Review article: pharmacotherapy for alcohol dependence - the why, the what and the wherefore

Advances in the understanding and management of alcohol-related liver disease

Alcohol-related liver disease (ALD) is a major cause of liver-related morbidity and mortality. Epidemiological trends indicate recent and predicted increases in the burden of disease. Disease progression is driven by continued alcohol exposure on a background of genetic predisposition together with environmental cofactors. Most individuals present with advanced disease despite a long history of excessive alcohol consumption and multiple missed opportunities to intervene. Increasing evidence supports the use of non-invasive tests to screen for and identify disease at earlier stages. There is a definite role for public health measures to reduce the overall burden of disease. At an individual level, however, the ability to influence subsequent disease course by modifying alcohol consumption or the underlying pathogenic mechanisms remains limited due to a comparative lack of effective, disease-modifying medical interventions. Abstinence from alcohol is the key determinant of outcome in established ALD and the cornerstone of clinical management. In those with decompensated ALD, liver transplant has a clear role. There is consensus that abstinence from alcohol for an arbitrary period should not be the sole determinant in a decision to transplant. An increasing understanding of the mechanisms by which alcohol causes liver disease in susceptible individuals offers the prospect of new therapeutic targets for disease-modifying drugs. Successful translation will require significant public and private investment in a disease area which has traditionally been underfunded when compared to its overall prevalence.

Mortality rates among patients successfully treated for hepatitis C in the era of interferon-free antivirals: population based cohort study

OBJECTIVES

To quantify mortality rates for patients successfully treated for hepatitis C in the era of interferon-free, direct acting antivirals and compare these rates with those of the general population.

DESIGN

Population based cohort study.

SETTING

British Columbia, Scotland, and England (England cohort consists of patients with cirrhosis only).

PARTICIPANTS

21 790 people who were successfully treated for hepatitis C in the era of interferon-free antivirals (2014-19). Participants were divided into three liver disease severity groups: people without cirrhosis (pre-cirrhosis), those with compensated cirrhosis, and those with end stage liver disease. Follow-up started 12 weeks after antiviral treatment completion and ended on date of death or 31 December 2019.

MAIN OUTCOME MEASURES

Crude and age-sex standardised mortality rates, and standardised mortality ratio comparing the number of deaths with that of the general population, adjusting for age, sex, and year. Poisson regression was used to identify factors associated with all cause mortality rates.

RESULTS

1572 (7%) participants died during follow-up. The leading causes of death were drug related mortality (n=383, 24%), liver failure (n=286, 18%), and liver cancer (n=250, 16%). Crude all cause mortality rates (deaths per 1000 person years) were 31.4 (95% confidence interval 29.3 to 33.7), 22.7 (20.7 to 25.0), and 39.6 (35.4 to 44.3) for cohorts from British Columbia, Scotland, and England, respectively. All cause mortality was considerably higher than the rate for the general population across all disease severity groups and settings; for example, all cause mortality was three times higher among people without cirrhosis in British Columbia (standardised mortality ratio 2.96, 95% confidence interval 2.71 to 3.23; P<0.001) and more than 10 times higher for patients with end stage liver disease in British Columbia (13.61, 11.94 to 15.49; P<0.001). In regression analyses, older age, recent substance misuse, alcohol misuse, and comorbidities were associated with higher mortality rates.

CONCLUSION

Mortality rates among people successfully treated for hepatitis C in the era of interferon-free, direct acting antivirals are high compared with the general population. Drug and liver related causes of death were the main drivers of excess mortality. These findings highlight the need for continued support and follow-up after successful treatment for hepatitis C to maximise the impact of direct acting antivirals.

MANEMOS. The Trigger Situations Inventory. Validation of a Measure Helping Relapse Prevention in the Treatment of Alcohol Use Disorders

Background: Relapse Prevention (RP) is a cognitive-behavioral approach that aims to identify situations at high risk of relapse and to support patients with alcohol use disorders (AUDs) in developing coping strategies for the maintenance of desired behavioral changes. Based on this framework, the present study aims to assess and validate the psychometric properties of the MANEMOS, a 24-item inventory of alcohol relapse triggering situations. Methods: The internal consistency and factor structure of the MANEMOS were analyzed in a sample of 313 (27.7% women) in-patients and out-patients, attending alcohol treatment programs in Italian addiction treatment facilities. Results: The results support the internal reliability and validity of the measure. A confirmative factor analysis has revealed the existence of eight distinct dimensions measuring relapse risk situations: namely, Pleasant emotions, Unpleasant emotions, Craving, Conflicts with others, Occasions, Social Pressure, Personal Control, and Physical Discomfort. The patients' assessment of the riskiness of the situation showed some significant differences depending on gender and on type of treatment received. Conclusions: The findings indicate that MANEMOS is a valid measure for identifying and reflecting on patients' high relapse-risk situations. This easy and flexible assessment measure may have important implications for prevention and clinical intervention.

Role of Cannabinoid CB2 Receptor in Alcohol Use Disorders: From Animal to Human Studies

Cumulative evidence has pointed out cannabinoid CB2 receptors (CB₂r) as a potential therapeutic key target for treating alcohol use disorder (AUD). This review provides the most relevant results obtained from rodent and human studies, including an integrative section focused on the involvement of CB₂r in the neurobiology of alcohol addiction. A literature search was conducted using the electronic databases Medline and Scopus for articles. The search strategy was as follows: “Receptor, Cannabinoid, CB2” AND “Alcohol-Related Disorders” AND “human/or patients”; “Receptor, Cannabinoid, CB2” AND “Alcohol” OR “Ethanol” AND “rodents/or mice/or rats”. Pharmacological approaches demonstrated that the activation or blockade of CB₂r modulated different alcohol-addictive behaviors. Rodent models of alcoholism revealed significant alterations of CB₂r in brain areas of the reward system. In addition, mice lacking CB₂r (CB₂KO) show increased alcohol consumption, motivation, and relapse alterations. It has been stressed that the potential neurobiological mechanisms underlying their behavioral effects involve critical elements of the alcohol reward system. Interestingly, recent postmortem studies showed CNR2 alterations in brain areas of alcoholic patients. Moreover, although the number of studies is limited, the results revealed an association between some genetic alterations of the CNR2 and an increased risk for developing AUD. This review provides evidence that CB₂r may play a role in alcohol addiction. Clinical studies are necessary to figure out whether CB₂r ligands may prove useful for the treatment of AUD in humans.

Treating Alcohol Use Disorder in Patients with Alcohol-Associated Liver Disease: Controversies in Pharmacological Therapy

Alcohol use disorder (AUD) is one of the main causes of global death and disability. The liver represents the main target of alcohol damage, and alcohol-associated liver disease (ALD) represents the first cause of liver cirrhosis in Western countries. Alcohol abstinence is the main goal of treatment in AUD patients with ALD, as treatments for ALD are less effective when drinking continues. Moreover, the persistence of alcohol consumption is associated with higher mortality, increased need for liver transplantation, and graft loss. The most effective treatment for AUD is the combination of psychosocial interventions, pharmacological therapy, and medical management. However, the effectiveness of these treatments in patients with ALD is doubtful even because AUD patients with ALD are usually excluded from pharmacological trials due to concerns on liver safety. This narrative review will discuss the treatment options for AUD-ALD patients focusing on controversies in pharmacological therapy.

Comorbid alcohol use and post-traumatic stress disorders: Pharmacotherapy with aldehyde dehydrogenase 2 inhibitors versus current agents

The increased risk of alcohol use disorder (AUD) in individuals with post-traumatic stress disorder (PTSD) is well-documented. Compared to individuals with PTSD or AUD alone, those with co-existing PTSD and AUD exhibit greater symptom severity, poorer quality of life, and poorer treatment outcomes. Although the treatment of comorbid AUD is vital for the effective management of PTSD, there is a lack of evidence on how to best treat comorbid PTSD and AUD, and currently, there are no FDA-approved treatments for the PTSD-AUD comorbidity. The objective of this manuscript is to review the evidence of a promising target for treating the AUD-PTSD comorbidity. First, we summarize the epidemiological evidence and review the completed clinical studies that have tested pharmacotherapeutic approaches for co-existing AUD and PTSD. Next, we summarize the shared pathological factors between AUD and PTSD. We conclude by providing a rationale for selectively inhibiting aldehyde dehydrogenase-2 as a potential target to treat comorbid AUD in persons with PTSD.

Service Users' Views and Experiences of Alcohol Relapse Prevention Treatment and Adherence: New Role for Pharmacists?

AIMS

To understand service users' views and experiences of alcohol relapse prevention medication, views of a telephone behavioural modification intervention delivered by pharmacists and the use of Contingency Management (CM) to support acamprosate adherence following assisted alcohol withdrawal.

METHODS

Four focus groups were conducted within four alcohol treatment and recovery groups across England (UK), with service users with lived experience of alcohol dependence (26 participants). Semi-structured topic guide was used to explore participants' views and experiences of alcohol relapse prevention medication, a telephone behavioural modification medication intervention delivered by pharmacists, and the use of CM to support acamprosate adherence. These were audio-recorded, transcribed verbatim and thematically analysed inductively and deductively.

RESULTS

Four themes were identified: concerns about support and availability of alcohol relapse prevention medication; lack of knowledge and understanding about acamprosate treatment; positive perceptions of acamprosate adherence telephone support from pharmacists; and negative perceptions of CM to support acamprosate adherence. There were misunderstandings about acamprosate's mode of action and strong negative beliefs about CM. However, most were positive about pharmacists' new role to support acamprosate adherence.

CONCLUSION

This study highlighted challenges service users face to commence alcohol relapse prevention medication. It appears service users could benefit from a pharmacist-led telephone intervention to improve understanding about acamprosate medication, particularly, if delivered in an engaging and motivating way.

rTMS Reduces Craving and Alcohol Use in Patients with Alcohol Use Disorder: Results of a Randomized, Sham-Controlled Clinical Trial

(1) Background: Current evidence-based treatments for alcohol use disorder (AUD) are moderately effective. Studies testing repetitive transcranial magnetic stimulation (rTMS) in AUD commonly apply a limited number of rTMS sessions with different rTMS settings, showing inconsistent effects on craving for alcohol. This study tested the efficacy of a robust rTMS protocol on craving and alcohol use. (2) Methods: In a single-blind randomized controlled trial in recently detoxified patients with AUD, ten days of high-frequency rTMS over the right dorsolateral prefrontal cortex on top of treatment as usual (n = 14) was compared with sham rTMS (n = 16). Outcome measures were alcohol craving and use over a follow-up period of one year. Analysis was performed by means of repeated measures multivariate analysis of variance. (3) Results: The results showed a main group-by-time interaction effect on craving (Wilks’ Λ = 0.348, F (12, 17) = 2.654, p = 0.032) and an effect of group on alcohol use (Wilk’s Λ = 0.44, F (6, 23) = 4.9, p = 0.002), with lower alcohol craving and use in the group with active rTMS compared to the control group. Differences in craving between groups were most prominent three months after treatment. At 12 months follow-up, there was no effect of rTMS on craving or abstinence. (4) Conclusions: This small-scale randomized controlled trial showed the efficacy of high-frequency rTMS over the right dlPFC diminished alcohol craving and use in recently detoxified patients with AUD during the first months after detoxification. These findings suggest that rTMS might be an effective add-on in treating patients with AUD and warrant replication in future large-scale studies.

Modulation of relapse-like drinking in male Sprague-Dawley rats by ligands targeting the α5GABAA receptor

Preclinical evidence suggests a key role for GABA_A receptors containing the α5 subunit (i.e., α5GABA_A receptors) in the abuse-related effects of alcohol, including the reinforcing and discriminative stimulus effects, as well as cue-induced alcohol-seeking behavior. However, the contribution of this GABA_A receptor subtype to relapse-like drinking behavior remains unknown. The present study evaluated the capacity of ligands targeting α5GABA_A receptors to modulate the alcohol deprivation effect (ADE), a model of relapse-like drinking. Groups of Sprague-Dawley rats underwent repeated cycles of long-term access to alcohol solutions (5%, 10%, 20% v/v) and water in the home cage followed by water only deprivation periods. Upon evidence that the ADE could be reliably expressed across cycles, drug treatment was initiated. One group received the α5GABA_A receptor-preferring agonist QH-ii-066 and the other group received the α5GABA_A receptor-selective inverse agonist L-655,708. At the end of ADE testing, rats underwent testing in the elevated zero maze under vehicle or L-655,708 treatment for assessment of anxiety-like behavior. The ADE was reliably expressed across repeated cycles of alcohol access/deprivation in a subset of rats. Low doses of QH-ii-066 enhanced expression of the ADE; whereas, L-655,708 dose-dependently inhibited expression of the ADE. L-655,708 did not engender anxiogenic effects in the elevated zero maze under the conditions evaluated. These findings suggest a key role for α5GABA_A receptor mechanisms in relapse-like drinking. Moreover, they suggest that α5GABA_A receptors may represent a novel pharmacological target for the development of medications to prevent or reduce alcohol relapse.

First-line Medications for the Outpatient Treatment of Alcohol Use Disorder: A Systematic Review of Perceived Barriers

OBJECTIVES

Alcohol use disorder (AUD) is a common illness with significant health and economic consequences. Although three pharmacotherapeutic agents have been shown to decrease heavy drinking days among individuals with AUD, they are vastly underutilized in clinical practice. The objective of this review was to elucidate barriers that may prevent patients from obtaining medication for addiction treatment (MAT) for AUD in an outpatient or residential setting.

METHODS

Electronic searches of Medline and EMBASE were conducted, and reference lists were hand-searched. All study designs which discussed the use of MAT for AUD in an outpatient or residential setting were eligible for inclusion. Two reviewers independently screened the search output to identify potentially eligible articles, the full texts of which were retrieved and assessed for inclusion.

RESULTS

After eliminating duplicate citations and articles that did not meet eligibility criteria, 23 articles were included in the review. Perceived barriers to obtaining pharmacotherapy for the treatment of AUD in an outpatient or residential setting were grouped into 3 themes: lack of knowledge and concerns about efficacy and complexity of prescribing; treatment philosophy and stigma; medication accessibility including formulary restrictions, geographical and socioeconomic barriers.

CONCLUSIONS

Although evidence-based pharmacotherapeutics have been approved for the treatment of AUD, our findings suggest patients continue to experience barriers to the use of these medications. Efforts should be made to increase rates of prescribing by providers and the use of medications by patients. More research is needed to further elucidate perceived barriers to MAT use, along with strategies to overcome them.

Use of pharmacotherapy for alcohol use disorder in Manitoba, Canada: A whole-population cohort study

OBJECTIVE

Update the evidence on use of pharmacotherapy for alcohol use disorder in a Canadian population.

METHODS

Using whole-population administrative data from Manitoba, Canada, we identified all residents age 12+ who were first diagnosed with alcohol use disorder between April 1, 1996 and March 31, 2015, and compared characteristics of those who filled a prescription for naltrexone, acamprosate or disulfiram at least once during that period to those who did not fill a prescription for an alcohol use disorder medication.

RESULTS

Only 1.3% of individuals with alcohol use disorder received pharmacotherapy (62.3% of prescriptions were for naltrexone, 39.4% for acamprosate, 7.5% for disulfiram). Most prescriptions came from family physicians in urban alcohol use disorder (53.6%) and psychiatrists (22.3%). Individuals were more likely to fill a prescription for alcohol use disorder medication if they lived in an urban vs rural environment (OR 2.25; 95% CI 1.83-2.77) or had a mood/anxiety disorder diagnosis vs no diagnosis (OR 2.40, 95% CI 1.98-2.90) in the five years before being diagnosed with alcohol use disorder.

CONCLUSION

Despite established evidence for the effectiveness of pharmacotherapy for alcohol use disorder, these medications continue to be profoundly underutilized in Canada.

Current Interventions for People Living with HIV Who Use Alcohol: Why Gender Matters

PURPOSE OF REVIEW

Alcohol is the most misused substance in the world. For people living with HIV (PLWH), alcohol misuse may impact ART adherence and viral suppression. This review of the most recently published alcohol intervention studies with PLWH examines how these studies considered gender in the samples, design, and analyses.

RECENT FINDINGS

Three searches were conducted initially, and 13 intervention studies fit our criteria with alcohol outcomes. In general, most studies did not consider gender and had used small samples, and few demonstrated significant efficacy/effectiveness outcomes. Five studies considered gender in their samples or analyses and/or were woman-focused with larger samples and demonstrated significant outcomes. It is essential for women who misuse alcohol to not only be well represented in alcohol and HIV research but also for studies to consider the barriers to reaching them and their contextual demands and/or co-occurring issues that may affect participation and outcomes in intervention research.

Real-world effectiveness of pharmacological treatments of alcohol use disorders in a Swedish nation-wide cohort of 125 556 patients

BACKGROUND AND AIM

Pharmacotherapy for alcohol use disorder (AUD) is recommendable, but under-used, possibly due to deficient knowledge of medications. This study aimed to investigate the real-world effectiveness of approved pharmacological treatments (disulfiram, acamprosate, naltrexone and nalmefene) of AUD.

DESIGN

A nation-wide, register-based cohort study.

SETTING

Sweden.

PARTICIPANTS

All residents aged 16-64 years living in Sweden with registered first-time treatment contact due to AUD from July 2006 to December 2016 (n = 125 556, 62.5% men) were identified from nation-wide registers.

MEASUREMENTS

The main outcome was hospitalization due to AUD. The secondary outcomes were hospitalization due to any cause, alcohol-related somatic causes, as well as work disability (sickness absence or disability pension), and death. Mortality was analysed with between-individual analysis using a traditional multivariate-adjusted Cox hazards regression model. Recurrent outcomes, such as hospitalization-based events and work disability, were analysed with within-individual analyses to eliminate selection bias.

FINDINGS

Naltrexone combined with acamprosate [hazard ratio (HR) = 0.74; 95% confidence interval (CI) = 0.61-0.89], combined with disulfiram (HR = 0.76, 95% CI = 0.60-0.96) and as monotherapy (HR = 0.89, 95% CI = 0.81-0.97) was associated with a significantly lower risk of AUD-hospitalization compared with no use of AUD medication. Similar results were found for risk of hospitalization due to any cause. Benzodiazepine use and acamprosate monotherapy were associated with an increased risk of AUD-hospitalization (HR = 1.18, 95% CI = 1.14-1.22 and HR = 1.10, 95% CI = 1.04-1.17, respectively). No statistically significant effects were found for work disability or mortality.

CONCLUSIONS

Naltrexone as monotherapy and when combined with disulfiram and acamprosate appears to be associated with lower risk of hospitalization due to any and alcohol-related causes, compared with no use of alcohol use disorder (AUD) medication. Acamprosate monotherapy and benzodiazepine use appear to be associated with increased risk of AUD-associated hospitalization.

Neurobiological correlates of cue-reactivity in alcohol-use disorders: A voxel-wise meta-analysis of fMRI studies

Altered brain responses to alcohol-associated stimuli are a neural hallmark of alcohol-use disorder (AUD) and a promising target for pharmacotherapy. However, findings in cue-reactivity based functional MRI (fMRI) studies are inconclusive. To investigate the neural substrates of cue-reactivity and their relevance to treatment outcomes, alcohol craving and relapse in AUD patients, we performed five meta-analyses using signed differential mapping software. Our meta-analysis revealed that alcohol cues evoke greater cue-reactivity than neutral cues in the mesocorticolimbic circuit and lower reactivity in the parietal and temporal regions in AUD patients. Compared to controls, AUD individuals displayed hyperactivations in the medial prefrontal cortex and anterior/middle part of the cingulate cortex. After receiving AUD treatment, AUD patients exhibited greater activations in the precentral gyrus but reduced activations in the bilateral caudate nucleus, insula, right DLPFC, and left superior frontal gyrus. No significant results were found in cue-reactivity correlates of alcohol craving and relapse. Our results implicate cue-induced abnormalities in corticostriatal-limbic circuits may underline the pathophysiology of AUD, and have translational value for treatment development.

Evidence-Based Guidelines and Secondary Meta-Analysis for the Use of Transcranial Direct Current Stimulation in Neurological and Psychiatric Disorders

BACKGROUND

Transcranial direct current stimulation has shown promising clinical results, leading to increased demand for an evidence-based review on its clinical effects.

OBJECTIVE

We convened a team of transcranial direct current stimulation experts to conduct a systematic review of clinical trials with more than 1 session of stimulation testing: pain, Parkinson's disease motor function and cognition, stroke motor function and language, epilepsy, major depressive disorder, obsessive compulsive disorder, Tourette syndrome, schizophrenia, and drug addiction.

METHODS

Experts were asked to conduct this systematic review according to the search methodology from PRISMA guidelines. Recommendations on efficacy were categorized into Levels A (definitely effective), B (probably effective), C (possibly effective), or no recommendation. We assessed risk of bias for all included studies to confirm whether results were driven by potentially biased studies.

RESULTS

Although most of the clinical trials have been designed as proof-of-concept trials, some of the indications analyzed in this review can be considered as definitely effective (Level A), such as depression, and probably effective (Level B), such as neuropathic pain, fibromyalgia, migraine, post-operative patient-controlled analgesia and pain, Parkinson's disease (motor and cognition), stroke (motor), epilepsy, schizophrenia, and alcohol addiction. Assessment of bias showed that most of the studies had low risk of biases, and sensitivity analysis for bias did not change these results. Effect sizes vary from 0.01 to 0.70 and were significant in about 8 conditions, with the largest effect size being in postoperative acute pain and smaller in stroke motor recovery (nonsignificant when combined with robotic therapy).

CONCLUSION

All recommendations listed here are based on current published PubMed-indexed data. Despite high levels of evidence in some conditions, it must be underscored that effect sizes and duration of effects are often limited; thus, real clinical impact needs to be further determined with different study designs.

Protective effect of Terminalia arjuna against alcohol induced oxidative damage of rat erythrocyte membranes

Background

Alcohol is a widely abused drug with many health implications, mainly caused by the oxidative and nitrosative stress on different body parts. Ayurvedic herbalism authenticates the multiple therapeutic applications of Terminalia arjuna bark due to its rich phytochemical repertoire.

Objective

To observe the extent of oxidative damage caused to erythrocytes by alcohol and assess the protective ability of T. arjuna bark powder aqueous extract (AETA) against the damage.

Materials and methods

Wister albino rats were categorized into four groups of eight rats per group; first group (control) was fed with glucose, second group was given alcohol at a dose of 20% v/v; 5g alcohol/kg b. wt/day, third group was co-administered with AETA (0.5 g/kg b. wt/day) and alcohol and the fourth group was kept on bark extract alone. Blood samples were collected and evaluated for different biochemical parameters after the completion of the treatment period.

Results

Alcohol significantly increased the erythrocyte membrane protein carbonyl and malondialdehyde (MDA) contents, along with a concomitant decrease in the membrane antioxidant status, when compared to the control group. Chromatographic analysis of the alcohol-treated rat erythrocyte membranes revealed altered membrane individual phospholipid contents and fluidity properties. Alcohol-induced morphological changes in the erythrocytes and its effect on decreasing the resistance of hypotonic shock induced by NaCl are evident from the hemolysis curves. However, AETA administration to alcoholic rats beneficially modulated the membrane properties anvd protected erythrocytes from damage.

Conclusion

Results suggest that AETA protects erythrocytes from alcohol-induced oxidative stress, biophysical, and biochemical changes very effectively.

[How to deal with alcohol: a qualitative evaluation of 30 interviews with alcohol-dependent patients]

INTRODUCTION

Alcohol dependence syndrome is a chronic-recurrent substance use disorder. Various treatments have been shown to be effective with a positive impact on the course of the disease. The patients' subjective perception of their disease and the offered treatments remain unclear.

METHODS

30 alcohol-dependent patients (n = 20 psychiatric clinic, n = 10 addiction counseling) were asked how they had dealt with their alcohol problem in the past. The interviews were recorded, transcribed and analyzed using current qualitative research methods.

RESULTS

While most patients positively rated many aspects in the three areas of alcohol abstinence, treatment and the social environment, they also described negative aspects in these areas.

DISCUSSION

The contradicting statements show an area of conflict that demonstrates the ambivalence of alcohol-dependent patients in relevant fields. This ambivalence can be considered as important for the therapy and the course of the disease.

[Pharmacotherapy of alcohol withdrawal: update and new developments]

Bislang sind nur wenige Medikamente zur pharmakologischen Rückfallprophylaxe der Alkoholabhängigkeit zugelassen. Neben dem in Deutschland nicht mehr vertriebenen Disulfiram sind es die Opioidantagonisten Naltrexon und Nalmefen sowie das vermutlich über glutamaterge Neurone wirkende Acamprosat. Baclofen und γ‑Hydroxybutyrat (GHB) sind in einzelnen Ländern zugelassen. Wirkstoffe wie z. B. Vareniclin, Gabapentin und Topiramat können für die Rückfallprophylaxe der Alkoholabhängigkeit von Interesse sein, jedoch ist bislang keine Zulassung erfolgt. Vor dem Hintergrund der zur Revision anstehenden S3-Leitlinie zur Diagnose und Behandlung alkoholbezogener Störungen wird der heutige Kenntnisstand zur Pharmakotherapie der Alkoholabhängigkeit dargestellt.

The influence of anxiety symptoms on clinical outcomes during baclofen treatment of alcohol use disorder: A systematic review and meta-analysis

Given the high coexistence of anxiety symptoms in people with alcohol use disorder (AUD), we aimed to determine the influence of anxiety symptoms on outcomes in patients with AUD treated with the GABA_B receptor agonist baclofen. A meta-analysis of 13 comparisons (published 2010-2020) including baseline and outcome data on alcohol consumption and anxiety after 12 weeks was undertaken. There were significantly higher rates of abstinent days in patients treated with baclofen compared to placebo (p = 0.004; high certainty evidence); specifically in those with higher baseline anxiety levels (p < 0.00001; high certainty evidence) compared to those with lower baseline anxiety levels (p = 0.20; moderate certainty evidence). The change in anxiety ratings over 12 weeks did not differ between those treated with baclofen or placebo (p = 0.84; moderate certainty evidence). This may be due to different anxiety constructs being measured by scales not validated in this patient group, or that anxiety is not a biobehavioral mechanism by which baclofen may reduce alcohol drinking. Given the prevalence of anxiety symptoms in AUD all these factors warrant further research.

Understanding the neurobiological effects of drug abuse: Lessons from zebrafish models

Drug abuse and brain disorders related to drug comsumption are public health problems with harmful individual and social consequences. The identification of therapeutic targets and precise pharmacological treatments to these neuropsychiatric conditions associated with drug abuse are urgently needed. Understanding the link between neurobiological mechanisms and behavior is a key aspect of elucidating drug abuse-related targets. Due to various molecular, biochemical, pharmacological, and physiological features, the zebrafish (Danio rerio) has been considered a suitable vertebrate for modeling complex processes involved in drug abuse responses. In this review, we discuss how the zebrafish has been successfully used for modeling neurobehavioral phenotypes related to drug abuse and review the effects of opioids, cannabinoids, alcohol, nicotine, and psychedelic drugs on the central nervous system (CNS). Moreover, we summarize recent advances in zebrafish-based studies and outline potential advantages and limitations of the existing zebrafish models to explore the neurochemical bases of drug abuse and addiction. Finally, we discuss how the use of zebrafish models may present fruitful approaches to provide valuable clinically translatable data.

Impact of Alcohol Use Disorder Treatment on Clinical Outcomes Among Patients With Cirrhosis

BACKGROUND AND AIMS

Despite the significant medical and economic consequences of coexisting alcohol use disorder (AUD) in patients with cirrhosis, little is known about AUD treatment patterns and their impact on clinical outcomes in this population. We aimed to characterize the use of and outcomes associated with AUD treatment in patients with cirrhosis.

APPROACH AND RESULTS

This retrospective cohort study included Veterans with cirrhosis who received Veterans Health Administration care and had an index diagnosis of AUD between 2011 and 2015. We assessed the baseline factors associated with AUD treatment (pharmacotherapy or behavioral therapy) and clinical outcomes for 180 days following the first AUD diagnosis code within the study time frame. Among 93,612 Veterans with cirrhosis, we identified 35,682 with AUD, after excluding 2,671 who had prior diagnoses of AUD and recent treatment. Over 180 days following the index diagnosis of AUD, 5,088 (14%) received AUD treatment, including 4,461 (12%) who received behavioral therapy alone, 159 (0.4%) who received pharmacotherapy alone, and 468 (1%) who received both behavioral therapy and pharmacotherapy. In adjusted analyses, behavioral and/or pharmacotherapy-based AUD treatment was associated with a significant reduction in incident hepatic decompensation (6.5% vs. 11.6%, adjusted odds ratio [AOR], 0.63; 95% confidence interval [CI], 0.52, 0.76), a nonsignificant decrease in short-term all-cause mortality (2.6% vs. 3.9%, AOR, 0.79; 95% CI, 0.57, 1.08), and a significant decrease in long-term all-cause mortality (51% vs. 58%, AOR, 0.87; 95% CI, 0.80, 0.96).

CONCLUSIONS

Most Veterans with cirrhosis and coexisting AUD did not receive behavioral therapy or pharmacotherapy treatment for AUD over a 6-month follow-up. The reductions in hepatic decompensation and mortality suggest that future studies should focus on delivering evidence-based AUD treatments to patients with coexisting AUD and cirrhosis.

Effects of quetiapine on behavioral changes and expression of myelin proteins in a chronic alcohol dependence rat model

BACKGROUND

As an atypical antipsychotic drug, quetiapine had been approved for bipolar disorder and for adjunctive therapy in major depressive disorder and schizophrenia. Recently quetiapine has been suggested to be a promising pharmacotherapy for alcohol dependence. This study was performed to determine the effects of quetiapine in rats chronically exposed to ethanol.

METHODS

Rats were exposed to ethanol solution (10 %; v/v) for 6 weeks. Saline or one of three doses of quetiapine (10, 20 or 40 mg/kg/day) was given by oral gavage while ethanol exposure for the next 14 weeks. Performance of learning and memory and withdrawal signs were evaluated. Then immunohistochemistry, western blot, quantitative real-time-PCR and transmission electron microscopy were performed to determine the effects of quetiapine on alterations of brain white matter markers (myelin basic protein, MBP; proteolipid protein, PLP) and morphology caused by chronic ethanol exposure.

RESULTS

Quetiapine treatment significantly alleviated withdrawal signs in the ethanol exposed rats. Chronic ethanol exposure reduced Y-type electric maze scores and the protein/mRNA expression levels of MBP and PLP in the prefrontal cortex and hippocampus, and these effects were reversed by quetiapine treatment. Similar ultrastructure morphological changes were observed.

CONCLUSIONS

Chronic quetiapine treatment alleviated the damage induced by chronic ethanol exposure with regard to learning and memory ability and to brain white matter. Thus, quetiapine appears to be a potentially promising pharmacotherapy for the treatment of alcohol use disorder.

Screening and care for alcohol use disorder in France: expectations, barriers and levers using a mixed-methods approach

Background

The widespread under-screening and under-treatment of alcohol use disorder (AUD) contributes to its health and socioeconomic burden. We conducted a mixed-methods (qualitative and qualitative) study in people with alcohol use disorder (PWAUD) to explore their expectations, as well as barriers and levers to AUD care.

Methods

Individuals with AUDIT > 15 (N = 179) were interviewed using computer-assisted interviews in several medical and non-medical sites (e.g., bars) (quantitative substudy). We also conducted semi-structured face-to-face interviews with 36 PWAUD (qualitative substudy). Using logistic regression, we explored factors associated with having previously received/sought care for AUD. Three major themes were identified in the qualitative textual analysis using a descending hierarchical classification.

Results

Not socializing with heavy drinkers (AOR [95%CI]:3.84[1.66–8.85]), regular smoking (9.72[3.91–24.15]) and feeling discriminated against (2.35[1.10–5.05]) were independent levers to having sought/received care for AUD, while being aged < 50 and employment were independent barriers. The five predominant themes in PWAUD discourses emerging from the textual analysis were: drinking context, medical care, alcohol treatment, tobacco/addiction and family. When triangulating results from the logistic regression and the textual analysis, two barriers (social drinking and difficulties with the medical care system), and two levers (family influence and tobacco addiction), emerged.

Conclusion

These results underline the need for interventions targeting families and the social network to increase awareness about AUD and related care. Simplified and novel comprehensive care trajectories are urgently needed to reduce the clinical and public health burden of AUD.

Alcoholism and nutrition: a review of vitamin supplementation and treatment

PURPOSE OF REVIEW

This is a review of the research on the effectiveness of vitamin supplementation for alcoholism and alcohol-related illnesses. The focus is on research, both clinical and basic on alcohol treatment and nutritional effectiveness of these vital nutrients.

RECENT FINDINGS

Most of the research involves basic experiments exploring the impact of vitamin depletion or deficits on physiological systems, especially liver and brain, in rodents. These often include behavioral measures that use cognitive, learning/memory and motivation experiments that model clinical studies. These provide support for hypotheses concerning the impact of such deficiencies in clinical populations. Clinical studies are rare and involve evaluation of the outcome of supplementation usually in the context of a treatment program. Specific vitamins, dosages and treatment programs vary. Deficiencies in retinoids (vitamin A), thiamine (B1) and niacin (B3) are the most frequently investigated. However, there is a greater need for further research on other vitamins, and for more uniform supplementation and treatment procedures.

SUMMARY

The literature is primarily basic research on specific vitamins. There are very significant findings with individual vitamin supplementation and combinations that show promise of our understanding of the role of vitamins in the disease of alcoholism and its treatment.

Diagnosis and Management of Alcohol Use Disorder in Patients with Liver Disease: Lights and Shadows

Alcohol use disorder is the most common cause of advanced liver disease in the Western world. Diagnosis of alcohol use disorder can be difficult because patients with liver disease tend to deny alcohol intake for the fear of being excluded from treatment and because available biomarkers of alcohol intake have poor specificity in these patients. Alcohol abstinence is the cornerstone of the therapy in these patients. However, pharmacological treatments for alcohol use disorders have not been formally tested in patients with advanced liver disease, except for baclofen. Psychosocial intervention became crucial in these patients considering the limited pharmacological choice. However, psychosocial approach and an appropriate team to manage these patients are not still well defined. In this review, we critically discuss the diagnosis and the management of alcohol use disorder in patients with liver disease.

Survey of Addiction Specialists' Use of Medications to Treat Alcohol Use Disorder

OBJECTIVES

Several medications have been shown to be safe and effective for treating alcohol use disorder (AUD); however, these medications are prescribed infrequently. We conducted a survey of the demographics, practice characteristics, and self-perceived knowledge, experience, and opinions of addiction specialists on the use of AUD medications and how to increase their use.

METHODS

We sent a 19-question survey to members of the American Society of Addiction Medicine (ASAM) and the American Academy of Addiction Psychiatry (AAAP).

RESULTS

We received a total of 395 responses from ASAM members and 194 responses from AAAP members. One hundred of the respondents were members of both organizations. The large majority of respondents (92.6%) were prescribers, and 81.6% were non-trainee physicians. The two most frequently used medications for treating AUD were oral naltrexone (27%) and long-acting naltrexone (18%). Respondents were significantly more confident in the strength of the research findings and evidence for the efficacy and safety of naltrexone than other AUD medications (p < 0.001 ). Respondents identified additional education to current providers about existing medications as the most important potential intervention to increase the use of AUD medications.

CONCLUSIONS

Compared with a survey published in 2001, in 2018 the proportion of respondents who reported using naltrexone more than doubled and addiction specialists were more confident in their use of AUD medications, rating their efficacy and safety more highly. Consistent with findings from other recent studies, providing more education to practitioners about existing AUD medications may be the most effective way to increase their use.

Management of end-stage alcohol-related liver disease and severe acute alcohol-related hepatitis: position paper of the Italian Society on Alcohol (SIA)

Worldwide, the prevalence of alcohol use disorder (AUD) is 20-30% in men and 10-15% in women, and cirrhosis due to alcohol-related liver disease (ALD) is responsible for 0.9% of global deaths and 47.9% of cirrhosis-related deaths. End-stage ALD (ESALD) is the final condition of alcohol-related cirrhosis, and severe acute alcohol-related hepatitis (SAAH) is a distinct clinical syndrome associated with the consumption of large amounts of alcohol. In some cases, ESALD, and SAAH may need liver transplantation (LT). Thus, the management of ESALD and SAAH in patients affected by AUD may be an essential part of the clinical skills for hepatologists. For these reasons, the national board of the Italian Society on Alcohol have reviewed the most recent data on the management of ESALD, SAAH and LT for ALD in patients with AUD, formulating a position paper with related recommendations regarding four issues of specific clinical interest in this field: (a) the management of hepatic encephalopathy in patients with AUD, and LT in patients with ESALD; (b) the management of SAAH; (c) the management of AUD in patients with ESALD and SAAH; (d) special populations: polydrug addicts.

The melanocortin system as a potential target for treating alcohol use disorders: A review of pre-clinical data

The melanocortin (MC) system consists of neuropeptides that are cleaved from the polypeptide precursor proopiomelanocortin (POMC). In the brain, MC neuropeptides signal primarily through the MC-3 and MC-4 receptors, which are widely expressed throughout the brain. While the MC system has been largely studied for its role in food intake and body weight regulation, converging evidence has emerged over approximately the last 20-years showing that alcohol (ethanol), and other drugs of abuse influence the central MC system, and that manipulating MC receptor signalling modulates ethanol intake. Although there is divergent evidence, the wealth of data appears to suggest that activating MC signalling, primarily through the MC-4 receptor, is protective against excessive ethanol consumption. In the present review, we first describe the MC system and then detail how ethanol exposure and consumption alters central MC and MC-receptor expression and levels. This is followed by a review of the data, from pharmacological and genetic studies, which show that manipulations of MC receptor activity alter ethanol intake. We then briefly highlight studies implicating a role for the MC system in modulating neurobiological responses and intake of other drugs of abuse, including amphetamine, cocaine and opioids. Finally, we introduce relatively new observations that the drug, bupropion (BUP), a drug that activates central MC activity, significantly reduces ethanol intake in rodent models when administered alone and in combination with the non-selective opioid receptor antagonist, naltrexone. Phase II clinical trials are currently underway to assess the efficacy of BUP as a treatment for alcohol use disorders.

A real-world study on clinical predictors of relapse after hospitalized detoxification in a Chinese cohort with alcohol dependence

BACKGROUND

The relapse rate of alcohol dependence (AD) after detoxification is high, but few studies have investigated the clinical predictors of relapse after hospitalized detoxification in real-world clinical practice, especially among Chinese patients.

METHODS

This longitudinal cohort study followed up 122 AD patients who were discharged from January 1, 2016 to January 30, 2018 from their most recent hospitalization for detoxification. These patients were interviewed by telephone from May 20, 2017, to June 30, 2018, at least 6 months after discharge. During the interview, the relapse were assessed by using a revised Chinese version of the Alcohol Use Disorder Identification Test. Candidate predictors, such as therapeutic modalities during hospitalization and at discharge, medical history data related to alcohol use, and demographic information, were obtained from the medical records in the hospital information system.

RESULTS

During the 6-24 months (with a median of 9 months) follow-up period, the relapse rate was 53.3%. Individuals with a college education level and those who had not been treated with the brief comprehensive cognitive-motivational-behavioural intervention (CCMBI) were more likely than their counterparts to relapse after hospitalized detoxification, and their adjusted HRs (95% CIs) were 1.85 (1.09, 3.16) and 2.00 (1.16, 3.46), respectively. The CCMBI use predicted a reduction in the relapse rate by approximately one-fifth.

CONCLUSION

Undergoing the CCMBI during detoxification hospitalization and having less than a college-level education could predict a reduced risk of AD relapse. These findings provide useful information both for further clinical research and for real-world practice.

Pharmacogenetics of alcohol addiction: current perspectives

Genetics of alcohol addiction is currently a contradictive and complex field, where data in the most studies reflect methods’ limitations rather than meaningful and complementary results. In our review, we focus on the genetics of alcohol addiction, leaving genetics of acute alcohol intoxication out of the scope. A review of the literature on pharmacogenetic biomarkers development for the pharmacotherapy personalization reveals that today the evidence base concerning these biomarkers is still insufficient. In particular, now the researches with the design of randomized controlled trials and meta-analysis investigating the effect of the SNPs as biomarkers on the therapy efficacy are available for naltrexone only. For other medications, there are only a few studies in small samples. It decreases the possibilities to implement the pharmacogenetic algorithms for the pharmacotherapy personalization in patients with alcohol use disorders (AUD). In view of the importance of the precision approaches development not in addiction medicine only, but in other fields of medicine also to increase the efficacy and safety of the therapy, studies on pharmacogenetic biomarkers development for the medications used in patients with AUD (eg, naltrexone, disulfiram, nalmefene, acamprosate, etc.) remain relevant to this day.

Diagnosis and Treatment of Alcohol Use Disorder in Patients With End-Stage Alcoholic Liver Disease

Between 14%-30% of the world's population is affected by alcohol use disorder (AUD), and excessive alcohol consumption represents the most common cause of liver disease in the western world. The clinical picture of alcoholic end-stage liver disease is rendered extremely complex, as manifestations such as alcohol withdrawal syndrome, craving and physical dependence, as well as extrahepatic alcohol-related diseases merge with the complications of advanced cirrhosis. This makes AUD recognition and assessment difficult and its management arduous as many drugs commonly used to treat complications such as alcohol withdrawal syndrome are often contraindicated by the presence of hepatic encephalopathy or hepatorenal syndrome. Reaching and maintaining abstinence represents the mainstay of managing patients with AUD and end-stage liver disease. Psychosocial interventions are an essential component of treatment to reach these goals. However, these interventions alone often prove insufficient in AUD patients and even more frequently in those with end-stage liver disease because of inadequate adherence due to poor functional and physical status. Pharmacological treatments need to be associated, but the available options are greatly limited in end-stage liver disease because many GABA-Ergic drugs can favor the development of hepatic encephalopathy, whereas drugs undergoing extensive liver metabolism should be avoided or used with the greatest caution. Because of these limitations, the management of end-stage AUD is extremely challenging and requires an integrated multidisciplinary approach.

Selecting an appropriate alcohol pharmacotherapy: review of recent findings

PURPOSE OF REVIEW

Only a few pharmacological treatments are available for treating alcohol use disorders (AUDs). Disulfiram, naltrexone and acamprosate are Food and Drug Administration (FDA)-approved and nalmefene is EMA-approved in European Union. Off-label medications, such as baclofen, gabapentin, ondansetron and topiramate are medications commonly prescribed for the treatment of AUD. The aim of this review is to give an update on recent randomized controlled trials (RCTs) and reviews evaluating pharmacological treatment for AUD.

RECENT FINDINGS

A literature search was conducted for pharmacological treatment for alcohol use disorder, published from January 2017 to January 2019. An additional search from two ongoing-study databases was performed. A total of 13 studies, 11 reviews and 7 on-going clinical trials were identified. Interest in studying baclofen as a treatment for AUD was greater compared with other medications, yet with inconclusive results. Three new RCTs of first-line medication naltrexone showed reduction in drinking.

SUMMARY

Three new published RCTs focus on baclofen and naltrexone. These results are consistent with old findings demonstrating that naltrexone reduces heavy drinking. Several RCT on baclofen do not support the use of baclofen for treatment of AUD. Encouraging results have been reported for topiramate, gabapentin and also varenicline, which might be useful in patients with comorbid nicotine dependence.

The effects of histone deacetylase inhibitors on the attentional set-shifting task performance of alcohol-dependent rats

OBJECTIVES

Alcohol dependence causes extensive damage to the central nervous system, resulting in impaired brain structure and behavioral changes. Moreover, histone deacetylase (HDAC) inhibitors restrain the activity of HDAC and cause increased histone acetylation, which may be related to alcohol dependence.

METHODS

Ethanol dependence was modelled in animals by persistent alcohol exposure and tested in the conditioned place preference (CPP) paradigm. To induce CPP, the alcohol-treated rats were given orally gradient concentration (3%, 6%, and 9% v/v) alcohol administration for 20 consecutive days. The sodium butyrate (NaB)-treated rats were injected daily. Cognitive flexibility was evaluated using an attentional set-shifting task (ASST) in which the rats performed a series of seven consecutive discriminations after the final CPP paradigm.

RESULTS

Ethanol administration induced alcohol dependence behaviors, with more time spent in the ethanol-paired compartment. Compared with the CPP scores of the control group, the scores of the ethanol- and NaB-treated groups were significantly higher. In the ASST, alcohol-treated rats had significantly increased number of trials to reach criteria (TTC) in most phases, higher error rate, and lower cognitive levels compared to the control group. Moreover, the present findings demonstrated that NaB combined with ethanol caused cognitive deficits as the result of an increased number of TTC during the ASST.

CONCLUSIONS

The attentional/cognitive flexibility of the prefrontal cortex of alcohol-dependent rats was damaged and the NaB administration procedure itself did not produce cognitive deficits, but instead exacerbated cognitive impairment in alcohol-dependent rats.

The Use of Naltrexone in Dermatology. Current Evidence and Future Directions

Naltrexone is a competitive opioid receptor antagonist approved as supportive treatment in alcohol dependence and opioid addiction. At a dose of 50-100 mg daily, naltrexone is used off-label in dermatology for the treatment of trichotillomania and different types of pruritus. At a dose as low as 1- 5 mg per day, naltrexone demonstrates immunomodulatory action i.e. modulates Toll-like receptors signaling, decreases release of proinflammatory cytokines (tumor necrosis factor, interleukin-6, interleukin- 12), inhibits T lymphocyte proliferation, down-regulates the expression of chemokine receptors and adhesion molecules. The efficacy of standard and low doses of naltrexone in a variety of dermatological disorders has been reported. These include diseases such as familial benign chronic pemphigus (Hailey-Hailey disease), dermatomyositis, systemic sclerosis, psoriasis and lichen planopilaris. Optimistic preliminary findings, low cost of therapy and good tolerance make naltrexone a promising alternative therapy or adjunct drug in dermatology.

Advances in the treatment of severe alcoholic hepatitis

Severe alcoholic hepatitis (SAH) is a costly and worldwide public health issue with high morbidity and mortality. Specific effective treatments for SAH have yet to be established. The aim of the present article is to review the current knowledge of the pathogenesis, assessment and treatment options in patients with SAH. To date, alcohol abstinence and enteral nutrition are the recommended first-line treatments. Although corticosteroids remain the preferred therapy for certain patients with a modified Maddrey discriminant function level greater than 54, they only improve short-term survival rates. New research focuses on liver inflammation, liver regeneration, the gut-liver axis, human induced pluripotent stem cells and extracorporeal albumin dialysis. Liver transplantation is considered the last medical option for patients with SAH who are nonresponsive to other medical treatments.

Repetitive transcranial magnetic stimulation: Re-wiring the alcoholic human brain

Alcohol use disorders (AUDs) are one of the leading causes of mortality and morbidity worldwide. In spite of significant advances in understanding the neural underpinnings of AUDs, therapeutic options remain limited. Recent studies have highlighted the potential of repetitive transcranial magnetic stimulation (rTMS) as an innovative, safe, and cost-effective treatment for AUDs. Here, we summarize the fundamental principles of rTMS and its putative mechanisms of action via neurocircuitries related to alcohol addiction. We will also discuss advantages and limitations of rTMS, and argue that Hebbian plasticity and connectivity changes, as well as state-dependency, play a role in shaping some of the long-term effects of rTMS. Visual imaging studies will be linked to recent clinical pilot studies describing the effect of rTMS on alcohol craving and intake, pinpointing new advances, and highlighting conceptual gaps to be filled by future controlled studies.

Access to care for people with alcohol use disorder in France: a mixed-method cross-sectional study protocol (ASIA)

INTRODUCTION

Alcohol use disorder (AUD) is a major public health concern worldwide. In France, only 10% of people with AUD (PWAUD) receive medical care. General practitioners (GP) are one of the main entry points for AUD care. The present ongoing study, entitled ASIA (Access to Care and Indifference toward Alcohol, Accès aux Soins et Indifference à l'Alcool in French), aims to improve knowledge about factors associated with access to care for AUD by exploring related GP and PWAUD practices, experiences and perceptions.

METHODS AND ANALYSIS

The ASIA project is an ongoing cross-sectional multisite study based on a complementary mixed-method approach (quantitative and qualitative) using a convergent parallel design. The double-perspective design of the study will enable us to collect and compare data regarding both PWAUD and GP points of view. For the PWAUD quantitative study, 260 PWAUD will be interviewed using a telephone-based questionnaire. For the qualitative study, 36 PWAUD have already been interviewed. The GP quantitative study will include 100 GP in a 15 min survey. Fifteen GP have already participated in semistructured interviews for the qualitative study. Logistic regression will be used to identify predictors for access to care. With respect to data analyses, qualitative interviews will be analysed using semantic analysis while quantitative logistic regression will be used for quantitative interviews.

ETHICS AND DISSEMINATION

This study was approved by the CNIL (French National Commission on Informatics and Liberties) (approval reference number: C16-10, date of approval: 17 July 2017), the CCTIRS (Advisory Committee on Information Processing in Material Research in the Field of Health) and the CEEI (Evaluation and Ethics Committee) (approval reference number: 16-312, date of approval: 8 July 2016) of INSERM (French National Institute of Health and Medical Research). Results from ASIA will be disseminated in peer-reviewed publications, conference presentations, reports and in a PhD thesis.

Baclofen in the Treatment of Patients With Alcohol Use Disorder and Other Mental Health Disorders

A limited number of medications are approved to treat Alcohol Use Disorder (AUD). Furthermore, the magnitude of their therapeutic effect is relatively modest, suggesting the potential for subtypes of patients who respond to a specific medication. The use of these medications is also limited in clinical practice by a series of contraindications such as medical comorbidities and/or concurrent use of other medications. In recent years, animal and human studies have been conducted to evaluate the efficacy of baclofen, a GABAB receptor agonist approved for clinical use as a muscle relaxant, in the treatment of AUD. However, these studies have yielded contrasting results. Despite this discrepancy, baclofen is often used off-label to treat AUD, especially in some European countries and Australia. Recently, several factors have been considered to try to shed light on the potential reasons and mechanisms underlying the inconsistent results obtained until now. The presence of a psychiatric comorbidity may be amongst the abovementioned factors playing a role in explaining different responses to baclofen treatment in terms of alcohol drinking outcomes. Therefore, the aim here was to conduct a narrative review of the scientific literature related to the use of baclofen in AUD, both in patients with and without concomitant psychiatric disorders. All clinical studies (randomized and controlled, open-label, retrospective, human laboratory studies, and case reports) were analyzed and discussed, bearing in mind other potential factors that may have influenced baclofen response, including dose administered, severity of AUD, use of other psychosocial therapies, and the presence of physical disorders. This review indicates that the most frequent psychiatric comorbidities in patients affected by AUD undergoing baclofen treatment are anxiety and mood disorders. Unfortunately, no definitive conclusions can be drawn due to the lack of specific analyses on whether baclofen efficacy is different in AUD patients with comorbid psychiatric disorders vs. those without. Therefore, it will be critical that psychiatric comorbidities are considered in the planning of future studies and in the analysis of the data, with the ultimate goal of understanding whether subtypes of AUD patients may respond best to baclofen.

Exploring the role of low-frequency and rare exonic variants in alcohol and tobacco use

BACKGROUND

Alcohol and tobacco use are heritable phenotypes. However, only a small number of common genetic variants have been identified, and common variants account for a modest proportion of the heritability. Therefore, this study aims to investigate the role of low-frequency and rare variants in alcohol and tobacco use.

METHODS

We meta-analyzed ExomeChip association results from eight discovery cohorts and included 12,466 subjects and 7432 smokers in the analysis of alcohol consumption and tobacco use, respectively. The ExomeChip interrogates low-frequency and rare exonic variants, and in addition a small pool of common variants. We investigated top variants in an independent sample in which ICD-9 diagnoses of "alcoholism" (N = 25,508) and "tobacco use disorder" (N = 27,068) had been assessed. In addition to the single variant analysis, we performed gene-based, polygenic risk score (PRS), and pathway analyses.

RESULTS

The meta-analysis did not yield exome-wide significant results. When we jointly analyzed our top results with the independent sample, no low-frequency or rare variants reached significance for alcohol consumption or tobacco use. However, two common variants that were present on the ExomeChip, rs16969968 (p = 2.39 × 10^-7) and rs8034191 (p = 6.31 × 10^-7) located in CHRNA5 and AGPHD1 at 15q25.1, showed evidence for association with tobacco use.

DISCUSSION

Low-frequency and rare exonic variants with large effects do not play a major role in alcohol and tobacco use, nor does the aggregate effect of ExomeChip variants. However, our results confirmed the role of the CHRNA5-CHRNA3-CHRNB4 cluster of nicotinic acetylcholine receptor subunit genes in tobacco use.

Combined exposure to carbon disulfide and low-frequency noise reversibly affects vestibular function

Chronic occupational exposure to carbon disulfide (CS2) has debilitating motor and sensory effects in humans, which can increase the risk of falls. Although no mention of vestibulotoxic effects is contained in the literature, epidemiological and experimental data suggest that CS2 could cause low-frequency hearing loss when associated with noise exposure. Low-frequency noise might also perturb the peripheral balance receptor through an as-yet unclear mechanism. Here, we studied how exposure to a low-frequency noise combined with 250-ppm CS2 affected balance in rats. Vestibular function was tested based on post-rotary nystagmus recorded by a video-oculography system. These measurements were completed by behavioral tests and analysis of the cerebellum to measure expression levels for gene expression associated with neurotoxicity. Assays were performed prior to and following a 4-week exposure, and again after a 4-week recovery period. Functional measurements were completed by histological analyses of the peripheral organs.Nystagmus was unaltered by exposure to noise alone, while CS2 alone caused a moderate 19% decrease of the saccade number. In contrast, coexposure to 250-ppm CS2 and low-frequency noise decreased both saccade number and duration by 33% and 34%, respectively. After four weeks, recovery was only partial but measures were not significantly different from pre-exposure values. Real-time quantitative polymerase chain reaction (RT-qPCR) analysis of cerebellar tissue revealed a slight but significant modification in expression levels for two genes linked to neurotoxicity in CS2-exposed animals. However, neither histopathological changes to the peripheral receptor nor behavioral differences were observed. Based on all these results, we propose that the effects of CS2 were due to reversible neurochemical disturbance of the efferent pathways managing post-rotatory nystagmus. Because the nervous structures involving the vestibular function appear particularly sensitive to CS2, post-rotary nystagmus could be used as an early, non-invasive measurement to diagnose CS2 intoxication as part of an occupational conservation program.

In Vitro Functional Characterization of GET73 as Possible Negative Allosteric Modulator of Metabotropic Glutamate Receptor 5

The present study was aimed to further characterize the pharmacological profile of N-[4-(trifluoromethyl) benzyl]-4-methoxybutyramide (GET73), a putative negative allosteric modulator (NAM) of metabotropic glutamate subtype 5 receptor (mGluR5) under development as a novel medication for the treatment of alcohol dependence. This aim has been accomplished by means of a series of in vitro functional assays. These assays include the measure of several down-stream signaling [intracellular Ca⁺⁺ levels, inositol phosphate (IP) formation and CREB phosphorylation (pCREB)] which are generally affected by mGluR5 ligands. In particular, GET73 (0.1 nM-10 μM) was explored for its ability to displace the concentration-response curve of some mGluR5 agonists/probes (glutamate, L-quisqualate, CHPG) in different native preparations. GET73 produced a rightward shift of concentration-response curves of glutamate- and CHPG-induced intracellular Ca⁺⁺ levels in primary cultures of rat cortical astrocytes. The compound also induced a rightward shift of concentration response curve of glutamate- and L-quisqualate-induced increase in IP turnover in rat hippocampus slices, along with a reduction of CHPG (10 mM)-induced increase in IP formation. Moreover, GET73 produced a rightward shift of concentration-response curve of glutamate-, CHPG- and L-quisqualate-induced pCREB levels in rat cerebral cortex neurons. Although the engagement of other targets cannot be definitively ruled out, these data support the view that GET73 acts as an mGluR5 NAM and support the significance of further investigating the possible mechanism of action of the compound.

Pharmacologically controlled drinking in the treatment of alcohol dependence or alcohol use disorders: a systematic review with direct and network meta-analyses on nalmefene, naltrexone, acamprosate, baclofen and topiramate

BACKGROUND AND AIMS

Pharmacologically controlled drinking in the treatment of alcohol dependence or alcohol use disorders (AUDs) is an emerging concept. Our objective was to explore the comparative effectiveness of drugs used in this indication.

DESIGN

Systematic review with direct and network meta-analysis of double-blind randomized controlled trials (RCTs) assessing the efficacy of nalmefene, naltrexone, acamprosate, baclofen or topiramate in non-abstinent adults diagnosed with alcohol dependence or AUDs. Two independent reviewers selected published and unpublished studies on Medline, the Cochrane Library, Embase, ClinicalTrials.gov, contacted pharmaceutical companies, the European Medicines Agency and the Food and Drug Administration, and extracted data.

SETTING

Thirty-two RCTs.

PARTICIPANTS

A total of 6036 patients.

MEASUREMENTS

The primary outcome was total alcohol consumption (TAC). Other consumption outcomes and health outcomes were considered as secondary outcomes.

FINDINGS

No study provided direct comparisons between drugs. A risk of incomplete outcome data was identified in 26 studies (81%) and risk of selective outcome reporting in 17 (53%). Nalmefene [standardized mean difference (SMD) = -0.19, 95% confidence interval (CI) = -0.29, -0.10; I²  = 0%], baclofen (SMD = -1.00, 95% CI = -1.80, -0.19; one study) and topiramate (SMD = -0.77, 95% CI = -1.12, -0.42; I²  = 0%) showed superiority over placebo on TAC. No efficacy was observed for naltrexone or acamprosate. Similar results were observed for other consumption outcomes, except for baclofen (the favourable outcome on TAC was not reproduced). The number of withdrawals for safety reasons increased under nalmefene and naltrexone. No treatment demonstrated any harm reduction (no study was powered to explore health outcomes). Indirect comparisons suggested that topiramate was superior to nalmefene, naltrexone and acamprosate on consumption outcomes, but its safety profile is known to be poor.

CONCLUSIONS

There is currently no high-grade evidence for pharmacological treatment to control drinking using nalmefene, naltrexone, acamprosate, baclofen or topiramate in patients with alcohol dependence or alcohol use disorder. Some treatments show low to medium efficacy in reducing drinking across a range of studies with a high risk of bias. None demonstrates any benefit on health outcomes.

Alcohol addiction - the safety of available approved treatment options

INTRODUCTION

Alcohol Use Disorders (AUD) is a leading cause of mortality and morbidity worldwide. At present disulfiram, naltrexone and acamprosate are approved for the treatment of AUD in U.S. and Europe. Nalmefene is approved in Europe and sodium oxybate is approved in Italy and Austria only. Baclofen received a 'temporary recommendation for use' in France.

AREAS COVERED

The safety of the above mentioned medications on liver, digestive system, kidney function, nervous system, pregnancy and lactation and their possible side effects are described and discussed.

EXPERT OPINION

Mechanism of action and metabolism of these drugs as well as patients' clinical characteristics can affect the safety of treatment. All approved medications are valid tools for the treatment of AUD in patients without advanced liver disease. For some drugs, attention should be paid to patients with renal failure and medications may be used with caution, adjusting the dosage according to kidney function. In patients with AUD and advanced liver disease, at present only baclofen has been formally tested in randomized controlled trials showing its safety in this population.

Review article: recent insights into clinical decision-making in severe alcoholic hepatitis

BACKGROUND

Alcoholic hepatitis is a severe acute manifestation of alcoholic liver disease with a high mortality. Management of patients with this condition has been a matter of controversy for many years; however, recent clinical studies have sought to improve the clinical approach to these patients.

AIM

To use these recent studies in order to guide clinical management.

METHODS

A MeSH search of Medline was performed to specifically identify recent studies which influenced clinical diagnosis, assessment and management of alcoholic hepatitis.

RESULTS

Fulfilment of clear clinical criteria including a minimum threshold of bilirubin, defined periods of jaundice and alcohol ingestion negates the need for liver biopsy in most patients. Corticosteroids improve short-term mortality only (28 day) with other factors such as abstinence likely to be significant in long-term outcome. Pentoxifylline is not an effective treatment. The Glasgow Alcoholic Hepatitis Score (GAHS) score can identify those patients likely to benefit from corticosteroids, but scores that include the evolution of bilirubin over 1 week of such treatment (such as the Lille Score) define "response". Underlying infection may contribute towards corticosteroid nonresponse and needs to be actively sought out and treated. Liver transplant remains controversial; however, it has been shown to be feasible in alcoholic hepatitis.

CONCLUSIONS

Recent studies have helped to define patients who may benefit from corticosteroid treatment. However, there remains a need for more accurate scores of prognosis and treatment response, and a clear need for alternative treatments for those patients not responding to corticosteroid therapy.