Biobehavioral mechanisms of topiramate's effects on alcohol use: an investigation pairing laboratory and ecological momentary assessments

Advancements in addressing drug dependence: A review of promising therapeutic strategies and interventions

Substance dependence represents a pervasive global concern within the realm of public health. Presently, it is delineated as a persistent and recurrent neurological disorder stemming from drug-triggered neuroadaptations in the brain's reward circuitry. Despite the availability of various therapeutic modalities, there has been a steady escalation in the mortality rate attributed to drug overdoses. Substantial endeavors have been directed towards the exploration of innovative interventions aimed at mitigating cravings and drug-induced repetitive behaviors. Within this review, we encapsulate the most auspicious contemporary treatment methodologies, accentuating meta-analyses of efficacious pharmacological and non-pharmacological approaches: including gabapentin, topiramate, prazosin, physical exercise regimens, and cerebral stimulation techniques.

Design and rationale for a randomized clinical trial testing the efficacy of a lifestyle physical activity intervention for people with HIV and engaged in unhealthy drinking

BACKGROUND

Among people living with HIV (PLWH), unhealthy drinking presents an increased risk for negative outcomes. Physical inactivity and sedentariness raise additional health risks. Despite evidence that physical activity (PA) is associated with improved physical and mental functioning and reduced alcohol cravings, there have been no PA studies conducted with PLWH engaged in unhealthy drinking. We describe a study protocol of a remote lifestyle physical activity (LPA) intervention to increase PA and reduce alcohol consumption among PLWH.

METHODS

Using online advertisements, 220 low-active PLWH engaged in unhealthy drinking will be recruited and randomized nationwide. After providing informed consent and completing a baseline interview, participants will receive a Fitbit. Participants will complete 15 days of ecologic momentary assessment through a phone application and up to 15 days of Fitbit wear time. Following this period, participants will be randomly assigned to a Fitbit-only control condition or a LPA and Fitbit intervention condition. Health counselors meet with control participants once (and have 6 subsequent brief check ins on Fibit use) and with intervention participants 7 times for PA counseling over a 12-week period. Follow-up assessments will be conducted at 3- and 6-months post-randomization. We hypothesize that individuals in the LPA and Fitbit condition will have lower rates of alcohol consumption and higher rates of PA at 6-month follow-up.

CONCLUSION

The randomized controlled trial described in this paper investigates remote methods to influence multimorbidity among PLWH using a LPA approach for increasing PA and reducing alcohol consumption.

Endpoints for Pharmacotherapy Trials for Alcohol Use Disorder

Alcohol use disorder (AUD) is a debilitating disorder, yet currently approved pharmacotherapies to treat AUD are under-utilized. The three medications approved by the US Food and Drug Administration (FDA) for the indication of AUD are disulfiram, acamprosate, and naltrexone. The current landscape of pharmacotherapies for AUD suggests opportunities for improvement. Clinical trials investigating novel pharmacotherapies for AUD traditionally use abstinence-based drinking outcomes or no heavy drinking days as trial endpoints to determine the efficacy of pharmacotherapies. These outcomes are typically measured through patient self-report endorsements of their drinking. Apart from these traditional outcomes, there have been recent developments in novel endpoints for AUD pharmacotherapies. These novel endpoints include utilizing the World Health Organization (WHO) risk drinking level reductions to promote a harm-reduction endpoint rather than an abstinence-based endpoint. Additionally, in contrast to patient self-report measurements, biological markers of alcohol use may serve as objective endpoints in AUD pharmacotherapy trials. Lastly, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) definition of recovery from AUD and patient-oriented outcomes offer new frameworks to consider endpoints associated with more than alcohol consumption itself, such as the provider-patient experiences with novel pharmacotherapies. These recent developments in new endpoints for AUD pharmacotherapies offer promising future opportunities for pharmacotherapy development, so long as validity and reliability measures are demonstrated for the endpoints. A greater breadth of endpoint utilization may better capture the complexity of AUD symptomatology.

Beyond mediators: A critical review and methodological path forward for studying mechanisms in alcohol use treatment research

Understanding how treatments for alcohol use disorder (AUD) facilitate behavior change has long been recognized as an important area of research for advancing clinical care. However, despite decades of research, the specific mechanisms of change for most AUD treatments remain largely unknown because most prior work in the field has focused only on statistical mediation. Statistical mediation is a necessary but not sufficient condition to establish evidence for a mechanism of change. Mediators are intermediate variables that account statistically for the relationship between independent and dependent variables, whereas mechanisms provide more detailed explanations of how an intervention leads to a desired outcome. Thus, mediators and mechanisms are not equivalent. To advance mechanisms of behavior change research, in this critical review we provide an overview of methodological shortfalls of existing AUD treatment mechanism research and introduce an etiologically informed precision medicine approach that facilitates the testing of mechanisms of behavior change rather than treatment mediators. We propose a framework for studying mechanisms in alcohol treatment research that promises to facilitate our understanding of behavior change and precision medicine (i.e., for whom a given mechanism of behavior change operates and under what conditions). The framework presented in this review has several overarching goals, one of which is to provide a methodological roadmap for testing AUD recovery mechanisms. We provide two examples of our framework, one pharmacological and one behavioral, to facilitate future efforts to implement this methodological approach to mechanism research. The framework proposed in this critical review facilitates the alignment of AUD treatment mechanism research with current theories of etiologic mechanisms, precision medicine efforts, and cross-disciplinary approaches to testing mechanisms. Although no framework can address all the challenges related to mechanisms research, our goal is to help facilitate a shift toward more rigorous and falsifiable behavior change research.

Does sleep relate to next-day cannabis use during treatment? Findings from an adolescent and young adult motivational enhancement and cognitive behavioral therapy plus topiramate intervention

BACKGROUND

Interventions for youth cannabis use have limited efficacy. Sleep is likely to affect treatment response, as sleep difficulties are cross-sectionally associated with use and common during treatment. This analysis examined how sleep duration and subjective trouble sleeping related to next-day cannabis use among youth during cannabis treatment.

METHOD

Participants (N=64) received a psychosocial intervention plus topiramate versus placebo while completing a 6-week ecological momentary assessment study. Time-varying effect modeling (TVEM) examined within- and between-person associations between sleep and cannabis use and how the strength of within-person associations varied over the course of treatment.

RESULTS

TVEM resvealed that, between-participants, youth with longer average sleep duration used cannabis less often controlling for baseline cannabis use, topiramate, and weekend status. Daily within-person fluctuations in sleep duration and trouble were not associated with use.

CONCLUSIONS

Findings suggest regularly shorter sleep may impede treatment outcomes. Adolescents who regularly have insufficient sleep durations likely need additional intervention to improve sleep difficulties in tandem with cannabis use reduction.

Testing pharmacotherapies for alcohol use disorder with cue exposure paradigms: A systematic review and quantitative synthesis of human laboratory trial methodology

Alcohol cue exposure is a widely used experimental paradigm for screening pharmacotherapies for alcohol use disorder (AUD). Medication-related reductions in cue-reactivity signal early efficacy and inform medications development. Yet, across trials, the design of cue exposure, parameter testing, and outcome reporting is heterogeneous. This systematic review is a quantitative synthesis of trial methodologies and effect size estimation for AUD medication-related craving and psychophysiological outcomes under the cue exposure paradigm. A PubMed search was conducted on January 3, 2022 based on identified pharmacotherapies for peer-reviewed articles reported in English. Study-level characteristics, including sample descriptors, paradigm design, analytic approach, and Cochrane Risk of Bias, along with descriptive statistics for cue-exposure outcomes, were coded by two independent raters. Study-level effect sizes were estimated for craving and psychophysiological outcomes separately and sample-level effect sizes were calculated for each medication. Thirty-six trials, comprising 1640 participants and testing 19 different medications satisfied eligibility criteria. All studies reported on biological sex (71% male participants on average). The exposure paradigms implemented used in vivo (n = 26), visual (n = 8), and audio script (n = 2) cues. Some trials included means for craving by medication condition in text (k = 7) or figures (k = 18). The quantitative synthesis included 63 effect sizes (craving kes  = 47; psychophysiological kes  = 16) from 28 unique randomized trials testing 15 medications for effects on cue reactivity. For cue-induced craving, eight medications (kes range: 1-12) demonstrated small-to-medium effects (Cohen's d range: |0.24-0.64|) compared to placebo, with individuals randomized to receive medication reporting lower craving following cue exposure. Recommendations are provided to promote further consilience, so that the utility of cue exposure paradigms can be maximized in the development of effective AUD pharmacotherapies. Future work should explore the predictive utility of medication-related reductions in cue-reactivity on clinical outcomes.

Alcohol use disorder in community management of chronic liver diseases

Rising rates of alcohol use disorder (AUD) combined with increases in alcohol-related liver disease (ALD) and other liver disease have resulted in the need to develop alcohol management strategies at all levels of patient care. For those with pre-existing liver disease, whether ALD or others, attention to alcohol use treatment and abstinence becomes critical to avoiding worsening liver-related consequences. Modalities to help patients reduce or stop alcohol include screening/brief intervention/referral to treatment, various therapeutic modalities including cognitive behavioral therapy, motivational enhancement therapy and 12-step facilitation, and alcohol relapse prevention medications. Harm reduction approaches versus total abstinence may be considered, but for those with existing ALD, particularly advanced ALD (cirrhosis or acute alcoholic hepatitis), total abstinence from alcohol is the recommendation, given clear data that ongoing alcohol use worsens mortality and liver-related morbidity. For certain populations, alcohol cessation is even more critically important. For those with hepatitis C or NAFLD, alcohol use accelerates negative liver-related outcomes. In women, alcohol use accelerates liver damage and results in worsened liver-related mortality. Efforts to integrate AUD and liver disease care are urgently needed and can occur at several levels, with establishment of multidisciplinary ALD clinics for fully integrated co-management as an important goal.

The neurobiological markers of acute alcohol's subjective effects in humans

The ingestion of alcohol yields acute biphasic subjective effects: stimulation before sedation. Despite their predictive relevance to the development of alcohol use disorders (AUD), the neurobiological markers accounting for the biphasic effects of alcohol remain poorly understood in humans. Informed by converging lines of evidence, this study tested the hypothesis that alcohol ingestion acutely increases gamma-aminobutyric acid (GABA)-mediated inhibition, which would positively and negatively predict the feeling of stimulation and sedation, respectively. To do so, healthy participants (n = 20) ingested a single dose of 94% ABV alcohol (males: 1.0 ml/kg; females: 0.85 ml/kg) in a randomized placebo-controlled cross-over design. The alcohol's biphasic effects were assessed with the Brief-Biphasic Alcohol Effects Scale, and non-invasive neurobiological markers were measured with transcranial magnetic stimulation, before and every 30 min (up to 120 min) after the complete ingestion of the beverage. Results showed that acute alcohol ingestion selectively increased the duration of the cortical silent period (CSP) as compared to placebo, suggesting that alcohol increases non-specific GABAergic inhibition. Importantly, CSP duration positively and negatively predicted increases in the feeling of stimulation and sedation, respectively, suggesting that stimulation emerges as GABAergic inhibition increases and that sedation emerges as GABAergic inhibition returns to baseline values. Overall, these results suggest that modulations of GABAergic inhibition are central to the acute biphasic subjective effects of alcohol, providing a potential preventive target to curb the progression of at-risk individuals to AUD.

The effect of neuroimmune modulation on subjective response to alcohol in the natural environment

BACKGROUND

Despite the promising implications for novel immune therapeutics, few clinical trials have tested these therapies to date. An understanding of how immune pharmacotherapies influence complex alcohol use disorder (AUD) profiles, including subjective response to alcohol, is very limited. Initial findings show that ibudilast, a neuroimmune modulator, reduces rates of heavy drinking and measures of alcohol craving.

METHODS

This study is a secondary analysis of a 2-week clinical trial of ibudilast that enrolled a nontreatment-seeking sample with AUD. Eligible participants (N = 52) were randomized to receive ibudilast or matched placebo and completed daily diary assessments (DDAs) during the 2-week period. Each morning, participants reported on their mood and craving levels both before and during the previous day's drinking episode, as well as stimulation and sedation levels during the previous day's drinking episode. Multilevel models were used to compare the effects of ibudilast and placebo on subjective alcohol response. Exploratory analyses tested whether ibudilast moderated the relationship between daily stimulation/sedation and alcohol intake and whether withdrawal-related dysphoria moderated ibudilast's effects on subjective response.

RESULTS

Ibudilast did not significantly alter mean levels of stimulation or sedation (p's > 0.05). It did, however, moderate the effect of daily stimulation on drinking (p = 0.045). Ibudilast attenuated alcohol-induced increases in craving compared with placebo (p = 0.047), but not other subjective response measures. Ibudilast significantly tempered daily alcohol-induced changes in urge to drink and positive mood only among individuals without withdrawal-related dysphoria.

CONCLUSIONS

Ibudilast's effects on subjective alcohol responses appear to be nuanced and perhaps most salient for individuals drinking for positive reinforcement as distinguished from those who drink to feel normal. Consistent with previous findings, reductions in alcohol craving may represent a primary mechanism of ibudilast's effects on drinking. The ecologically valid nature of DDAs provide a clinically useful window into how individuals experience alcohol's effects while taking ibudilast.

Topiramate decreases the salience of motivationally relevant visual cues among smokers with alcohol use disorder

BACKGROUND

There is preliminary evidence that the anticonvulsant topiramate increases the likelihood of both smoking and alcohol abstinence among smokers with alcohol use disorder (AUD), but its therapeutic mechanism has not been determined. We used event-related potentials (ERPs) to evaluate topiramate's effect on the salience of drug-related, emotional, and neutral pictorial cues to identify whether one of its potential therapeutic mechanisms involves reduction of the salience of motivationally relevant cues.

METHODS

Participants enrolled in a multisite clinical trial treating smokers with AUD were randomly assigned to receive placebo, low-dose topiramate (up to 125 mg/day), or high-dose topiramate (up to 250 mg/day), along with brief behavioral compliance enhancement treatment. A subsample (n = 101) completed ERP assessments at baseline (1 week pre-medication) and week 5 (5 weeks on medication; 1 week pre-quit). We assessed the salience of pleasant, unpleasant, cigarette-related, alcohol-related, and neutral pictorial cues using the late positive potential (LPP) ERP component and measured self-reported substance use, reinforcement, craving, and withdrawal.

RESULTS

Five weeks of high-dose topiramate treatment decreased LPP amplitudes in response to both emotional (pleasant and unpleasant) and drug-related cues (alcohol and cigarette), but not to neutral cues. However, results showed that the LPPs were not significant mediators of the relationship between topiramate dose and post-quit measures of substance use, reinforcement, craving, or withdrawal.

CONCLUSIONS

These findings suggest that high-dose topiramate (up to 250 mg/day) decreases the motivational salience of both drug-related and emotional cues among smokers with AUD. However, the nonsignificant mediation analyses preclude any firm conclusions about whether this effect represents one of topiramate's therapeutic mechanisms of action.

Behavioral economic analysis of topiramate pharmacotherapy for alcohol: a placebo-controlled investigation of effects on alcohol reinforcing value and delayed reward discounting

RATIONALE

Pharmacotherapies are an important clinical strategy for treating alcohol use disorder and an understanding of their functional mechanisms can inform optimal use. Behavioral economics provides a translational platform that may advance our understanding of the motivational impacts of pharmacotherapies.

OBJECTIVES

This secondary analysis study examined the effect of topiramate, a promising pharmacotherapy for treating alcohol use disorder, on two behavioral economic domains, the reinforcing value of alcohol (alcohol demand and alcohol-specific monetary expenditures) and delayed reward discounting (preference for smaller immediate rewards over larger delayed rewards).

METHODS

A double-blind randomized placebo-controlled study (n = 99) was conducted with non-treatment seeking heavy drinkers, comparing topiramate (target dose of 200 mg/day titrated for 3 weeks and remained at the target dose for 2 weeks) to matched placebo.

RESULTS

We found that compared to placebo, topiramate reduced the reinforcing value of alcohol, as shown by a reduction in two alcohol demand indices (intensity and Omax), money spent per week on alcohol and an almost a 50% increase in days without expenditures on alcohol from baseline. Directionally consistent patterns were also present for breakpoint and elasticity (ps = .08). No significant effects were found for delayed reward discounting.

CONCLUSIONS

This study provides evidence that topiramate reduces alcohol's reinforcing value as measured by alcohol demand and alcohol expenditure. More broadly, these findings support the utility of behavioral economics for understanding how medications reduce alcohol use.

Co-use of medication and alcohol: The influence on subjective effects of intoxication and affect

Co-use of alcohol and medication can have serious negative health effects (e.g., overdose risk, liver damage). Research has primarily focused on older adults or the pharmacokinetics of specific medication-alcohol combinations. Little work has focused on the subjective experience of persons who take alcohol-interactive (AI) medications and also drink alcohol, particularly in psychiatric samples at high risk for problematic alcohol use and high rates of prescription medication use, such as individuals with borderline personality disorder (BPD). Data from a larger ecological momentary assessment study of alcohol use in 52 persons diagnosed with BPD (83% women; Mage = 26 years) were used to examine the influence of alcohol intoxication (i.e., estimated blood alcohol concentration [eBAC]) and medication co-use on momentary subjective experience while drinking. Participants reported AI medication use at baseline and completed multiple ecological momentary assessment reports per day over 21 days, which included reports of alcohol use, subjective effects of alcohol (e.g., pleasure, feeling worse), and negative and positive affect. AI medications significantly moderated the association between eBAC and pleasurable effects of alcohol, such that at higher levels of eBAC, those taking AI medications experienced blunted subjective pleasure compared with those not taking AI medications. AI medications did not moderate the associations between eBAC and subjective relief, feeling worse, positive affect, or negative affect. Attenuated pleasure during drinking could lead to increased drinking in an attempt to achieve a desirable state among individuals who co-use psychiatric medications and alcohol, and therefore may represent a useful target for prevention and intervention. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The Anticonvulsant Lamotrigine Reduces Bout-Like Alcohol Drinking in Rats

We used an optical lickometer system to study drinking microstructure and effect of lamotrigine in voluntary alcohol-drinking rats. We showed that, similar to humans, animals differ by their drinking microstructure where some consume alcohol exclusively in a bout-like patterns. The study suggests that anticonvulsants, such as lamotrigine, may be one treatment strategy specifically affecting this type of drinking.

Daily associations between alcohol and sweets craving and consumption in early AUD recovery: Results from an ecological momentary assessment study

INTRODUCTION

Alcohol cravings can predict relapse in persons with alcohol use disorder (AUD). Consuming sweets is a commonly recommend strategy to quell alcohol cravings in early recovery from AUD, yet research is equivocal on whether consuming sweets mitigates alcohol cravings or relapse risk. The current study used ecological momentary assessment (EMA) data to examine real-time alcohol cravings, sweet cravings, and consumption of sweets among adults in early recovery from AUD.

METHODS

We used EMA methods to follow 25 adults (n = 14 women, 56%; M. age 40, S.D. 10.68) recently discharged from a partial hospitalization program for AUD for 21 days. Prompts were sent to the participants for completion four times per day via a mobile app. EMA data were disaggregated prior to analysis to examine between- and within-person effects. A series of three mixed linear models tested: 1) the contemporaneous effect of sweet and alcohol cravings, 2) alcohol cravings predicting sweet consumption later in the day, and 3) sweet consumption predicting alcohol craving later in the day.

RESULTS

The results of the first model revealed alcohol cravings were associated with sweet cravings early in recovery. In the second model, no effect occurred between alcohol cravings earlier in the day predicting sweet consumption later in the day. The third model suggested consuming sweets earlier in the day predicted higher alcohol cravings later in the day.

DISCUSSION

Sweet craving and consumption are associated with alcohol cravings among adults in early recovery from AUD. These findings suggest consuming sweets may increase alcohol cravings. If future studies can replicate this result, consuming sweets in early recovery may emerge as a potential risk for relapse in this population.

Combined pharmacotherapy and evidence-based psychosocial Cannabis treatment for youth and selection of cannabis-using friends

BACKGROUND

Theoretical models of behavior change argue that youth should decrease their time with cannabis-using friends and increase their time with non-using friends during treatment. Informed by behavior-change models of recovery and socialization and selection peer-influence models, the current study examined whether combining evidence-based psychosocial treatment with adjunctive pharmacotherapy helps youth decrease their affiliations with cannabis-using friends and increase their affiliations with non-using friends during cannabis misuse treatment.

METHODS

Youth ages 15-24 years (51 % male), participated in a double-blind randomized clinical trial that tested the effects of motivational enhancement and cognitive behavioral therapy (MET-CBT) plus topiramate (N = 39) or placebo (N = 26) on cannabis craving and use. Ecological momentary assessment data, collected via smartphones throughout the six-week intervention, assessed youths' time with cannabis-using and non-using friends, cannabis use, and craving in daily life. Multiple group multilevel structural equation modeling tested study hypotheses.

RESULTS

Across the topiramate (48 % completion rate) and placebo (77 % completion rate) conditions, greater time spent with cannabis-using friends promoted greater next day cannabis use and craving (socialization effect). In turn, cannabis craving, but not use, promoted continued selection of cannabis-using friends. This indirect effect was only supported in the placebo condition due to the selection piece of this cycle not being significant for youth who received topiramate. Neither cannabis craving nor use were associated with time with non-using friends the next day.

CONCLUSIONS

MET-CBT and adjunctive topiramate pharmacotherapy interrupted youth selection processes. This finding suggests that changing peer affiliations could be one mechanism by which treatments can work.

Effects of topiramate on neural responses to alcohol cues in treatment-seeking individuals with alcohol use disorder: preliminary findings from a randomized, placebo-controlled trial

Topiramate, a GABA/glutamate modulator, is efficacious in reducing alcohol consumption, though the mechanisms underlying this effect are not well characterized. This study analyzed functional magnetic resonance imaging (fMRI) data from 22 heavy drinkers enrolled in a 12-week placebo-controlled, randomized clinical trial of topiramate to examine the effects of topiramate on alcohol cue-elicited brain responses, craving, and heavy drinking in individuals with DSM-5 alcohol use disorder. Patients were randomized to receive either topiramate (maximal daily dosage of 200 mg/day) or placebo and were administered an fMRI alcohol cue-reactivity task at baseline (before starting medication) and after 6 weeks of double-blind treatment. Analyses compared the topiramate (n = 12) and placebo (n = 8) groups on (1) the change in brain responses during alcohol cue exposure (vs non-alcohol cues) within five a priori regions of interest related to reward-the bilateral and medial orbitofrontal cortex (OFC) and bilateral ventral striatum (VS) and (2) change in craving and heavy drinking days (HDDs) from baseline and scan 2. Topiramate, relative to placebo, reduced alcohol cue-elicited activation of the left VS, bilateral OFC, and medial OFC, alcohol cue-elicited craving, and HDDs between baseline and 6 weeks of treatment. The reduction in alcohol cue-elicited activation in the medial OFC correlated with reductions in craving, and reduced activation in the right VS, right OFC, and medial OFC correlated with the reduction in HDD. This preliminary study provides evidence that topiramate's attenuation of alcohol cue-elicited brain activation and craving are key elements of the drug's neurobiological mechanism of action in reducing heavy drinking.

Alcohol subjective responses in heavy drinkers: Measuring acute effects in the natural environment versus the controlled laboratory setting

BACKGROUND

For decades, laboratory alcohol challenges have been the "gold standard" for measuring individual differences in alcohol's subjective effects. However, these approaches are expensive and labor-intensive, making them impractical for large-scale use. This study examined the reliability and validity of a new high-resolution EMA (HR-EMA) ambulatory approach to assessing alcohol use and subjective responses in drinkers' natural environments.

METHODS

Participants were 83 young adult heavy social drinkers (58% male; mean ± SD age = 25.4 ± 2.6 years) who completed up to two smartphone-based, 3-h HR-EMA assessments of alcohol use and related subjective responses in their typical drinking environments. Reported alcohol consumption during the HR-EMA periods was used to calculate estimated blood alcohol concentration (eBAC). Subjective effects were measured using the Brief Biphasic Alcohol Effects Scale (B-BAES) and Drug Effects Questionnaire (DEQ). All participants also completed identical measures during a separate, 4 to 5-h laboratory session in which they received a 0.8 g/kg alcohol challenge.

RESULTS

Most natural environment drinking episodes (87%) met or exceeded the threshold for binge drinking (final mean eBAC = 0.12 g/dl). Associations between reported alcohol use and subjective responses on the B-BAES and DEQ were strongest earlier in the drinking events, with fair reliability of reported subjective effects across two HR-EMA episodes (intraclass correlation [ICC] range = 0.46-0.49). There was fair-to-good correspondence between HR-EMA- and laboratory-derived subjective responses (ICC range = 0.49-0.74), even after accounting for differences in alcohol consumption and drinking context. Reported stimulating and rewarding alcohol effects were higher in the ambulatory than laboratory setting, and vice versa for sedating effects.

CONCLUSIONS

This study supports the reliability and validity of smartphone-based HR-EMA to measure alcohol use and subjective responses in heavy drinkers' natural environments. These findings lend support to the use of ambulatory HR-EMA as a measure of alcohol subjective responses in risky drinkers when a laboratory protocol is not practical, feasible, or safe.

Translational approach to understanding momentary factors associated with alcohol consumption

Multiple interindividual and intra-individual factors underlie variability in drinking motives, challenging clinical translatability of animal research and limiting treatment success of substance use-related problems. Intra-individual variability refers to time-dependent continuous and discrete changes within the individual and in substance use research is studied as momentary variation in the internal states (craving, stressed, anxious, impulsive and tired) and response to external triggers (stressors, drug-associated environmental cues and social encounters). These momentary stimuli have a direct impact on behavioural decisions and may be triggers and predictors of substance consumption. They also present potential targets for real-time behavioural and pharmacological interventions. In this review, we provide an overview of the studies demonstrating different momentary risk factors associated with increased probability of alcohol drinking in humans and changes in alcohol seeking and consumption in animals. The review also provides an overview of pharmacological interventions related to every individual risk factor.

The Human Laboratory and Drug Development in Alcohol Use Disorder: Recent Updates

Despite a number of approved medications for alcohol use disorder (AUD), this chronic relapsing disease still produces a considerable global burden, with both health-related and financial consequences. While clinical trials are a critical step in drug development, human laboratory studies provide the field with means of screening pharmacotherapy for more nuanced aspects of AUD. Specifically, studies employing alcohol administration techniques (e.g., alcohol challenge and self-administration) are able to investigate potential drugs with respect to their ability to alter various responses to alcohol administration or alter alcohol consumption in laboratory settings. This chapter reviews methodological designs and provides updates from alcohol administration studies used to screen for potential AUD pharmacotherapy over the past decade. These recent studies have supported the efficacy of approved drugs, identified some promising novel drugs, and investigated other drugs that appear ineffective in AUD treatment. Yet, few drugs are explored using the different variants of alcohol administration methods, and using the different methods has provided inconsistent results for the same drug. Future research would aid advancement in the field by testing medication with various methodologies and refining recently developed techniques.

Topiramate Pharmacotherapy for Alcohol Use Disorder and Other Addictions: A Narrative Review

: Topiramate is a non-benzodiazepine anticonvulsant medication with multi-faceted pharmacologic action. It has emerged as an efficacious pharmacotherapeutic option for the treatment of addiction, especially alcohol use disorder (AUD). We present a broad narrative review of the putative mechanism of action and clinical utility of topiramate with regard to AUD and other substance use disorders. Collective evidence suggests topiramate is an effective treatment option in AUD, with notable efficacy in reducing harmful drinking patterns in AUD. Though not currently approved by the United States Food and Drug Administration for the indication of AUD, topiramate should be considered as a pharmacological treatment option with high utility among AUD patients. Early pharmacogenetic studies raise the intriguing possibility of identifying patients likely to respond to topiramate using genetic testing, and initial studies show that topiramate may also be useful in treating cocaine use disorder, smoking cessation and behavioral addictions. However, further research is needed in all these areas.

Why don't they stop? Understanding unplanned marijuana use among adolescents and young adults

Difficulty regulating substance use is a core feature of addiction that can manifest as unplanned use. This study sought to identify internal and situational influences on unplanned marijuana use among youth ages 15 to 24 years (N = 85; 48% female; 27% age <18 years). Additionally, we disentangled person-level associations from within-person day-to-day influences. Ecological momentary assessment methods captured affective (positive: energized, excited, sociable, happy, relaxed; negative: bored, tense, sad, stressed) and situational factors in real-world settings during a 1-week monitoring period. Participants reported no plan to use on 51% of days (269/527), and youth ultimately used marijuana on 35% of these unplanned days. At the day level, on days when youth spent more time in the presence of marijuana-related cues than they typically do, they used more grams on planned days and less on unplanned days. Regardless of use plans, youth were more likely to use on days when they spent more time with using friends and if they reported greater availability of marijuana in general across the monitoring period. At the person level, youth who generally reported higher positive affect, relative to other participants, used more on planned days and less on unplanned days. Regardless of use plans, youth who generally reported greater craving and time in the presence of marijuana-related cues used more grams, whereas youth who generally reported greater negative affect used less. Together, findings revealed several factors, with clear clinical relevance, which may explain why some youth struggle to control their marijuana use. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Mobile alcohol biosensors and pharmacotherapy development research

Recent advances in biosensor technology herald a major shift in the way alcohol use will be tracked in humans. Wearable biosensors can passively and continuously monitor wearers' alcohol consumption in real time. An important application of these biosensors is to improve the way medication for alcohol use disorder (AUD) is tested in clinical research. Both laboratory-based screening paradigms and clinical trials have methodological problems that impact their efficiency and predictive validity. Medication screening using laboratory-based methods is a resource-intensive assessment of a single episode of behavior in a non-representative setting. Clinical trials rely on participant self-report to document medication-induced changes in drinking behavior. This review describes how mobile biosensors can be leveraged to improve AUD medication development research. We first review the current state of alcohol biosensor technology with a focus on strengths and limitations of the devices. We describe how multiple biosensors can be combined to create a far more detailed record of drinking compared to single biosensor platforms. We then discuss each phase of the medication development pipeline in turn (i.e., phases 1-4) and describe how mobile biosensors can be incorporated in standard medication testing paradigms to improve efficiency and predictive validity. We conclude with discussion of challenges associated with using currently available biosensors for medication testing and recommendations for researchers wishing to incorporate alcohol biosensors into their own research.

Rate of alcohol consumption in the daily life of adolescents and emerging adults

RATIONALE

Alcohol consumption in adolescents and emerging adults is a significant issue. However, our understanding of the topography of alcohol use within drinking episodes in this population is at a nascent stage.

OBJECTIVES

This study characterized rate of alcohol consumption in the daily lives of problem drinkers ages 16-24 years (N = 75). We examined whether AUD symptoms and the presence of peers, factors relevant to alcohol consumption in youth, were associated with rate of consumption.

METHODS

Ecological momentary assessment (EMA) was used (N_observations = 799). Rate of consumption was defined as change in estimated blood alcohol concentration (eBAC) relative to the start of the drinking episode. Piecewise multi-level modeling was used to test hypotheses. As a comparison, we examined whether indicators of quantity and frequency (Q-F) were associated with AUD symptoms and presence of peers.

RESULTS

For all participants, eBAC increased sharply early in the episode, then plateaued. Participants with more AUD symptoms or who were in the presence of peers had significantly steeper increases in eBAC over the early part of the episode. Participants with more AUD symptoms were also more likely to engage in binge-like behavior. For Q-F, only peak eBAC and peak number of standard drinks were associated with AUD symptoms, and not presence of peers.

CONCLUSIONS

Findings highlight the value of rate of consumption as an indicator of use in youth, one sensitive to the influence of relevant person-level and situational factors. Intervention efforts may benefit from targeting the speed at which youth drink.

Using Ecological Momentary Assessment to Identify Mechanisms of Change: An Application From a Pharmacotherapy Trial With Adolescent Cannabis Users

OBJECTIVE

The present study used youth's in vivo reports of subjective responses to cannabis while smoking in their natural environments to identify real-world mechanisms of topiramate treatment for cannabis misuse.

METHOD

Participants were 40 cannabis users (≥ twice weekly in past 30 days), ages 15-24 years (47.5% female), with at least one cannabis use episode during the final 3 weeks of a 6-week, randomized clinical trial. Youth reported subjective "high" while smoking, stimulation, sedation, stress, craving, and grams of marijuana used in the natural environment via wireless electronic devices. Bayesian multilevel structural equation modeling (MSEM) evaluated mediation via indirect effect tests.

RESULTS

Significant within (daily) and between (person) variability and distinctive within and between effects supported the MSEM approach. Subjective high while smoking was significantly reduced for youth in the topiramate condition, relative to placebo, and the indirect effect of reduced subjective high on total grams of cannabis smoked that day was significant. Indirect effects through other subjective responses were not significant.

CONCLUSIONS

The results of this initial study suggest that altering subjective responses to smoking, specifically subjective high, may be a key target for developing adjunctive pharmacotherapies for cannabis misuse. More generally, this work provides an example for applying ecological momentary assessment and analytic techniques to evaluate mechanisms of behavior change in longitudinal data.

Assessment of Alcohol Use in the Natural Environment

The current article critically reviews 3 methodological options for assessing drinking episodes in the natural environment. Ecological momentary assessment (EMA) typically involves using mobile devices to collect self-report data from participants in daily life. This technique is now widely used in alcohol research, but investigators have implemented diverse assessment strategies. This article focuses on "high-resolution" EMA protocols that oversample experiences and behaviors within individual drinking episodes. A number of approaches have been used to accomplish this, including using signaled follow-ups tied to drinking initiation, asking participants to log entries before and after individual drinks or drinking episodes, and delivering frequent signaled assessments during periods of the day when alcohol use is most common. Transdermal alcohol sensors (TAS) are devices that are worn continuously and are capable of detecting alcohol eliminated through the skin. These methods are appealing because they do not rely upon drinkers' self-report. Studies using TAS have been appearing with greater frequency over the past several years. New methods are making the use of TAS more tractable by permitting back-translation of transdermal alcohol concentration data to more familiar estimates of blood alcohol concentration or breath alcohol concentration. However, the current generation of devices can have problems with missing data and tend to be relatively insensitive to low-level drinking. An emerging area of research investigates the possibility of using mobile device data and machine learning to passively detect the user's drinking, with promising early findings. EMA, TAS, and sensor-based approaches are all valid, and tend to produce convergent information when used in conjunction with one another. Each has a unique profile of advantages, disadvantages, and threats to validity. Therefore, the nature of the underlying research question must dictate the method(s) investigators select.

Medication Development for Alcohol Use Disorder: A Focus on Clinical Studies

Compared to other medical disorders, including other brain diseases, the number of medications approved for alcohol use disorder (AUD) is very small. Disulfiram, naltrexone (oral and long-acting), and acamprosate are approved by the US Food and Drug Administration (FDA) to treat patients with AUD. These medications are also approved in other countries, including in Europe, where the European Medicines Agency (EMA) also approved nalmefene for AUD. Furthermore, baclofen was recently approved for AUD in France. These approved medications have small effect sizes, which are probably the consequence of the fact that they only work for some patients, yet a personalized approach to match the right medication with the right patient is still in its infancy. Therefore, research is needed to expand the armamentarium of medications that clinicians can use to treat their patients, as well as to better develop personalized approaches. This book chapter reviews other medications, beyond those approved by the FDA, that have shown efficacy in clinical trials, as well as medications which are still in the early stages of evaluation in human studies.

Comparing and Combining Topiramate and Aripiprazole on Alcohol-Related Outcomes in a Human Laboratory Study

Aims

The goal of this study was to evaluate the efficacy of topiramate up to 200 mg/day and of aripiprazole up to 15 mg/day, alone and combined, in reducing alcohol-related outcomes in a human laboratory study.

Method

This was a 5 week, between-subject, double-blind, placebo-controlled human laboratory study with topiramate [0 mg/day (placebo), 100 mg/day, 200 mg/day] and aripiprazole [0 mg/day (placebo), 7.5 mg/day, 15 mg/day] in 90 non-treatment seeking, heavy drinking, alcohol-dependent individuals. Main outcomes were the efficacy of 200 mg/day topiramate and 15 mg/day aripiprazole, alone and combined, in reducing drinks consumed during an alcohol self-administration procedure (human laboratory phase) and while receiving the study medications prior to the laboratory session (naturalistic drinking phase). Other outcomes in the laboratory phase included alcohol craving, and alcohol biphasic effects.

Results

In the human laboratory phase, topiramate 200 mg/day reduced alcohol craving [**P < 0.01] and amplified alcohol-induced stimulation [*P < 0.05], but did not reduce the number of drinks consumed. Topiramate 200 mg/day was also effective in reducing drinking days [*P < 0.05], and alcohol craving [*P < 0.05], in the naturalistic drinking phase. No significant findings were found for aripiprazole for any of the outcomes analyzed.

Conclusion

Participants receiving 200 mg/day topiramate reported reduced alcohol drinking and craving, and increased alcohol-related stimulation. These findings provide further support for the role of topiramate as a pharmacological treatment for AUD.

ClinicalTrial.gov Identifier

NCT00884884.

Short Summary

This study tested topiramate and aripiprazole alone and in combination. The results replicate past findings and suggest that topiramate may be an effective treatment for alcohol use disorder. The present results suggest that the combination of topiramate and aripiprazole do not warrant further evaluation.

Real-time assessment of alcohol craving and naltrexone treatment responsiveness in a randomized clinical trial

INTRODUCTION

This secondary data analysis examined whether and how the dopamine receptor D₄ gene (DRD4) influenced naltrexone treatment responsiveness in a randomized clinical trial. We leveraged intensive experience sampling methods to test the hypothesis that craving recorded at drinking and non-drinking moments would mediate naltrexone effects on the likelihood of heavy drinking, but only among carriers of the DRD4 long (DRD4-L) allele.

METHODS

Participants (M_age=29.8years, SD=12.1) were non-treatment seeking heavy drinkers (n=104, 54.8% female, 61.5% alcohol dependent) randomized to 3weeks of daily naltrexone (50mg) or placebo. During these 3weeks, participants used handheld electronic devices to complete real-time reports of alcohol use and craving multiple times per day in their natural environments. This approach afforded intensive repeated assessment of focal variables and provided in-the-moment data to test whether craving when not drinking or early in drinking episodes explained naltrexone effects on drinking.

RESULTS

Moderated-mediation multilevel structural equation models showed that craving during non-drinking moments mediated the treatment effect of naltrexone on heavy drinking but only among carriers of the DRD4-L allele. The same pattern of associations was not shown when evaluating craving while participants were consuming alcoholic beverages.

CONCLUSIONS

Findings provide the first in vivo evidence that, among carriers of the DRD4-L allele, naltrexone blunts craving in real-world settings, and this effect in turn reduces the likelihood of heavy drinking. This work highlights the utility of EMA methods for elucidating how treatments work and further demonstrates the importance of genetic factors for understanding individual differences in pharmacotherapy responsiveness.

Cardiac vagal dysfunction moderates patterns of craving across the day in moderate to heavy consumers of alcohol

Background

Alcohol craving, a known correlate of vulnerability to Alcohol Use Disorder (AUD), has been found to be inversely related to cardiac vagal tone (CVT). Here we examine how resting CVT, CVT reactivity to a postural challenge, and their interaction influence craving during imposed alcohol abstinence and their usual drinking among moderate to heavy drinkers.

Methods

Participants were recruited from the local community (final n = 29) and assessed for CVT functioning via respiratory sinus arrhythmia (RSA) at rest (RSA-rest) and during a postural challenge (RSA-react). Craving intensity was assessed throughout the day during 3-day periods of imposed alcohol abstinence (abstained days) and drinking as usual (normal days) via Ecological Momentary Assessment (EMA). Multilevel statistical modeling assessed relationships between patterns of CVT and diurnal craving. The primary hypothesis of interest was that the interaction of RSA-rest with RSA-react would be significantly associated with increased craving across the day.

Results

Overall, craving increased throughout the day and significantly decreased after drinking (p < 0.001). There was a significant interaction between RSA-rest and RSA-react with plots revealing that this effect was driven by an aberrant craving pattern among participants with higher RSA-rest and a sluggish vagal brake in response to a postural shift—atypical RSA-react.

Conclusion

Although additional research is needed to corroborate these findings, our results suggest that moderate-heavy drinkers characterized by higher RSA-rest and atypical RSA-react exhibit aberrant patterns of craving across the day that may represent a risk factor for AUD.

Why cognitive event-related potentials (ERPs) should have a role in the management of alcohol disorders

Alcohol dependence is currently one of the most serious public health problems. Indeed, 3-8% of all deaths worldwide are attributable to effects of alcohol consumption. Although the first step in alcohol dependence treatment is straightforward, the main problem for clinicians lies with the prevention of relapse, as 40-70% of patients who only undergo psychosocial therapy resume alcohol use within a year following treatment. This review of the literature regarding event-related potentials (ERPs) is focused on two major neurocognitive factors that partially account for the inability of many alcoholics to remain abstinent: attentional biases towards alcohol-related stimuli that increase the urge to drink, and impaired response inhibition towards these cues that makes it more difficult for alcoholics to resist the temptation to drink. On this basis, we propose new research avenues to better implement ERPs in the management of alcohol disorders, according to four main directions that relate to (1) the development of ERP serial recordings; (2) the promotion of a multi-component ERP approach; (3) the definition of multi-site guidelines; and (4) the use of more representative laboratory situations through the use of more compelling environments.

Using ecological momentary assessment to examine the relationship between craving and affect with opioid use in a clinical trial of clonidine as an adjunct medication to buprenorphine treatment

BACKGROUND

In a recent clinical trial (NCT00295308), we demonstrated that clonidine decreased the association between opioid craving and moderate levels of stress and affect in patients receiving buprenorphine-based opioid agonist therapy.

OBJECTIVES

To examine the relationship between illicit opioid use and craving and affect during the evaluation of clonidine as an adjunct medication in buprenorphine treatment for opioid use disorder. Secondarily, to examine whether those relationships are driven by within- or between-participant factors.

METHODS

This was a secondary data analysis from our original trial. Participants (N = 108, female: n = 23, male n = 85) receiving buprenorphine were randomized to receive adjunct clonidine or placebo. Participants used portable electronic devices to rate stress, mood, and craving via ecological momentary assessment (EMA) four times randomly each day. To associate the EMA data with illicit opioid use, each EMA report was linked to participants' next urine drug screen (thrice weekly). We used generalized linear mixed models to examine the interaction between treatment group and illicit opioid use, as well as to decompose the analysis into within- and between-participant effects.

RESULTS

Craving for opioids and cocaine was increased when participants were using illicit opioids; this effect was greater in the clonidine group. For affect, mood was poorer during periods preceding opioid-positive urines than opioid-negative urines for clonidine-treated participants, whereas there was no difference for placebo participants.

CONCLUSION

This secondary analysis provides evidence that for participants maintained on opioid agonist therapy, clonidine minimized the behavioral impact of moderate levels of negative affect and craving.

Using REDCap for ambulatory assessment: Implementation in a clinical trial for smoking cessation to augment in-person data collection

BACKGROUND

The use of ambulatory assessment to study behavior and physiology in daily life is becoming more common, yet barriers to implementation remain. Limitations in budget, time, and expertise may inhibit development or purchase of dedicated ambulatory assessment software. Research Electronic Data Capture (REDCap) is widely used worldwide, offering a cost-effective and accessible option for implementing research studies.

OBJECTIVES

To present a step-by-step guideline on how to implement ambulatory assessment using REDCap and provide preliminary evidence of feasibility.

METHODS

Feasibility and acceptability data are presented for randomized participants (N ranged from 19 to 36, depending on analysis) from an ongoing 8-week smoking cessation pharmacological clinical trial (ClinicalTrials.gov Identifier: NCT02737358). Participants (N = 36; 50% female) completed up to three ambulatory assessment surveys per day, depending on the phase of the study. These included self-report and video confirmation of smoking biomarkers and medication adherence.

RESULTS

Participants completed 74.8% of morning reports (86.6% for study completers), 73.8% of videos confirming smoking biomarkers, and 70.4% of videos confirming medication adherence. Study completers reported that the REDCap assessments were easy to use, and 78.9% of participants preferred the REDCap assessments to traditional, paper measures.

CONCLUSIONS

These data from a pharmacological trial suggest feasibility of remote data collection using REDCap. As REDCap functionality is continually evolving, it is likely that options for collecting ambulatory assessment data via this platform will progressively improve allowing for greater individualization of assessment scheduling for enhancing data collection in clinical trials.

Advancing Analytic Approaches to Address Key Questions in Mechanisms of Behavior Change Research

OBJECTIVE

Interest in studying mechanisms of behavior change (MOBCs) in substance use disorder (SUD) treatments has grown considerably in the past two decades. Much of this work has focused on identifying which variables statistically mediate the effect of SUD treatments on clinical outcomes. However, a fuller conceptualization of MOBCs will require greater understanding of questions that extend beyond traditional mediation analysis, including better understanding of when MOBCs change during treatment, when they are most critical to aiding the initiation or maintenance of change, and how MOBCs themselves arise as a function of treatment processes.

METHOD

In the present study, we review why these MOBC-related questions are often minimally addressed in empirical research and provide examples of data analytic methods that may address these issues. We highlight several recent studies that have used such methods and discuss how these methods can provide unique theoretical insights and actionable clinical information.

RESULTS

Several statistical approaches can enhance the field's understanding of the timing and development of MOBCs, including growth-curve modeling, time-varying effect modeling, moderated mediation analysis, dynamic systems modeling, and simulation methods.

CONCLUSIONS

Adopting greater diversity in methods for modeling MOBCs will help researchers better understand the timing and development of key change variables and will expand the theoretical precision and clinical impact of MOBC research. Advances in research design, measurement, and technology are key to supporting these advances.

Elevated Behavioral Economic Demand for Alcohol in a Community Sample of Heavy Drinking Smokers

OBJECTIVE

Cigarette smokers are more likely to consume alcohol at higher levels and experience poorer response to treatment for alcohol problems than are nonsmokers. One previous study in university students suggests that a potential reason for the high overlap between alcohol and tobacco use is that concurrent smoking is associated with overvaluation of alcohol, as reflected in elevated behavioral economic demand. The present study sought to extend these initial findings in a community sample with heavier levels of alcohol and tobacco use.

METHOD

Participants were 111 non-treatment-seeking heavy drinkers(defined as 18+/14+ drinks per week for men/women) from a larger study on alcohol pharmacotherapy mechanisms. Forty-nine participants (44%) reported regular smoking (≥5 cigarettes/day). Participants completed a hypothetical alcohol purchase task assessing alcohol consumption at escalating levels of price. Covariates included demographics, drinking quantity, alcohol use disorder severity, depression, and delay discounting.

RESULTS

In covariate-adjusted models, smokers reported significantly higher maximum alcohol expenditures (O_max) and breakpoint price (first price suppressing consumption to zero) compared with nonsmokers. Elevated alcohol demand correlated with drinking quantity and severity in the entire sample, but not with smoking frequency or nicotine dependence among smokers only.

CONCLUSIONS

This study offers further evidence of increased reinforcing value of alcohol among smokers in a sample of heavy drinkers from the community. Clinical implications and potential mechanisms underlying this relationship are discussed.

Advances in Pharmacotherapy Development: Human Clinical Studies

For more than 25 years, researchers have made advances in developing medications to treat alcohol use disorder (AUD), highlighted by the US Food and Drug Administration's (FDA's) approval of disulfiram, naltrexone (oral and long-acting), and acamprosate. These medications are also approved in Europe, where the European Medicines Agency (EMA) recently added a fourth medication, nalmefene, for AUD. Despite these advances, today's medications have a small effect size, showing efficacy for only a limited number of individuals with AUD. However, a host of new medications, which act on variety of pharmacologic targets, are in the pipeline and have been evaluated in numerous human studies. This article reviews the efficacy and safety of medications currently being tested in human trials and looks at ongoing efforts to identify candidate compounds in human studies. As mentioned in the National Institute on Alcohol Abuse and Alcoholism's Strategic Plan 2017-2021 ( https://www.niaaa.nih.gov/sites/default/files/StrategicPlan_NIAAA_optimized_2017-2020.pdf ), medications development remains a high priority. By developing more effective and safe medications, and identifying those patients who will benefit the most from these treatments, we can provide clinicians with the tools they need to treat this devastating disorder, providing relief for patients and their families and markedly improving public health and safety.

e-Addictology: An Overview of New Technologies for Assessing and Intervening in Addictive Behaviors

BACKGROUND

New technologies can profoundly change the way we understand psychiatric pathologies and addictive disorders. New concepts are emerging with the development of more accurate means of collecting live data, computerized questionnaires, and the use of passive data. Digital phenotyping, a paradigmatic example, refers to the use of computerized measurement tools to capture the characteristics of different psychiatric disorders. Similarly, machine learning-a form of artificial intelligence-can improve the classification of patients based on patterns that clinicians have not always considered in the past. Remote or automated interventions (web-based or smartphone-based apps), as well as virtual reality and neurofeedback, are already available or under development.

OBJECTIVE

These recent changes have the potential to disrupt practices, as well as practitioners' beliefs, ethics and representations, and may even call into question their professional culture. However, the impact of new technologies on health professionals' practice in addictive disorder care has yet to be determined. In the present paper, we therefore present an overview of new technology in the field of addiction medicine.

METHOD

Using the keywords [e-health], [m-health], [computer], [mobile], [smartphone], [wearable], [digital], [machine learning], [ecological momentary assessment], [biofeedback] and [virtual reality], we searched the PubMed database for the most representative articles in the field of assessment and interventions in substance use disorders.

RESULTS

We screened 595 abstracts and analyzed 92 articles, dividing them into seven categories: e-health program and web-based interventions, machine learning, computerized adaptive testing, wearable devices and digital phenotyping, ecological momentary assessment, biofeedback, and virtual reality.

CONCLUSION

This overview shows that new technologies can improve assessment and interventions in the field of addictive disorders. The precise role of connected devices, artificial intelligence and remote monitoring remains to be defined. If they are to be used effectively, these tools must be explained and adapted to the different profiles of physicians and patients. The involvement of patients, caregivers and other health professionals is essential to their design and assessment.

The Corticotropin Releasing Factor Receptor 1 in Alcohol Use Disorder: Still a Valid Drug Target?

Corticotropin releasing factor (CRF) is a neuropeptide that plays a key role in behavioral and physiological responses to stress. A large body of animal literature implicates CRF acting at type 1 CRF receptors (CRFR1) in consumption by alcohol-dependent subjects, stress-induced reinstatement of alcohol seeking, and possibly binge alcohol consumption. These studies have encouraged recent pilot studies of CRFR1 antagonists in humans with alcohol use disorder (AUD). It was a great disappointment to many in the field that these studies failed to show an effect of these compounds on stress-induced alcohol craving. Here, we examine these studies to explore potential limitations and discuss preclinical and human literature to ask whether CRFR1 is still a valid drug target to pursue for the treatment of AUD.

Topiramate and motivational enhancement therapy for cannabis use among youth: a randomized placebo-controlled pilot study

Cannabis misuse accounts for nearly all of the substance abuse treatment admissions among youth in the United States. Most youth do not experience sustained benefit from existing psychosocial treatments; however, medication development research for treating adolescent cannabis misuse is almost nonexistent. We conducted a double-blind, placebo-controlled, pilot study to test the potential efficacy of topiramate plus motivational enhancement therapy (MET) for treating cannabis use among adolescents. Sixty-six heavy cannabis users, ages 15 to 24 years, were randomized to one of two 6-week treatment conditions: topiramate plus MET or placebo plus MET. Topiramate was titrated over 4 weeks then stabilized at 200 mg/day for 2 weeks. MET was delivered biweekly for a total of three sessions. Only 48 percent of youths randomized to topiramate completed the 6-week trial (n = 19), compared with 77 percent of youths in the placebo condition (n = 20). Adverse medication side effects were the most common reason for withdrawal among participants in the topiramate group. Latent growth models showed that topiramate was superior to placebo for reducing the number of grams smoked per use day, but it did not improve abstinence rates. The same pattern of results was found when values for missing outcomes were imputed. We show that topiramate combined with MET demonstrated efficacy for reducing how much cannabis adolescents smoked when they used but did not affect abstinence rates. The magnitude of this effect was modest, however, and topiramate was poorly tolerated by youths, which calls into question the clinical importance of these findings.

Acute subjective response to alcohol as a function of reward and punishment sensitivity

Individual differences in subjective response to alcohol play a crucial role in the development of heavy drinking and related problems. In light of this, a growing focus of research has been identifying factors that contribute to differences in response. The aim of the present study was to determine whether individual differences in the subjective experience of rewarding and aversive effects of alcohol are a specific manifestation of general differences in reward and punishment sensitivity. Eighty-nine participants (M age=22.4, SD=1.9; 47.2% women) consumed a moderate dose of alcohol, i.e., peak breath alcohol concentration (BrAC)≈0.080g%, and rated their level of stimulation and sedation at seven timepoints over the BrAC curve. Sensitivity to reward and punishment were assessed by a self-report questionnaire prior to consumption. Multilevel growth models showed that post-consumption changes in stimulation ratings varied as a function of participants' level of reward and punishment sensitivity. Drinkers more sensitive to reward reported feeling more stimulated shortly after drinking and exhibited an attenuated rate of decline in stimulation over the blood alcohol curve, relative to drinkers with less strong reward sensitivity. Reward sensitivity was not related to subjective ratings of sedation, and punishment sensitivity was not related to either stimulation or sedation ratings. Findings suggest that reward sensitivity may increase risk for alcohol misuse among young adult social drinkers by increasing their subjective feelings of stimulation while drinking.

Emerging Pharmacologic Treatments for Adolescent Substance Use: Challenges and New Directions

Adolescence is a key period in the development of substance use and misuse. Substance use typically begins during adolescence and prevalence rates for many substance use disorders peak before age 21 years. Yet, despite clinical demand, treatments for youth rely almost entirely on psychosocial interventions that yield only modest benefit. One potential way to improve treatment effects is to augment the best available psychosocial interventions with pharmacotherapy. Although pharmacotherapy research has advanced care for adults with substance use disorders, no medication is indicated for adolescents and controlled trials with teenagers are scant. Optimizing treatments for youth will require closing this important gap in medication development research. In this paper we review the paucity of pharmacotherapy research for adolescent substance misuse, and we discuss how we can leverage human laboratory paradigms and technology to advance our understanding regarding if and how medications may improve treatment options for youths.

Active Ingredients of Treatment and Client Mechanisms of Change in Behavioral Treatments for Alcohol Use Disorders: Progress 10 Years Later

BACKGROUND

The current review revisits the article entitled: "Active Ingredients: How and Why Evidence-Based Alcohol Behavioral Treatment Interventions Work" published in Alcoholism: Clinical and Experimental Research. This work summarized proceedings from a 2004 Symposium of the same name that was held at the Annual Meeting of the Research Society on Alcoholism (RSA). A decade has passed, which provides occasion for an evaluation of progress. In 2014, an RSA symposium titled Active Treatment Ingredients and Client Mechanisms of Change in Behavioral Treatments for Alcohol Use Disorders: Progress 10 Years Later did just that.

METHODS

The current review revisits state-of-the-art research on the 3 treatments examined 10 years ago: cognitive behavioral therapy, alcohol behavior couples therapy, and 12-step facilitation. Because of its empirically validated effectiveness and robust research agenda on the study of process outcome, motivational interviewing has been selected as the fourth treatment modality to be discussed. For each of these 4 treatments, the reviewers provide a critical assessment of current theory and research with a special emphasis on key recommendations for the future.

RESULTS

Noteworthy progress has been made in identifying active ingredients of treatments and mechanisms of behavior change in these 4 behavioral interventions for alcohol and other drug use disorders. Not only have we established some of the mechanisms through which these evidence-based treatments work, but we have also uncovered some of the limitations in our existing frameworks and methods.

CONCLUSIONS

Further progress in this area will require a broader view with respect to conceptual frameworks, analytic methods, and measurement instrumentation.

Recommendations for the Design and Analysis of Treatment Trials for Alcohol Use Disorders

BACKGROUND

Over the past 60 years, the view that "alcoholism" is a disease for which the only acceptable goal of treatment is abstinence has given way to the recognition that alcohol use disorders (AUDs) occur on a continuum of severity, for which a variety of treatment options are appropriate. However, because the available treatments for AUDs are not effective for everyone, more research is needed to develop novel and more efficacious treatments to address the range of AUD severity in diverse populations. Here we offer recommendations for the design and analysis of alcohol treatment trials, with a specific focus on the careful conduct of randomized clinical trials of medications and nonpharmacological interventions for AUDs.

METHODS

This paper provides a narrative review of the quality of published clinical trials and recommendations for the optimal design and analysis of treatment trials for AUDs.

RESULTS

Despite considerable improvements in the design of alcohol clinical trials over the past 2 decades, many studies of AUD treatments have used faulty design features and statistical methods that are known to produce biased estimates of treatment efficacy.

CONCLUSIONS

The published statistical and methodological literatures provide clear guidance on methods to improve clinical trial design and analysis. Consistent use of state-of-the-art design features and analytic approaches will enhance the internal and external validity of treatment trials for AUDs across the spectrum of severity. The ultimate result of this attention to methodological rigor is that better treatment options will be identified for patients with an AUD.