3) 675 alcohol-dependent patients ≥ 18 years of age to 52 weeks of as-needed treatment with placebo or nalmefene 18 mg/day: A total of 112 patients (68%) in the placebo group and 310 (62%) in the nalmefene group completed the study. At month 6, the co-primary outcome variables showed no statistically-significant differences between the treatment groups; but at month 13, nalmefene was more effective than placebo, both in the reduction of the number of heavy drinking days (HDDs) (- 1.6 days/month (95% CI - 2.9; - 0.3); p = 0.017) and the reduction of total alcohol consumption (TAC) (- 6.5 g/day last month (95% CI - 12.5; - 0.4); p = 0.036). In a subgroup analysis of patients with high/very high drinking risk levels at screening and at randomisation (the target population), there was a significant effect in favour of nalmefene on TAC at month 6, and on both HDD and TAC at month 13. Improvements in Clinical Global Impression and liver enzymes were greater with nalmefene, compared to placebo. Most adverse events were mild or moderate, and transient; adverse events, including those leading to dropout, were more common with nalmefene. This study provides evidence for the long-term safety and efficacy of nalmefene as-needed in alcohol-dependent patients whom continue to drink heavily, following a brief intervention.
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Affiliation(s)
- Wim van den Brink
- Department of Psychiatry, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Karl Mann
- Central Institute of Mental Health, University of Heidelberg, Mannheim, Germany
| | - Antoni Gual
- Neurosciences Institute, Hospital Clinic, Barcelona, Spain
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Collins SE, Saxon AJ, Duncan MH, Smart BF, Merrill JO, Malone DK, Jackson TR, Clifasefi SL, Joesch J, Ries RK. Harm reduction with pharmacotherapy for homeless people with alcohol dependence: protocol for a randomized controlled trial. Contemp Clin Trials 2014; 38:221-34. [PMID: 24846619 PMCID: PMC4104260 DOI: 10.1016/j.cct.2014.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 05/05/2014] [Accepted: 05/10/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Interventions requiring abstinence from alcohol are neither preferred by nor shown to be highly effective with many homeless individuals with alcohol dependence. It is therefore important to develop lower-threshold, patient-centered interventions for this multimorbid and high-utilizing population. Harm-reduction counseling requires neither abstinence nor use reduction and pairs a compassionate style with patient-driven goal-setting. Extended-release naltrexone (XR-NTX), a monthly injectable formulation of an opioid receptor antagonist, reduces craving and may support achievement of harm-reduction goals. Together, harm-reduction counseling and XR-NTX may support alcohol harm reduction and quality-of-life improvement. AIMS Study aims include testing: a) the relative efficacy of XR-NTX and harm-reduction counseling compared to a community-based, supportive-services-as-usual control, b) theory-based mediators of treatment effects, and c) treatment effects on publicly funded service costs. METHODS This RCT involves four arms: a) XR-NTX+harm-reduction counseling, b) placebo+harm-reduction counseling, c) harm-reduction counseling only, and d) community-based, supportive-services-as-usual control conditions. Participants are currently/formerly homeless, alcohol dependent individuals (N=300). Outcomes include alcohol variables (i.e., craving, quantity/frequency, problems and biomarkers), health-related quality of life, and publicly funded service utilization and associated costs. Mediators include 10-point motivation rulers and the Penn Alcohol Craving Scale. XR-NTX and harm-reduction counseling are administered every 4weeks over the 12-week treatment course. Follow-up assessments are conducted at weeks 24 and 36. DISCUSSION If found efficacious, XR-NTX and harm-reduction counseling will be well-positioned to support reductions in alcohol-related harm, decreases in costs associated with publicly funded service utilization, and increases in quality of life among homeless, alcohol-dependent individuals.
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Affiliation(s)
- Susan E Collins
- Department of Psychiatry and Behavioral Sciences, University of Washington - Harborview Medical Center, 325 Ninth Ave Box 359911, Seattle, WA 98195, USA.
| | - Andrew J Saxon
- VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, USA; Department of Psychiatry and Behavioral Sciences, University of Washington, 1100 45th St. Box 354944, Seattle, WA 98195, USA.
| | - Mark H Duncan
- Department of Psychiatry and Behavioral Sciences, University of Washington - Harborview Medical Center, 325 Ninth Ave Box 359911, Seattle, WA 98195, USA.
| | - Brian F Smart
- Department of Psychiatry and Behavioral Sciences, University of Washington - Harborview Medical Center, 325 Ninth Ave Box 359911, Seattle, WA 98195, USA.
| | - Joseph O Merrill
- Department of Medicine, University of Washington - Harborview Medical Center, 325 Ninth Ave, Box 359780, Seattle, WA 98195, USA.
| | - Daniel K Malone
- Downtown Emergency Service Center (DESC), 515 Third Ave, Seattle, WA 98104, USA.
| | - T Ron Jackson
- Evergreen Treatment Services - REACH, 1700 Airport Way S, Seattle, WA 98134, USA.
| | - Seema L Clifasefi
- Department of Psychiatry and Behavioral Sciences, University of Washington, 1100 45th St. Box 354944, Seattle, WA 98195, USA.
| | - Jutta Joesch
- Department of Psychiatry and Behavioral Sciences, University of Washington - Harborview Medical Center, 325 Ninth Ave Box 359911, Seattle, WA 98195, USA.
| | - Richard K Ries
- Department of Psychiatry and Behavioral Sciences, University of Washington - Harborview Medical Center, 325 Ninth Ave Box 359911, Seattle, WA 98195, USA.
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Abstract
The burden of morbidity and mortality resulting from alcohol dependence is high. World Health Organization (WHO) figures suggest that in the UK the prevalence of alcohol use disorders in those aged 15 years and older is around 6.4% for men and 1.5% for women.1 Reduction of harm resulting from alcohol dependence remains a high priority in all four devolved health services in the UK.2-5 Several medicines are licensed for the maintenance of abstinence in alcohol-dependent patients. However, until recently no drug was licensed for the management of alcohol dependence in people who are still drinking. ▼Nalmefene (Selincro, Lundbeck), an opioid modulator licensed for the reduction of alcohol consumption, was launched in the UK in May 2013.6,7 Here we discuss the evidence for its effectiveness and safety and consider its place in therapy.
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Abstract
The role of the brain opioid system in alcohol dependence has been the subject of much research for over 25 years. This review explores the evidence: firstly describing the opioid receptors in terms of their individual subtypes, neuroanatomy, neurophysiology and ligands; secondly, summarising emerging data from specific neurochemical, behavioural and neuroimaging studies, explaining the characteristics of addiction with a focus on alcohol dependence and connecting the opioid system with alcohol dependence; and finally reviewing the known literature regarding opioid antagonists in clinical use for alcohol dependence. Further interrogation of how modulation of the opioid system, via use of MOP (mu), DOP (delta) and KOP (kappa) agents, restores the balance of a dysregulated system in alcohol dependence should increase our insight into this disease process and therefore guide better methods for understanding and treating alcohol dependence in the future.
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Sinclair J, Chick J, Sørensen P, Kiefer F, Batel P, Gual A. Can alcohol dependent patients adhere to an 'as-needed' medication regimen? Eur Addict Res 2014; 20:209-17. [PMID: 24557083 DOI: 10.1159/000357865] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 12/10/2013] [Indexed: 11/19/2022]
Abstract
A pooled analysis of 'as-needed medication use' data from 1,276 patients in two randomised, double-blind, placebo-controlled, parallel-group trials of nalmefene in the treatment of alcohol dependence was performed to explore whether an 'as-needed' regimen is an acceptable and feasible strategy in patients seeking help for alcohol dependence. Adherence was defined as alcohol consumption and medication intake, or no alcohol consumption (with or without medication intake). Nalmefene was taken on approximately half of the study days; placebo was taken more often than nalmefene (52.8 vs. 64.5% of days, respectively). In each treatment group medication intake appeared to vary according to patients' needs in that intake correlated with the baseline drinking pattern. Sixty-eight percent of the nalmefene-treated patients (78% of the study completers) adhered to the as-needed treatment regimen on at least 80% of the study days. In conclusion, as-needed use is a feasible, patient-centred approach that engages patients with alcohol dependence in the active management of their illness.
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Affiliation(s)
- Julia Sinclair
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
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A randomised, double-blind, placebo-controlled, efficacy study of nalmefene, as-needed use, in patients with alcohol dependence. Eur Neuropsychopharmacol 2013; 23:1432-42. [PMID: 23562264 DOI: 10.1016/j.euroneuro.2013.02.006] [Citation(s) in RCA: 144] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Revised: 01/17/2013] [Accepted: 02/28/2013] [Indexed: 12/18/2022]
Abstract
This study evaluated the efficacy of as-needed use of the opioid system modulator nalmefene in reducing alcohol consumption in patients with alcohol dependence. Seven hundred and eighteen patients (placebo=360; nalmefene=358), ≥ 18 years of age, with a diagnosis of alcohol dependence, ≥ 6 heavy drinking days and an average alcohol consumption ≥ WHO medium drinking risk level in the 4 weeks preceding screening, were randomised (1:1) to 24 weeks of as-needed placebo or nalmefene 18 mg/day. The co- primary efficacy analyses showed a significantly superior effect of nalmefene compared to placebo in the change from baseline to month 6 in heavy drinking days (group difference: -1.7 days/month [95% CI -3.1; -0.4]; p=0.012) and a better but not significant effect in reducing total alcohol consumption (group difference: -5.0 g/day last month [95% CI -10.6; 0.7]; p=0.088). A subgroup analysis showed that patients who did not reduce their drinking prior to randomisation benefitted more from nalmefene. Improvements in Clinical Global Impression and reductions in liver enzymes were greater in the nalmefene group than in the placebo group. Adverse events were more common with nalmefene; the incidence of adverse events leading to dropout was similar in both groups. This study provides evidence for the efficacy of nalmefene, which constitutes a new pharmacological treatment paradigm in terms of treatment goal (reduced drinking) and dosing regimen (as-needed), in alcohol dependent patients unable to reduce alcohol consumption on their own.
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49
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Abstract
In 1994, the US Food and Drug Administration approved the μ-opioid receptor antagonist naltrexone to treat alcohol dependence. However, treatments requiring daily administration, such as naltrexone, are inconsistently adhered to in substance abusing populations, and constant medication exposure can increase risk of adverse outcomes, e.g., hepatotoxicity. This has fostered a 'targeted' or 'as needed' approach to opioid receptor antagonist treatment, in which medications are used only in anticipation of or during high-risk situations, including times of intense cravings. Initial studies of the ability of targeted naltrexone to reduce drinking-related outcomes were conducted in problem drinkers and have been extended into larger, multi-site, placebo-controlled investigations with positive results. Another μ-opioid receptor antagonist, nalmefene, has been studied on an 'as-needed' basis to reduce heavy drinking in alcohol-dependent individuals. These studies include three large multi-site trials in Europe of up to 1 year in duration, and serve as the basis for the recent approval of nalmefene by the European Medicines Agency as an 'as-needed' adjunctive treatment for alcohol dependence. We review potential moderators of opioid receptor antagonist treatment response including subjective assessments, objective clinical measures and genetic variants. In sum, the targeted or 'as-needed' approach to treatment with opioid antagonists is an efficacious harm-reduction strategy for problem drinking and alcohol dependence.
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van den Brink W, Aubin HJ, Bladström A, Torup L, Gual A, Mann K. Efficacy of as-needed nalmefene in alcohol-dependent patients with at least a high drinking risk level: results from a subgroup analysis of two randomized controlled 6-month studies. Alcohol Alcohol 2013; 48:570-8. [PMID: 23873853 PMCID: PMC3746807 DOI: 10.1093/alcalc/agt061] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 06/05/2013] [Accepted: 06/06/2013] [Indexed: 12/20/2022] Open
Abstract
AIMS The aim of the study was to investigate the efficacy and safety of as-needed use of nalmefene 18 mg versus placebo in reducing alcohol consumption in patients who did not reduce their alcohol consumption after an initial assessment, i.e. the pooled subgroup of patients with at least a high drinking risk level (men: >60 g/day; women: >40 g/day) at both screening and randomization from the two randomized controlled 6-month studies ESENSE 1 (NCT00811720) and ESENSE 2 (NCT00812461). METHODS Nalmefene 18 mg and placebo were taken on an as-needed basis. All the patients also received a motivational and adherence-enhancing intervention (BRENDA). The co-primary outcomes were number of heavy drinking days (HDDs) and mean total alcohol consumption (g/day) in Month 6 measured using the Timeline Follow-back method. Additionally, data on clinical improvement, liver function and safety were collected throughout the study. RESULTS The pooled population consisted of 667 patients: placebo n = 332; nalmefene n = 335. There was a superior effect of nalmefene compared with placebo in reducing the number of HDDs [treatment difference: -3.2 days (95% CI: -4.8; -1.6); P < 0.0001] and total alcohol consumption [treatment difference: -14.3 g/day (-20.8; -7.8); P < 0.0001] at Month 6. Improvements in clinical status and liver parameters were greater in the nalmefene group compared with the placebo group. Adverse events and adverse events leading to dropout were more common with nalmefene than placebo. CONCLUSION As-needed nalmefene was efficacious in reducing alcohol consumption in patients with at least a high drinking risk level at both screening and randomization, and the effect in this subgroup was larger than in the total population.
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Affiliation(s)
- Wim van den Brink
- Department of Psychiatry, Amsterdam Institute for Addiction Research, University of Amsterdam, Amsterdam, The Netherlands.
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