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Hopf FW. Nucleus accumbens shell cholinergic interneurons potently drive binge alcohol drinking: A commentary on Sharma et al., 2024. ALCOHOL, CLINICAL & EXPERIMENTAL RESEARCH 2024. [PMID: 38811254 DOI: 10.1111/acer.15339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/15/2024] [Accepted: 04/16/2024] [Indexed: 05/31/2024]
Affiliation(s)
- Frederic Woodward Hopf
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Stark Neurosciences Research Institute, Indiana University, Indianapolis, Indiana, USA
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2
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Köhne S, Hillemacher T, Glahn A, Bach P. Emerging drugs in phase II and III clinical development for the treatment of alcohol use disorder. Expert Opin Emerg Drugs 2024:1-14. [PMID: 38606899 DOI: 10.1080/14728214.2024.2342951] [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: 12/15/2023] [Accepted: 04/10/2024] [Indexed: 04/13/2024]
Abstract
INTRODUCTION Alcohol Use Disorder (AUD) poses an ongoing significant global health burden. AUD is highly prevalent and affects not only the individuals with AUD, but also their communities and society at large. Even though pharmacotherapy is an integral part of AUD treatment, the few available substances show limited efficacy and limited clinical impact. Thus, there is a need for new innovative pharmacotherapeutic approaches. AREAS COVERED This paper provides a comprehensive review of drugs approved for the treatment of AUD as well as those currently in phase II and III development. Data from recent clinical trials has been reviewed and supplemented by additional literature based on a systematic search of the PubMed database and clinical trials registries. Compounds discussed include disulfiram, naltrexone, nalmefene, acamprosat, baclofen, sodium oxybate, doxazosin, varenicline, zonisamide, gabapentin, apremilast, ibudilast, ivermectin, tolcapone, mifepristone, suvorexant, ketamine, psilocybin, semaglutide, oxytocin and cannabidiol. EXPERT OPINION Even though the majority of the discussed compounds lack sufficient evidence to support their efficacy, multiple promising new treatment options are currently under investigation. Future research has to consider specific phenotypes and subgroups of AUD as well as a possible enhancement of the effects of psychotherapy through combination with pharmacotherapy. Practitioners should be encouraged to use available compounds to support existing therapeutic regimens.
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Affiliation(s)
- Sophie Köhne
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Medical School Hannover, Hannover, Germany
| | - Thomas Hillemacher
- Department of Psychiatry and Psychotherapy, Paracelsus Medical University Nuremberg, Nürnberg, Germany
| | - Alexander Glahn
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Medical School Hannover, Hannover, Germany
| | - Patrick Bach
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health, Medical Faculty Mannheim. Heidelberg University, Heidelberg, Germany
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Guiraud J, Spanagel R, van den Brink W. Substitution therapy for patients with alcohol dependence: Mechanisms of action and efficacy. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2024; 175:187-239. [PMID: 38555116 DOI: 10.1016/bs.irn.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
New approaches for the treatment of alcohol dependence (AD) may improve patient outcomes. Substitution maintenance therapy is one of the most effective treatment options for opioid and nicotine use disorders. So far, there has been little attention to substitution therapy for the treatment of AD. Here, we explain the mechanistic foundations of alcohol substitution maintenance therapy. Alcohol has many primary targets in the brain (and other organs) and the physical interaction of ethanol molecules with these specific ethanol-sensitive sites on a variety of ionotropic receptors (e.g. GABA-A, NMDA, and nicotinic acetylcholine (nACh) receptors) and ion channels provides the rationale for substitution. As such, a variety of compounds can interact with those ethanol-sensitive sites and can thus substitute for some of the effects of alcohol. For some of these compounds, alcohol discrimination studies have shown their substitution potential. Accordingly, potential substitution treatments include agonists acting at GABA receptors such as sodium oxybate, baclofen and benzodiazepines, NMDA receptor antagonists such as ketamine and memantine, or nAChRs agonists such as varenicline. All these compounds are already approved for other indications and we present clinical evidence for these drugs in the treatment of alcohol withdrawal syndrome (AWS) and in the long-term treatment of AD, and outline future steps for their acceptance as substitution treatment in AD. Finally, we discuss the substitution approach of managed alcohol programs for the most severely affected homeless populations. Results showed that sodium oxybate is probably the closest to a substitution therapy for AD and is already approved for the treatment of AWS and in the long-term treatment of AD in some countries. In conclusion, we argue that better AD treatment can be provided if substitution maintenance treatments for alcohol are implemented at a similar scale as for opioid and nicotine use disorder.
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Affiliation(s)
- Julien Guiraud
- Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Amsterdam, The Netherlands; Vergio, Clichy, France.
| | - Rainer Spanagel
- Institute of Psychopharmacology, Central Institute of Mental Health, Heidelberg University, Mannheim, Germany
| | - Wim van den Brink
- Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Amsterdam, The Netherlands
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Aubin HJ. Repurposing drugs for treatment of alcohol use disorder. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2024; 175:153-185. [PMID: 38555115 DOI: 10.1016/bs.irn.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Repurposing drugs for the treatment of alcohol dependence involves the use of drugs that were initially developed for other conditions, but have shown promise in reducing alcohol use or preventing relapse. This approach can offer a more cost-effective and time-efficient alternative to developing new drugs from scratch. Currently approved medications for alcohol use disorder (AUD) include acamprosate, disulfiram, naltrexone, nalmefene, baclofen, and sodium oxybate. Acamprosate was developed specifically for AUD, while disulfiram's alcohol-deterrent effects were discovered incidentally. Naltrexone and nalmefene were originally approved for opioids but found secondary applications in AUD. Baclofen and sodium oxybate were repurposed from neurological conditions. Other drugs show promise. Topiramate and zonisamide, anticonvulsants, demonstrate efficacy in reducing alcohol consumption. Another anticonvulsant, gabapentin has been disappointing overall, except in cases involving alcohol withdrawal symptoms. Varenicline, a nicotinic receptor agonist, benefits individuals with less severe AUD or concurrent nicotine use. Ondansetron, a 5-HT3 antagonist, has potential for early-onset AUD, especially when combined with naltrexone. Antipsychotic drugs like aripiprazole and quetiapine have limited efficacy. Further investigation is needed for potential repurposing of α1 adrenergic receptor antagonists prazosin and doxazosin, glucocorticoid receptor antagonist mifepristone, the phosphodiesterase inhibitor Ibudilast, the cysteine prodrug N-acetylcysteine, and the OX1R and OX2R blocker Suvorexant. This review supports repurposing drugs as an effective strategy for expanding treatment options for AUD.
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Affiliation(s)
- Henri-Jean Aubin
- Université Paris-Saclay, Inserm, CESP, Villejuif, France; AP-HP, Université Paris Saclay, Villejuif, France.
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Donato S, Ray LA. Neurobiology and the Treatment of Alcohol Use Disorder: A Review of the Evidence Base. Subst Abuse Rehabil 2023; 14:157-166. [PMID: 38026786 PMCID: PMC10657770 DOI: 10.2147/sar.s409943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Alcohol use disorder (AUD) is a significant public health concern, accounting for a majority of substance use disorder cases in the United States. Treatment for AUD is complex, with multiple intervention points that may be further complicated by genotype and phenotype, resulting in diverse outcomes. In order to better understand the current landscape of AUD treatment, the present review considers different etiological models of AUD and assesses the evidence base of current treatment options. The first section of this review summarizes various etiological models of AUD and presents different approaches to classifying the disorder. Various theories, including neurobiological models, are discussed. The second section presents a comprehensive analysis of available treatment options for AUD, encompassing behavioral and pharmacological interventions and their current evidence base. Finally, this review discusses the ongoing treatment gap and significant factors contributing to low treatment utilization. Together, this review provides an overview of different etiological processes and mechanisms of AUD, as well as summarizes the literature on key treatment approaches. By integrating historical, theoretical, and empirical data, this review aims to inform both researchers and providers with valuable insights to advance AUD treatment approaches and narrow the treatment gap.
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Affiliation(s)
- Suzanna Donato
- Department of Psychology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Lara A Ray
- Department of Psychology, University of California, Los Angeles, Los Angeles, CA, USA
- Brain Research Institute, University of California, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA
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Kranzler HR, Hartwell EE. Medications for treating alcohol use disorder: A narrative review. ALCOHOL, CLINICAL & EXPERIMENTAL RESEARCH 2023; 47:1224-1237. [PMID: 37526592 DOI: 10.1111/acer.15118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/01/2023] [Accepted: 05/12/2023] [Indexed: 08/02/2023]
Abstract
Chronic heavy alcohol use impacts all major neurotransmitter systems and is associated with multiple medical, psychiatric, and social problems. Available evidence-based medications to treat alcohol use disorder (AUD) are underutilized in clinical practice. These medications promote abstinence or reduce alcohol consumption, though there are questions regarding their optimal dosage, length of treatment, and utility in combination with one another. Pharmacogenetic approaches, which use a patient's genetic make-up to inform medication selection, have garnered great interest but have yet to yield results robust enough to incorporate them in routine clinical care. This narrative review summarizes the evidence both for medications approved by the Food and Drug Administration (disulfiram, oral naltrexone, acamprosate, and extended-release naltrexone) and those commonly used off-label (e.g., gabapentin, baclofen, and topiramate) for AUD treatment. We discuss these drugs' mechanisms of action, clinical use, pharmacogenetic findings, and treatment recommendations. We conclude that the most consistent evidence supporting the pharmacotherapy of AUD is for the opioid antagonists, naltrexone and nalmefene (which is not approved in the United States), and topiramate. These medications demonstrate consistent small or moderate effects in reducing the frequency of drinking and/or heavy drinking. Lastly, we make suggestions for research needed to refine and expand the current literature on effective pharmacotherapy for AUD.
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Affiliation(s)
- Henry R Kranzler
- Department of Psychiatry, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Veterans Integrated Service Network 4, Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, Pennsylvania, USA
| | - Emily E Hartwell
- Department of Psychiatry, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Veterans Integrated Service Network 4, Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, Pennsylvania, USA
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Donato S, Nieto S, Ray LA. The Brief Alcohol Use Disorder Severity Scale: An Initial Validation Evaluation. Alcohol Alcohol 2022; 57:762-767. [PMID: 36063825 PMCID: PMC9651986 DOI: 10.1093/alcalc/agac039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/10/2022] [Accepted: 07/24/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS The goal of this study was to develop a standard measure of AUD severity that includes multiple dimensions and can be used in clinical settings to inform treatment selection. METHODS A large sample (n = 1939) of moderate to heavy drinkers was amassed from six psychopharmacology studies. The severity factor was comprised of four dimensions: withdrawal, craving, AUD symptoms and alcohol-related consequences. First, a confirmatory factor analysis (CFA) was conducted to examine model fit. Next, a comprehensive item list from the four measures (i.e. CIWA, DrinC, PACs and SCID-5 AUD criteria) was reduced through exploratory factor analysis (EFA). Once the final items were merged into a preliminary assessment, an EFA was run to observe the factor structure. Initial validation of the measure was obtained via associations with clinical endpoints. RESULTS The chi-square test statistic (${\chi}^2(2)=2.432\ P=0.297$) for a single-factor model of severity demonstrated good fit. Additional goodness-of-fit indices from the CFA revealed similar support for the single-factor model of severity (i.e. SRMSR = 0.011; RMSEA = 0.011; CFI = 0.999). Next, nine items from the individual EFAs were selected based on factor loading. The final EFA conducted on the 9-item scale demonstrated that a single factor model of severity best fit the data. Analysis of the psychometric properties revealed good internal consistency ($\alpha$= 0.79). CONCLUSIONS The current study extends upon the measurement of severity and supports a brief severity measure. This brief 9-item scale can be leveraged in future studies as a screening instrument and as a tool for personalized medicine.
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Affiliation(s)
- Suzanna Donato
- Department of Psychology, University of California at Los Angeles, 1285 Franz Hall, Box 951563, Los Angeles, CA 90095, USA
| | - Steven Nieto
- Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, 760 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Lara A Ray
- Department of Psychology, University of California at Los Angeles, 1285 Franz Hall, Box 951563, Los Angeles, CA 90095, USA
- Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, 760 Westwood Plaza, Los Angeles, CA 90095, USA
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Fischler PV, Soyka M, Seifritz E, Mutschler J. Off-label and investigational drugs in the treatment of alcohol use disorder: A critical review. Front Pharmacol 2022; 13:927703. [PMID: 36263121 PMCID: PMC9574013 DOI: 10.3389/fphar.2022.927703] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 06/30/2022] [Indexed: 11/13/2022] Open
Abstract
Compounds known to be successful in the treatment of alcohol use disorder include the aversive agent, Disulfiram, the glutamatergic NMDA receptor antagonist, Acamprosate, and the opioid receptor antagonists, Naltrexone and Nalmefene. Although all four are effective in maintaining abstinence or reduction of alcohol consumption, only a small percentage of patients receive pharmacological treatment. In addition, many other medications have been investigated for their therapeutic potential in the treatment of alcohol use disorder. In this review we summarize and compare Baclofen, Gabapentin, Topiramate, Ondansetron, Varenicline, Aripiprazole, Quetiapine, Clozapine, Antidepressants, Lithium, Neuropeptide Y, Neuropeptide S, Corticotropin-releasing factor antagonists, Oxytocin, PF-05190457, Memantine, Ifenprodil, Samidorphan, Ondelopran, ABT-436, SSR149415, Mifepristone, Ibudilast, Citicoline, Rimonabant, Surinabant, AM4113 and Gamma-hydroxybutyrate While some have shown promising results in the treatment of alcohol use disorder, others have disappointed and should be excluded from further investigation. Here we discuss the most promising results and highlight medications that deserve further preclinical or clinical study. Effective, patient-tailored treatment will require greater understanding provided by many more preclinical and clinical studies.
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Affiliation(s)
- Pascal Valentin Fischler
- Department for Gynecology and Obstetrics, Women’s Clinic Lucerne, Cantonal Hospital of Lucerne, Lucerne, Switzerland
- *Correspondence: Pascal Valentin Fischler,
| | - Michael Soyka
- Psychiatric Hospital University of Munich, Munich, Germany
| | - Erich Seifritz
- Director of the Clinic for Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Clinic Zürich, Zürich, Switzerland
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Abstract
Alcohol use disorder (AUD) is a highly prevalent but severely under-treated disorder, with only three widely-approved pharmacotherapies. Given that AUD is a very heterogeneous disorder, it is unlikely that one single medication will be effective for all individuals with an AUD. As such, there is a need to develop new, more effective, and diverse pharmacological treatment options for AUD with the hopes of increasing utilization and improving care. In this qualitative literature review, we discuss the efficacy, mechanism of action, and tolerability of approved, repurposed, and novel pharmacotherapies for the treatment of AUD with a clinical perspective. Pharmacotherapies discussed include: disulfiram, acamprosate, naltrexone, nalmefene, topiramate, gabapentin, varenicline, baclofen, sodium oxybate, aripiprazole, ondansetron, mifepristone, ibudilast, suvorexant, prazosin, doxazosin, N-acetylcysteine, GET73, ASP8062, ABT-436, PF-5190457, and cannabidiol. Overall, many repurposed and novel agents discussed in this review demonstrate clinical effectiveness and promise for the future of AUD treatment. Importantly, these medications also offer potential improvements towards the advancement of precision medicine and personalized treatment for the heterogeneous AUD population. However, there remains a great need to improve access to treatment, increase the menu of approved pharmacological treatments, and de-stigmatize and increase treatment-seeking for AUD.
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