1
|
Sinha R. Stress and substance use disorders: risk, relapse, and treatment outcomes. J Clin Invest 2024; 134:e172883. [PMID: 39145454 PMCID: PMC11324296 DOI: 10.1172/jci172883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2024] Open
Abstract
Stress has long been associated with substance misuse and substance use disorders (SUDs). The past two decades have seen a surge in research aimed at understanding the underlying mechanisms driving this association. This Review introduces a multilevel "adaptive stress response" framework, encompassing a stress baseline, acute reaction, and recovery with return-to-homeostasis phase that occurs at varying response times and across domains of analysis. It also discusses evidence showing the disruption of this adaptive stress response in the context of chronic and repeated stressors, trauma, adverse social and drug-related environments, as well as with acute and chronic drug misuse and with drug withdrawal and abstinence sequelae. Subjective, cognitive, peripheral, and neurobiological disruptions in the adaptive stress response phases and their link to inflexible, maladaptive coping; increased craving; relapse risk; and maintenance of drug intake are also presented. Finally, the prevention and treatment implications of targeting this "stress pathophysiology of addiction" are discussed, along with specific aspects that may be targeted in intervention development to rescue stress-related alterations in drug motivation and to improve SUD treatment outcomes.
Collapse
|
2
|
Brewerton TD. The integrated treatment of eating disorders, posttraumatic stress disorder, and psychiatric comorbidity: a commentary on the evolution of principles and guidelines. Front Psychiatry 2023; 14:1149433. [PMID: 37252137 PMCID: PMC10213703 DOI: 10.3389/fpsyt.2023.1149433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 04/18/2023] [Indexed: 05/31/2023] Open
Abstract
Psychiatric comorbidity is the norm in the assessment and treatment of eating disorders (EDs), and traumatic events and lifetime PTSD are often major drivers of these challenging complexities. Given that trauma, PTSD, and psychiatric comorbidity significantly influence ED outcomes, it is imperative that these problems be appropriately addressed in ED practice guidelines. The presence of associated psychiatric comorbidity is noted in some but not all sets of existing guidelines, but they mostly do little to address the problem other than referring to independent guidelines for other disorders. This disconnect perpetuates a "silo effect," in which each set of guidelines do not address the complexity of the other comorbidities. Although there are several published practice guidelines for the treatment of EDs, and likewise, there are several published practice guidelines for the treatment of PTSD, none of them specifically address ED + PTSD. The result is a lack of integration between ED and PTSD treatment providers, which often leads to fragmented, incomplete, uncoordinated and ineffective care of severely ill patients with ED + PTSD. This situation can inadvertently promote chronicity and multimorbidity and may be particularly relevant for patients treated in higher levels of care, where prevalence rates of concurrent PTSD reach as high as 50% with many more having subthreshold PTSD. Although there has been some progress in the recognition and treatment of ED + PTSD, recommendations for treating this common comorbidity remain undeveloped, particularly when there are other co-occurring psychiatric disorders, such as mood, anxiety, dissociative, substance use, impulse control, obsessive-compulsive, attention-deficit hyperactivity, and personality disorders, all of which may also be trauma-related. In this commentary, guidelines for assessing and treating patients with ED + PTSD and related comorbidity are critically reviewed. An integrated set of principles used in treatment planning of PTSD and trauma-related disorders is recommended in the context of intensive ED therapy. These principles and strategies are borrowed from several relevant evidence-based approaches. Evidence suggests that continuing with traditional single-disorder focused, sequential treatment models that do not prioritize integrated, trauma-focused treatment approaches are short-sighted and often inadvertently perpetuate this dangerous multimorbidity. Future ED practice guidelines would do well to address concurrent illness in more depth.
Collapse
|
3
|
Arakelyan A, Kempkensteffen J, Verthein U. Systematische Literaturübersicht der Wirksamkeit von
Acamprosat, Naltrexon, Disulfiram und Nalmefen zur Trinkmengenreduktion und
Aufrechterhaltung der Abstinenz bei Alkoholabhängigkeit. SUCHTTHERAPIE 2021. [DOI: 10.1055/a-1494-4333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
ZusammenfassungDas Ziel der vorliegenden Übersichtsarbeit ist die systematische
Darstellung der aktuellen Evidenz zur Wirksamkeit von Acamprosat, Naltrexon,
Disulfiram und Nalmefen für die Aufrechterhaltung der Abstinenz oder
Trinkmengenreduktion bei alkoholabhängigen Patient:innen. Bezogen auf
den Zeitraum 2005 bis 2020 wurden insgesamt 27 Studien identifiziert, die alle
Einschlusskriterien (u. a. RCT, mind. 8 Wochen Behandlungsdauer)
erfüllten. Es wurden überwiegend Hinweise zur Wirksamkeit von
Nalmefen gefunden. Acamprosat war nicht (zusätzlich) wirksam. Naltrexon
trug in kombinierten Interventionen einen zusätzlichen Nutzen bei, dies
galt jedoch nicht für die Mehrzahl der Studien. Disulfiram war nicht
wirksam darin, einen zusätzlichen Nutzen zur Erhaltung der Abstinenz
beizutragen, im Vergleich zu Topiramat, einem Antikonvulsivum, jedoch
effektiver. Die Ergebnisse stehen nicht im Einklang mit dem bisher bekannten
Forschungsstand, der Acamprosat, Naltrexon und Nalmefen als überwiegend
effektiv und sicher einstuft und Disulfiram als mäßig wirksam.
Der pharmakologische Interventionsbedarf sollte bei Bestehen alkoholbezogener
Probleme exploriert und ggf. erwogen werden, damit diesbezüglich
Vorbehalte abgebaut und ein umfassendes und zugleich individuelles
Behandlungsangebot geschaffen wird. Hinsichtlich der Trinkmengenreduktion
sollten Aspekte der Schadensminderung als Behandlungsziel berücksichtigt
werden.
Collapse
Affiliation(s)
- Anna Arakelyan
- Universitätsklinikum Hamburg-Eppendorf, Zentrum für
Interdisziplinäre Suchtforschung der Universität Hamburg (ZIS),
Klinik für Psychiatrie und Psychotherapie
| | - Jürgen Kempkensteffen
- Universität Hamburg, Fakultät für Psychologie
und Bewegungswissenschaft, Klinische Psychologie und
Psychotherapie
| | - Uwe Verthein
- Universitätsklinikum Hamburg-Eppendorf, Zentrum für
Interdisziplinäre Suchtforschung der Universität Hamburg (ZIS),
Klinik für Psychiatrie und Psychotherapie
| |
Collapse
|
4
|
Abstract
The misuse of alcohol in the United States continues to take a large toll on society, resulting in the deaths of about 88,000 Americans per year. Moreover, it is estimated that nearly 14.6 million Americans currently meet diagnostic criteria for current alcohol use disorder (AUD). However, very few individuals receive treatment, with an even smaller portion receiving medications approved by the U.S. Food and Drug Administration (FDA) for the treatment of AUD, despite scientifically rigorous evidence showing the benefits of combining medication approved for treating AUD with evidence-based behavioral therapy. These benefits include higher rates of abstinence and less risk of relapse to heavy drinking, with associated improvements in medical and mental health and in quality of life. This review provides an overview of FDA-approved medications and "off-label" drugs for the treatment of AUD. The article emphasizes that AUD medical advice and prescription recommendations should come from professionals with training in the treatment of AUD and that treatment plans should consider medication in conjunction with evidence-based behavioral therapy. Finally, this review notes the limited number of medications available and the continued need for the development of new pharmacotherapies to optimize AUD recovery goals.
Collapse
Affiliation(s)
- Barbara J Mason
- Pearson Center for Alcoholism and Addiction Research, Department of Molecular Medicine, Scripps Research Institute, La Jolla, California. Center for Human Development, University of California, San Diego, La Jolla, California
| | - Charles J Heyser
- Pearson Center for Alcoholism and Addiction Research, Department of Molecular Medicine, Scripps Research Institute, La Jolla, California. Center for Human Development, University of California, San Diego, La Jolla, California
| |
Collapse
|
5
|
Boswell RG, Potenza MN, Grilo CM. The Neurobiology of Binge-eating Disorder Compared with Obesity: Implications for Differential Therapeutics. Clin Ther 2021; 43:50-69. [PMID: 33257092 PMCID: PMC7902428 DOI: 10.1016/j.clinthera.2020.10.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 10/30/2020] [Accepted: 10/30/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE Emerging work indicates divergence in the neurobiologies of binge-eating disorder (BED) and obesity despite their frequent co-occurrence. This review highlights specific distinguishing aspects of BED, including elevated impulsivity and compulsivity possibly involving the mesocorticolimbic dopamine system, and discusses implications for differential therapeutics for BED. METHODS This narrative review describes epidemiologic, clinical, genetic, and preclinical differences between BED and obesity. Subsequently, this review discusses human neuroimaging work reporting differences in executive functioning, reward processing, and emotion reactivity in BED compared with obesity. Finally, on the basis of the neurobiology of BED, this review identifies existing and new therapeutic agents that may be most promising given their specific targets based on putative mechanisms of action relevant specifically to BED. FINDINGS BED is characterized by elevated impulsivity and compulsivity compared with obesity, which is reflected in divergent neurobiological characteristics and effective pharmacotherapies. Therapeutic agents that influence both reward and executive function systems may be especially effective for BED. IMPLICATIONS Greater attention to impulsivity/compulsivity-related, reward-related, and emotion reactivity-related processes may enhance conceptualization and treatment approaches for patients with BED. Consideration of these distinguishing characteristics and processes could have implications for more targeted pharmacologic treatment research and interventions.
Collapse
Affiliation(s)
- Rebecca G Boswell
- Yale School of Medicine, Department of Psychiatry, New Haven, CT, USA.
| | - Marc N Potenza
- Yale School of Medicine, Department of Psychiatry, New Haven, CT, USA; Connecticut Mental Health Center, New Haven, CT, USA; Connecticut Council on Problem Gambling, Wethersfield, CT, USA; Yale School of Medicine, Child Study Center, New Haven, CT, USA; Yale University, Department of Neuroscience, New Haven, CT, USA
| | - Carlos M Grilo
- Yale School of Medicine, Department of Psychiatry, New Haven, CT, USA; Yale University, Department of Psychology, New Haven, CT, USA
| |
Collapse
|
6
|
Michael ML, Juarascio A. Differences in eating disorder symptoms and affect regulation for residential eating disorder patients with problematic substance use. Eat Weight Disord 2020; 25:1805-1811. [PMID: 31612371 DOI: 10.1007/s40519-019-00789-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 09/27/2019] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The aim of the current study was to investigate differences in treatment outcomes for residential eating disorder (ED) treatment patients diagnosed with comorbid substance use disorders (SUDs), particularly differences in ED pathology and affect dysregulation. METHOD Secondary data analysis was conducted on data from a previous study of 140 patients at a residential ED facility. SUD was diagnosed by a staff psychiatrist upon admission, and SUD diagnosis was extracted from electronic health records for the current study. Self-report measures of eating pathology and affect dysregulation from pre-treatment and post-treatment assessments were analyzed. RESULTS 20.1% of the sample (n = 29) were diagnosed with a substance use disorder at the start of treatment. Contrary to hypotheses, those with comorbid SUD did not significantly differ in eating pathology severity, depression symptoms, emotion dysregulation, or psychological acceptance at baseline. Also contrary to hypotheses, individuals with comorbid SUD and ED evidenced slightly larger improvements in certain areas of eating pathology and affect dysregulation throughout treatment than those with ED diagnosis only. CONCLUSIONS These findings suggest that residential ED treatment is an appropriate treatment choice for individuals with comorbid SUD. The observed improvements in affect dysregulation combined with a period of forced abstinence from maladaptive affect regulation behaviors may explain these positive results, though more research is needed to test the mechanisms of action of residential treatment for this population. LEVEL OF EVIDENCE IV, multiple time series analysis.
Collapse
Affiliation(s)
- Megan L Michael
- Center for Weight and Lifestyle Sciences, Drexel University, Philadelphia, PA, 19104, USA.
| | - Adrienne Juarascio
- Department of Psychology, Drexel University, Philadelphia, PA, 19104, USA
| |
Collapse
|
7
|
Abstract
The current article provides a brief summary of biopsychosocial gender differences in alcohol use disorder (AUD), then reviews existing literature on gender differences in treatment access, retention, outcomes, and longer-term recovery. Among psychotherapies for AUD, there is support for the efficacy of providing female-specific treatment, and for female-only treatment settings but only when female-specific treatment is included. However, despite mandates from the National Institutes of Health to do so, there is little work thus far that directly compares genders on outcomes of specific psychotherapies or pharmacotherapies for AUD. Although existing research has mixed findings on sex and gender differences in overall outcomes, there are more consistent findings suggesting different mechanisms of behavior change among men and women in AUD treatment and long-term recovery. Thus, more work is needed that attends to gender and sex differences, including planning studies that are structured to examine not only gender-differentiated outcomes in treatment response, but equally important, differences in treatment access and attendance as well as differences in mechanisms of change in drinking behavior.
Collapse
Affiliation(s)
- Cathryn Glanton Holzhauer
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts.,Division of Research and Education, VA Central Western Massachusetts, Leeds, Massachusetts
| | - Michael Cucciare
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas.,VA South Central Mental Illness Research, Education, and Clinical Center and Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas
| | - Elizabeth E Epstein
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts
| |
Collapse
|
8
|
Schick MR, Spillane NS, Hostetler KL. A Call to Action: A Systematic Review Examining the Failure to Include Females and Members of Minoritized Racial/Ethnic Groups in Clinical Trials of Pharmacological Treatments for Alcohol Use Disorder. Alcohol Clin Exp Res 2020; 44:1933-1951. [DOI: 10.1111/acer.14440] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/06/2020] [Accepted: 08/07/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Melissa R. Schick
- From the PATHS Lab Department of Psychology University of Rhode Island Kingston Rhode Island
| | - Nichea S. Spillane
- From the PATHS Lab Department of Psychology University of Rhode Island Kingston Rhode Island
| | - Katherine L. Hostetler
- From the PATHS Lab Department of Psychology University of Rhode Island Kingston Rhode Island
| |
Collapse
|
9
|
Bolton M, Hodkinson A, Boda S, Mould A, Panagioti M, Rhodes S, Riste L, van Marwijk H. Serious adverse events reported in placebo randomised controlled trials of oral naltrexone: a systematic review and meta-analysis. BMC Med 2019; 17:10. [PMID: 30642329 PMCID: PMC6332608 DOI: 10.1186/s12916-018-1242-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 12/17/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Naltrexone is an opioid antagonist used in many different conditions, both licensed and unlicensed. It is used at widely varying doses from 3 to 250 mg. The aim of this review was to extensively evaluate the safety of oral naltrexone by examining the risk of serious adverse events and adverse events in randomised controlled trials of naltrexone compared to placebo. METHODS A systematic search of the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, other databases and clinical trials registries was undertaken up to May 2018. Parallel placebo-controlled randomised controlled trials longer than 4 weeks published after 1 January 2001 of oral naltrexone at any dose were selected. Any condition or age group was included, excluding only studies in opioid or ex-opioid users owing to possible opioid/opioid antagonist interactions. The systematic review used the guidance of the Cochrane Handbook and Preferred Reporting Items for Systematic Reviews and Meta-analyses harms checklist throughout. Numerical data were independently extracted by two people and cross-checked. Risk of bias was assessed with the Cochrane risk-of-bias tool. Meta-analyses were performed in R using random effects models throughout. RESULTS Eighty-nine randomised controlled trials with 11,194 participants were found, studying alcohol use disorders (n = 38), various psychiatric disorders (n = 13), impulse control disorders (n = 9), other addictions including smoking (n = 18), obesity or eating disorders (n = 6), Crohn's disease (n = 2), fibromyalgia (n = 1) and cancers (n = 2). Twenty-six studies (4,960 participants) recorded serious adverse events occurring by arm of study. There was no evidence of increased risk of serious adverse events for naltrexone compared to placebo (risk ratio 0.84, 95% confidence interval 0.66-1.06). Sensitivity analyses pooling risk differences supported this conclusion (risk difference -0.01, 95% confidence interval -0.02-0.00) and subgroup analyses showed that results were consistent across different doses and disease groups. Secondary analysis revealed only six marginally significant adverse events for naltrexone compared to placebo, which were of mild severity. CONCLUSIONS Naltrexone does not appear to increase the risk of serious adverse events over placebo. These findings confirm the safety of oral naltrexone when used in licensed indications and encourage investments to undertake efficacy studies in unlicensed indications. TRIAL REGISTRATION PROSPERO 2017 CRD42017054421 .
Collapse
Affiliation(s)
- Monica Bolton
- School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9PL, UK
| | - Alex Hodkinson
- Centre for Primary Care, Division of Population Health, Health Services Research & Primary Care, Williamson Building, Oxford Road, Manchester, M13 9PL, UK.
| | - Shivani Boda
- School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9PL, UK
| | - Alan Mould
- Centre for Primary Care, Division of Population Health, Health Services Research & Primary Care, Williamson Building, Oxford Road, Manchester, M13 9PL, UK
| | - Maria Panagioti
- NIHR School for Primary Care Research, NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Brighton, M13 9PL, UK
| | - Sarah Rhodes
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9PL, UK
| | - Lisa Riste
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9PL, UK
| | - Harm van Marwijk
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9PL, UK
- Brighton and Sussex Medical School, Watson Building, University of Brighton, Brighton, BN1 9PH, UK
| |
Collapse
|
10
|
Vijay A, Cavallo D, Goldberg A, de Laat B, Nabulsi N, Huang Y, Krishnan-Sarin S, Morris ED. PET imaging reveals lower kappa opioid receptor availability in alcoholics but no effect of age. Neuropsychopharmacology 2018; 43:2539-2547. [PMID: 30188515 PMCID: PMC6224533 DOI: 10.1038/s41386-018-0199-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 08/01/2018] [Accepted: 08/08/2018] [Indexed: 11/24/2022]
Abstract
Opioid receptors are implicated in alcoholism, other addictions, withdrawal, and depression, and are considered potential pharmacological targets for treatment. Our goal in the present study was to compare the availability of kappa opioid receptors (KOR) between an alcohol-dependent cohort (AD) and a healthy control cohort (HC). Sixty-four participants-36 AD and 28 HC-underwent PET scans with [11C]LY2795050, a selective kappa antagonist tracer. Partial-volume correction was applied to all PET data to correct for atrophy. Volume of distribution (VT) of the tracer was estimated regionally as a measure of KOR availability. VT values of AD versus HC were compared for 15 defined ROIs. Multivariate analysis showed a main effect of group on VT across these 15 ROIs. Post hoc tests showed that AD had significantly lower VT and thus a lower KOR availability than HC in amygdala and pallidum (corrected for multiple comparisons). Exploratory analysis of change in VT with age was conducted; VT was not found to vary significantly with age in any region. Our findings of lower VT in AD versus HC in multiple regions are in contrast to findings in the mu and delta opioid receptor systems of higher VT in AD versus HC. Although age-related decline in receptors has previously been observed in the mu opioid receptor system, we found that KOR availability does not change with age.
Collapse
Affiliation(s)
- Aishwarya Vijay
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA
| | - Dana Cavallo
- Department of Psychiatry, Yale University, New Haven, CT, USA
| | - Alissa Goldberg
- Department of Psychiatry, Yale University, New Haven, CT, USA
| | - Bart de Laat
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA
| | - Nabeel Nabulsi
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA
| | - Yiyun Huang
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA
| | | | - Evan D Morris
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA.
- Department of Psychiatry, Yale University, New Haven, CT, USA.
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA.
| |
Collapse
|
11
|
Kohno M, Dennis LE, McCready H, Schwartz DL, Hoffman WF, Korthuis PT. A preliminary randomized clinical trial of naltrexone reduces striatal resting state functional connectivity in people with methamphetamine use disorder. Drug Alcohol Depend 2018; 192:186-192. [PMID: 30266003 PMCID: PMC6200637 DOI: 10.1016/j.drugalcdep.2018.07.045] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/31/2018] [Accepted: 07/31/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Naltrexone has been shown to attenuate craving and the subjective effects of methamphetamine. Although naltrexone has modulatory effects on neural activity at dopaminergic synapses, the effect on striatal connectivity is unclear. As methamphetamine use is associated with greater resting-state functional connectivity (RSFC) in the dopaminergic system, we examined whether extended-release naltrexone (XR-NTX) can normalize striatal connectivity and whether changes in RSFC are associated with changes in craving and methamphetamine use. METHODS Thirty-seven participants in or seeking treatment for methamphetamine use disorder took part in this clinical trial at a university-based research clinic between May 2013 and March 2015 (Clinicaltrials.gov NCT01822132). Participants were randomized by a random number generator to a single four-week injection of XR-NTX or placebo. Functional magnetic resonance imaging (fMRI) and self-reported measures of craving and methamphetamine use were conducted before and after double-blinded randomization. FINDINGS There was a significant reduction in methamphetamine use in the naltrexone group and a significant treatment-by-time interaction on RSFC between the ventral striatum, amygdala, hippocampus, and midbrain. Connectivity was significantly reduced over time in participants randomized to naltrexone but unchanged in those randomized to placebo (p < 0.05, whole-brain corrected). Interactions between treatment and changes in connectivity show that significant reductions in connectivity were associated with reductions in methamphetamine use. CONCLUSIONS Neurobiological deficits associated with methamphetamine use may undermine the efficacy of pharmacotherapies that directly target the dopamine reward system. Naltrexone, via antagonism of indirect mu-opioid effects on dopamine neurons, may attenuate reward system connectivity and aid in methamphetamine use treatment.
Collapse
Affiliation(s)
- Milky Kohno
- Department of Psychiatry, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA; Department of Behavioral Neuroscience, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA; Research and Development Service, Veterans Affairs Portland Health Care System, 3710 SW US Veterans Hospital Rd., Portland, OR 97239, USA; Methamphetamine Abuse Research Center, Oregon Health and Science University and Veterans Affairs Portland Health Care System, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA.
| | - Laura E Dennis
- Department of Psychiatry, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA; Research and Development Service, Veterans Affairs Portland Health Care System, 3710 SW US Veterans Hospital Rd., Portland, OR 97239, USA
| | - Holly McCready
- Department of Psychiatry, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA; Research and Development Service, Veterans Affairs Portland Health Care System, 3710 SW US Veterans Hospital Rd., Portland, OR 97239, USA
| | - Daniel L Schwartz
- Department of Neurology, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA; Advanced Imaging Research Center, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA
| | - William F Hoffman
- Department of Psychiatry, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA; Department of Behavioral Neuroscience, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA; Research and Development Service, Veterans Affairs Portland Health Care System, 3710 SW US Veterans Hospital Rd., Portland, OR 97239, USA; Mental Health Division, Veterans Affairs Portland Health Care System, 3710 SW US Veterans Hospital Rd., Portland, OR 97239, USA; Methamphetamine Abuse Research Center, Oregon Health and Science University and Veterans Affairs Portland Health Care System, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA
| | - P Todd Korthuis
- Section of Addiction Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA
| |
Collapse
|
12
|
Matzeu A, Terenius L, Martin-Fardon R. Exploring Sex Differences in the Attenuation of Ethanol Drinking by Naltrexone in Dependent Rats During Early and Protracted Abstinence. Alcohol Clin Exp Res 2018; 42:2466-2478. [PMID: 30320880 DOI: 10.1111/acer.13898] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 10/03/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Despite considerable efforts, few drugs are available for the treatment of alcohol (ethanol [EtOH]) use disorder (AUD). EtOH directly or indirectly modulates several aspects of the central nervous system, including neurotransmitter/neuromodulator systems. Relapse vulnerability is a challenge for the treatment of EtOH addiction. EtOH withdrawal symptoms create motivational states that lead to compulsive EtOH drinking and relapse even after long periods of abstinence. Among the therapeutics to treat AUD, naltrexone (NTX) is a pharmacological treatment for relapse. The present study evaluated the effect of NTX on EtOH drinking in male and female EtOH-dependent rats during abstinence. METHODS Wistar rats (males and females) were first trained to orally self-administer 10% EtOH. Half of the rats were then made dependent by chronic intermittent EtOH (CIE) vapor exposure, and the other half were exposed to air. Using this model, rats exhibit somatic and motivational signs of withdrawal. At the end of EtOH vapor (or air) exposure, the rats were tested for the effects of NTX (10 mg/kg, oral) on EtOH self-administration at 3 abstinence time points: acute abstinence (A-Abst, 8 hours), late abstinence (L-Abst, 2 weeks), and protracted abstinence (P-Abst, 6 weeks). RESULTS NTX decreased EtOH intake in nondependent rats, regardless of sex and abstinence time point. In postdependent rats, NTX decreased EtOH intake only at a delayed abstinence time point (P-Abst) in males, whereas it similarly reduced EtOH drinking in females at all abstinence time points. CONCLUSIONS The therapeutic efficacy of NTX depends on the time of intervention during abstinence and is different between males and females. The data further suggest that EtOH dependence causes different neuroadaptations in male and female rats, reflected by differential effects of NTX. The results underscore the significance of considering the duration of EtOH abstinence and sex as a biological variable as important factors when developing pharmacotherapies for AUD.
Collapse
Affiliation(s)
| | - Lars Terenius
- Department of Neuroscience, Scripps Research, La Jolla, California.,Clinical Neuroscience, Experimental Addiction Research, Karolinska Institute, Stockholm, Sweden
| | | |
Collapse
|
13
|
Epstein EE, McCrady BS, Hallgren KA, Gaba A, Cook S, Jensen N, Hildebrandt T, Holzhauer CG, Litt MD. Individual versus group female-specific cognitive behavior therapy for alcohol use disorder. J Subst Abuse Treat 2018; 88:27-43. [PMID: 29606224 PMCID: PMC6424104 DOI: 10.1016/j.jsat.2018.02.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 12/28/2017] [Accepted: 02/13/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To test group-based Female-Specific Cognitive Behavioral Therapy (G-FS-CBT) for women with Alcohol Use Disorder (AUD) against an individual Female-Specific Cognitive Behavioral Therapy (I-FS-CBT). This aims of this paper are to describe G-FS-CBT development, content, feasibility, acceptability, group process, engagement in treatment, and within- and post-treatment outcomes. METHODS Women with AUD (n=155) were randomly assigned to 12 manual-guided sessions of G-FS-CBT or I-FS-CBT; 138 women attended at least one treatment session. RESULTS Women in G-FS-CBT attended fewer sessions (M=7.6) than women in I-FS-CBT (M=9.7; p<.001). Women in both conditions reported high satisfaction with the treatments. Independent coders rated high fidelity of delivery of both G-FS-CBT and I-FS-CBT. Therapeutic alliance with the therapist was high in both conditions, with I-FS-CBT being slightly but significantly higher than G-FS-CBT. In the first six weeks of treatment, women in both treatment conditions significantly reduced their percent drinking days (PDD) and percent heavy days drinking (PHD) by equivalent amounts, maintained through the rest of treatment and the 12month follow up with no treatment condition effects. Women reported significant improvement in all but one of the secondary outcomes during treatment; gains made during treatment in depression, anxiety, autonomy, and interpersonal problems were maintained during the follow-up period, while gains made during treatment in use of coping skills, self-efficacy for abstinence, self-care, and sociotropy deteriorated over follow up but remained improved compared to baseline. CONCLUSIONS Findings support the feasibility, acceptability, and efficacy of a group format for female-specific CBT for AUD, a new 12-session, single gender, community friendly, group therapy with programming specifically for women. Similar, positive outcomes for individual and group treatment formats were found for drinking, mood, coping skills, self-confidence, interpersonal functioning, and self-care.
Collapse
Affiliation(s)
- Elizabeth E Epstein
- Center of Alcohol Studies, Rutgers University, 607 Allison Road, Piscataway, NJ 08854, United States; Department of Psychiatry, University of Massachusetts Medical School, 365 Plantation Street, Worcester, MA, 01605, United States.
| | - Barbara S McCrady
- Center of Alcohol Studies, Rutgers University, 607 Allison Road, Piscataway, NJ 08854, United States; Center on Alcoholism, Substance Abuse, and Addictions, University of New Mexico, 2650 Yale Blvd. SE, Albuquerque, NM 87106, United States.
| | - Kevin A Hallgren
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St., Box 356560, Seattle, WA 98195, United States
| | - Ayorkor Gaba
- Center of Alcohol Studies, Rutgers University, 607 Allison Road, Piscataway, NJ 08854, United States; Department of Psychiatry, University of Massachusetts Medical School, 365 Plantation Street, Worcester, MA, 01605, United States.
| | - Sharon Cook
- Center of Alcohol Studies, Rutgers University, 607 Allison Road, Piscataway, NJ 08854, United States.
| | - Noelle Jensen
- Center of Alcohol Studies, Rutgers University, 607 Allison Road, Piscataway, NJ 08854, United States.
| | - Thomas Hildebrandt
- Department of Psychiatry, Mt. Sinai School of Medicine, 1425 Madison Ave, Floor 6, Room 30, New York, NY 10029, United States.
| | - Cathryn Glanton Holzhauer
- Department of Psychiatry, University of Massachusetts Medical School, 365 Plantation Street, Worcester, MA, 01605, United States; Veterans Affairs VISN 1 Central Western Massachusetts, 421 North Main St Leeds MA 01053, United States.
| | - Mark D Litt
- University of Connecticut Health Center, Division of Behavioral Sciences and Community Health, 263 Farmington Avenue, MC 3910, Farmington, CT 06030-3910, United States.
| |
Collapse
|
14
|
Nieto SJ, Quave CB, Kosten TA. Naltrexone alters alcohol self-administration behaviors and hypothalamic-pituitary-adrenal axis activity in a sex-dependent manner in rats. Pharmacol Biochem Behav 2018; 167:50-59. [PMID: 29486222 PMCID: PMC6011835 DOI: 10.1016/j.pbb.2018.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/07/2018] [Accepted: 02/19/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND The mu-opioid antagonist, naltrexone (NTX), is a FDA-approved treatment for alcohol use disorder (AUD); however, the data on whether it differentially affects males vs. females are mixed. NTX increases hypothalamic-pituitary-adrenal (HPA) axis activity that associates with subjective responses to alcohol and craving in individuals with AUD. The present study tested for sex differences in the ability of NTX to decrease appetitive and consummatory behaviors in rats in operant alcohol self-administration. Because the opioid system and HPA axis are sexually dimorphic, we examined NTX's effect on adrenocorticotropic hormone (ACTH) and corticosterone (CORT) levels. METHODS Male and female Sprague-Dawley rats (n's = 6-8) were trained to lever press for alcohol (10% v/v) under a fixed-ratio 2 schedule of reinforcement. NTX doses (0, 0.1-10 mg/kg) were assessed in tests conducted under a progressive ratio schedule of reinforcement. Separate groups of alcohol and water drinking rats (n's = 8) were used to assess NTX's (10 mg/kg) effects on HPA axis hormones. RESULTS NTX decreased consummatory behaviors for alcohol in a dose-related manner, but not appetitive behaviors in males. In females, NTX decreased appetitive behaviors for alcohol in a dose-dependent manner, but only decreased consummatory behaviors at the highest (10 mg/kg) NTX dose. NTX increased ACTH levels in alcohol drinking females in diestrus, but not in other groups. However, NTX increased CORT levels for longer durations in alcohol drinking males relative to alcohol drinking females in diestrus. CONCLUSIONS Our findings suggest that NTX selectively reduces consummatory behaviors for alcohol in males and appetitive behaviors in females, while also showing differential sex effects on HPA hormones.
Collapse
Affiliation(s)
- Steven J Nieto
- University of Houston, Department of Psychology & Texas Institute for Measurement, Evaluation and Statistics (TIMES), Houston, TX 77204-6022, United States
| | - Cana B Quave
- University of Houston, Department of Psychology & Texas Institute for Measurement, Evaluation and Statistics (TIMES), Houston, TX 77204-6022, United States
| | - Therese A Kosten
- University of Houston, Department of Psychology & Texas Institute for Measurement, Evaluation and Statistics (TIMES), Houston, TX 77204-6022, United States.
| |
Collapse
|
15
|
Canidate SS, Carnaby GD, Cook CL, Cook RL. A Systematic Review of Naltrexone for Attenuating Alcohol Consumption in Women with Alcohol Use Disorders. Alcohol Clin Exp Res 2017; 41:466-472. [PMID: 28247556 PMCID: PMC5572298 DOI: 10.1111/acer.13313] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 12/14/2016] [Indexed: 10/20/2022]
Abstract
Several clinical trials have evaluated naltrexone as a treatment for alcohol use disorders (AUDs), but few have focused on women. The aim of this review was to systematically review and summarize the evidence regarding the impact of naltrexone compared to placebo for attenuating alcohol consumption in women with an AUD. A systematic review was conducted using PubMed, Cochrane, Web of Science, CINAHL, and Alcohol Studies Database to identify relevant peer-reviewed randomized controlled trials (RCTs) published between January 1990 and August 2016. Seven published trials have evaluated the impact of naltrexone on drinking outcomes in women distinct from men; 903 alcohol-dependent or heavy drinking women were randomized to receive once daily oral or depot (injectable) naltrexone or placebo with/without behavioral intervention. Two studies examining the quantity of drinks per day observed trends toward reduction in drinking quantity among women who received naltrexone versus placebo. The 4 studies examining the frequency of drinking had mixed results, with 1 study showing a trend that favored naltrexone, 2 showing a trend that favored placebo, and 1 that showed no difference. Two of the 3 studies examining time to relapse observed trends that tended to favor naltrexone for time to any drinking and time to heavy drinking among women who received naltrexone versus placebo. While the growing body of evidence suggests a variety of approaches to treat AUD, the impact of naltrexone to combat AUD in women is understudied. Taken together, the results suggest that naltrexone may lead to modest reductions in quantity of drinking and time to relapse, but not on the frequency of drinking in women. Future research should incorporate sophisticated study designs that examine gender differences and treatment effectiveness among those diagnosed with an AUD and present data separately for men and women.
Collapse
Affiliation(s)
- Shantrel S Canidate
- University of Florida College of Public Health and Health Professions, Gainesville, Florida
| | - Giselle D Carnaby
- University of Florida College of Public Health and Health Professions, Gainesville, Florida
- University of Central Florida College of Health and Public Affairs, Orlando, Florida
| | - Christa L Cook
- University of Florida College of Nursing, Gainesville, Florida
| | - Robert L Cook
- University of Florida College of Public Health and Health Professions, Gainesville, Florida
- University of Florida College of Medicine, Gainesville, Florida
| |
Collapse
|
16
|
Friedmann PD, Wilson D, Nunes EV, Hoskinson R, Lee JD, Gordon M, Murphy SM, Bonnie RJ, Chen DT, Boney TY, O'Brien CP. Do patient characteristics moderate the effect of extended-release naltrexone (XR-NTX) for opioid use disorder? J Subst Abuse Treat 2017; 85:61-65. [PMID: 28236511 DOI: 10.1016/j.jsat.2017.01.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 01/30/2017] [Accepted: 01/30/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Extended release naltrexone (XR-NTX) injected intramuscularly monthly has been shown to reduce relapse in persons with opioid use disorder. Baseline factors, including patients' demographics, comorbidities and lifestyle, may help identify patients who will benefit most or least from XR-NTX treatment. METHODS Potential moderators of XR-NTX's effect were examined in the largest North American randomized open-label effectiveness trial of XR-NTX. Relapse status (Yes/No) at 6-month follow-up was regressed on treatment group (XR-NTX, N=153; or Treatment-as-Usual [TAU], N=155), baseline covariates, and their two-way interaction to identify moderator effects. Baseline covariates included age, gender, summary scores for depression, suicidal thoughts, drug abuse risk, substance use, medical, psychiatric and employment status, socialization, legal and family/social issues, history of abuse and quality of life measures. RESULTS Alcohol use to intoxication in the 30days before randomization was a significant moderator: during the treatment phase, those who reported being recently intoxicated before randomization to XR-NTX relapsed to opioids at a rate (56%) similar to TAU (58%), while those without alcohol intoxication in the prior 30days had a lower rate of opioid relapse (41% vs. 65%, respectively, P<0.04). CONCLUSIONS XR-NTX appeared to work equally well across subgroups with diverse demographic, addiction, mental health and environmental characteristics, with the possible exception of working better among those without recent alcohol intoxication. These findings should be reassuring to practitioners increasingly using XR-NTX as medical addiction therapy in diverse and often vulnerable populations.
Collapse
Affiliation(s)
- Peter D Friedmann
- Office of Research, Department of Medicine, University of Massachusetts-Baystate and Baystate Health, Springfield, MA, United States.
| | - Donna Wilson
- Office of Research, Department of Medicine, University of Massachusetts-Baystate and Baystate Health, Springfield, MA, United States
| | - Edward V Nunes
- New York State Psychiatric Institute, Columbia University Medical Center, New York, NY, United States
| | - Randall Hoskinson
- Office of Research, Department of Medicine, University of Massachusetts-Baystate and Baystate Health, Springfield, MA, United States
| | - Joshua D Lee
- Department of Population Health, New York University School of Medicine, New York, United States
| | - Michael Gordon
- Friends Research Institute, Baltimore, MD, United States
| | - Sean M Murphy
- Department of Health Policy and Administration, Washington State University, Spokane, WA, United States
| | - Richard J Bonnie
- University of Virginia School of Law, Charlottesville, VA, United States
| | - Donna T Chen
- Center for Biomedical Ethics and Humanities, Departments of Public Health Sciences and Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Tamara Y Boney
- Treatment Research Institute, University of Pennsylvania, Philadelphia, PA, United States
| | - Charles P O'Brien
- Treatment Research Institute, University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
17
|
Fattore L, Melis M. Editorial: Exploring Gender and Sex Differences in Behavioral Dyscontrol: From Drug Addiction to Impulse Control Disorders. Front Psychiatry 2016; 7:19. [PMID: 26941657 PMCID: PMC4762070 DOI: 10.3389/fpsyt.2016.00019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 02/08/2016] [Indexed: 01/04/2023] Open
Affiliation(s)
- Liana Fattore
- CNR Neuroscience Institute, National Research Council , Cagliari , Italy
| | - Miriam Melis
- Department of Biomedical Sciences, University of Cagliari , Cagliari , Italy
| |
Collapse
|
18
|
Pan S, Jiang H, Du J, Chen H, Li Z, Ling W, Zhao M. Efficacy of Cognitive Behavioral Therapy on Opiate Use and Retention in Methadone Maintenance Treatment in China: A Randomised Trial. PLoS One 2015; 10:e0127598. [PMID: 26107818 PMCID: PMC4479610 DOI: 10.1371/journal.pone.0127598] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 03/30/2015] [Indexed: 12/12/2022] Open
Abstract
Aims Methadone maintenance treatment (MMT) is widely available in China; but, high rates of illicit opiate use and dropout are problematic. The aim of this study was to test whether cognitive behavioral therapy (CBT) in conjunction with MMT can improve treatment retention and reduce opiate use. Method A total of 240 opiate-dependent patients in community-based MMT clinics were randomly assigned to either weekly CBT plus standard MMT (CBT group, n=120) or standard MMT (control group, n=120) for 26 weeks. The primary outcomes were treatment retention and opiate-negative urine test results at 12 weeks and 26 weeks. The secondary outcomes were composite scores on the Addiction Severity Index (ASI) and total scores on the Perceived Stress Scale (PSS) at 12 weeks and 26 weeks. Results Compared to the control group in standard MMT, the CBT group had higher proportion of opiate-negative urine tests at both 12 weeks (59% vs. 69%, p<0.05) and 26 weeks (63% vs. 73%, p<0.05); however, the retention rates at 12 weeks (73.3% vs. 74.2%, p=0.88) and 26 weeks were not different (55.8% vs. 64.2%, p=0.19) between the two groups. At both 12 and 26 weeks, all of the ASI component scores and PSS total scores in the CBT group and control group decreased from baseline; but the CBT group exhibited more decreases in ASI employment scores at week 26 and more decrease in the PSS total score at week 12 and week 26. Conclusions CBT counselling is effective in reducing opiate use and improving employment function and in decreasing stress level for opiate-dependent patients in MMT in China. Trial Registration ClinicalTrials.gov NCT01144390
Collapse
Affiliation(s)
- Shujun Pan
- Shanghai Mental Health Center, Shanghai JiaoTong University School of Medicine, Shanghai, China, 200030
| | - Haifeng Jiang
- Shanghai Mental Health Center, Shanghai JiaoTong University School of Medicine, Shanghai, China, 200030
| | - Jiang Du
- Shanghai Mental Health Center, Shanghai JiaoTong University School of Medicine, Shanghai, China, 200030
| | - Hanhui Chen
- Shanghai Mental Health Center, Shanghai JiaoTong University School of Medicine, Shanghai, China, 200030
| | - Zhibin Li
- Shanghai Mental Health Center, Shanghai JiaoTong University School of Medicine, Shanghai, China, 200030
| | - Walter Ling
- Integrated Substance Abuse Programs, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, United States of America
| | - Min Zhao
- Shanghai Mental Health Center, Shanghai JiaoTong University School of Medicine, Shanghai, China, 200030
- * E-mail:
| |
Collapse
|
19
|
Carroll KM. Lost in translation? Moving contingency management and cognitive behavioral therapy into clinical practice. Ann N Y Acad Sci 2014; 1327:94-111. [PMID: 25204847 PMCID: PMC4206586 DOI: 10.1111/nyas.12501] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In the treatment of addictions, the gap between the availability of evidence-based therapies and their limited implementation in practice has not yet been bridged. Two empirically validated behavioral therapies, contingency management (CM) and cognitive behavioral therapy (CBT), exemplify this challenge. Both have a relatively strong level of empirical support but each has weak and uneven adoption in clinical practice. This review highlights examples of how barriers to their implementation in practice have been addressed systematically, using the Stage Model of Behavioral Therapies Development as an organizing framework. For CM, barriers such as cost and ideology have been addressed through the development of lower-cost and other adaptations to make it more community friendly. For CBT, barriers such as relative complexity, lack of trained providers, and need for supervision have been addressed via conversion to standardized computer-assisted versions that can serve as clinician extenders. Although these and other modifications have rendered both interventions more disseminable, diffusion of innovation remains a complex, often unpredictable process. The existing specialty addiction-treatment system may require significant reforms to fully implement CBT and CM, particularly greater focus on definable treatment goals and performance-based outcomes.
Collapse
Affiliation(s)
- Kathleen M Carroll
- Division of Substance Abuse, Yale University School of Medicine, West Haven, Connecticut
| |
Collapse
|
20
|
Lin SK. Pharmacological means of reducing human drug dependence: a selective and narrative review of the clinical literature. Br J Clin Pharmacol 2014; 77:242-52. [PMID: 23701272 DOI: 10.1111/bcp.12163] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 04/28/2013] [Indexed: 12/20/2022] Open
Abstract
Substance abuse or addictive disorder is a global problem. A greater understanding of the associated changes in brain pathophysiology supports the notion that pharmacological treatments are part of the necessary treatment options. Craving is a core symptom of addictive disorder. It refers to a strong desire to use drugs again either to re-experience positive effects or to diminish negative experiences. Currently there are a number of medicines that are effective in the treatment of addictive disorders. These medications can either be for substitution (same pharmacological effect as the abused substance) or anticraving (decrease the craving of the abused substance). In this MEDLNE based review, specific compounds (naltrexone, acamprosate, topiramate, disulfiram, baclofen, N-acetylcysteine and bupropion) were selected that are known to diminish desire to use (anticraving effect) and that have been trialled for a number of different substance addictive disorders. Their therapeutic potential in clinical practice is discussed in light of their efficacy.
Collapse
Affiliation(s)
- Shih-Ku Lin
- Department of Psychiatry, Taipei City Hospital and Psychiatric Center, Taipei, Taiwan; Department of Psychiatry, School of Medicine, Taipei Medical University, Taipei, Taiwan
| |
Collapse
|
21
|
Olney JJ, Navarro M, Thiele TE. Targeting central melanocortin receptors: a promising novel approach for treating alcohol abuse disorders. Front Neurosci 2014; 8:128. [PMID: 24917782 PMCID: PMC4042890 DOI: 10.3389/fnins.2014.00128] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 05/08/2014] [Indexed: 12/30/2022] Open
Abstract
The melanocortin (MC) peptides are produced centrally by propiomelanocortin (POMC) neurons within the arcuate nucleus of the hypothalamus and act through five seven-transmembrane G-protein coupled melanocortin receptor (MCR) subtypes. The MC3R and MC4R subtypes, the most abundant central MCRs, are widely expressed in brain regions known to modulate neurobiological responses to ethanol, including regions of the hypothalamus and extended amygdala. Agouti-related protein (AgRP), also produced in the arcuate nucleus, is secreted in terminals expressing MCRs and functions as an endogenous MCR antagonist. This review highlights recent genetic and pharmacological findings that have implicated roles for the MC and AgRP systems in modulating ethanol consumption. Ethanol consumption is associated with significant alterations in the expression levels of various MC peptides/protein, which suggests that ethanol-induced perturbations of MC/AgRP signaling may modulate excessive ethanol intake. Consistently, MCR agonists decrease, and AgRP increases, ethanol consumption in mice. MCR agonists fail to blunt ethanol intake in mutant mice lacking the MC4R, suggesting that the protective effects of MCR agonists are modulated by the MC4R. Interestingly, recent evidence reveals that MCR agonists are more effective at blunting binge-like ethanol intake in mutant mice lacking the MC3R, suggesting that the MC3R has opposing effects on the MC4R. Finally, mutant mice lacking AgRP exhibit blunted voluntary and binge-like ethanol drinking, consistent with pharmacological studies. Collectively, these preclinical observations provide compelling evidence that compounds that target the MC system may provide therapeutic value for treating alcohol abuse disorders and that the utilization of currently available MC-targeting compounds- such as those being used to treat eating disorders- may be used as effective treatments to this end.
Collapse
Affiliation(s)
- Jeffrey J Olney
- Department of Psychology, University of North Carolina Chapel Hill, NC, USA
| | - Montserrat Navarro
- Department of Psychology, University of North Carolina Chapel Hill, NC, USA
| | - Todd E Thiele
- Department of Psychology, University of North Carolina Chapel Hill, NC, USA ; Bowles Center for Alcohol Studies, University of North Carolina Chapel Hill, NC, USA
| |
Collapse
|
22
|
Abstract
In 1994, the US Food and Drug Administration approved the μ-opioid receptor antagonist naltrexone to treat alcohol dependence. However, treatments requiring daily administration, such as naltrexone, are inconsistently adhered to in substance abusing populations, and constant medication exposure can increase risk of adverse outcomes, e.g., hepatotoxicity. This has fostered a 'targeted' or 'as needed' approach to opioid receptor antagonist treatment, in which medications are used only in anticipation of or during high-risk situations, including times of intense cravings. Initial studies of the ability of targeted naltrexone to reduce drinking-related outcomes were conducted in problem drinkers and have been extended into larger, multi-site, placebo-controlled investigations with positive results. Another μ-opioid receptor antagonist, nalmefene, has been studied on an 'as-needed' basis to reduce heavy drinking in alcohol-dependent individuals. These studies include three large multi-site trials in Europe of up to 1 year in duration, and serve as the basis for the recent approval of nalmefene by the European Medicines Agency as an 'as-needed' adjunctive treatment for alcohol dependence. We review potential moderators of opioid receptor antagonist treatment response including subjective assessments, objective clinical measures and genetic variants. In sum, the targeted or 'as-needed' approach to treatment with opioid antagonists is an efficacious harm-reduction strategy for problem drinking and alcohol dependence.
Collapse
|
23
|
Litten RZ, Castle IJP, Falk D, Ryan M, Fertig J, Chen CM, Yi HY. The placebo effect in clinical trials for alcohol dependence: an exploratory analysis of 51 naltrexone and acamprosate studies. Alcohol Clin Exp Res 2013; 37:2128-37. [PMID: 23889231 DOI: 10.1111/acer.12197] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 04/17/2013] [Indexed: 01/07/2023]
Abstract
BACKGROUND The placebo effect often undermines efforts to determine treatment effectiveness in clinical trials. A significant placebo response occurs in alcohol trials, but it is not well understood. The purpose of this study was to characterize the placebo response across multiple naltrexone and acamprosate studies. METHODS Fifty-one trials, 3 with a naltrexone and an acamprosate arm, 31 with at least 1 naltrexone arm, and 17 with at least 1 acamprosate arm, were identified from Cochrane reviews and PubMed search. To be included in this study, patients had to be at least 18 years old, abstinent from alcohol before randomization, and meet a diagnosis of alcohol dependence. Pearson correlation coefficients (rp ) and simple linear regression were used to describe the strength of linear relationships between placebo response and treatment effect size. Spearman's rank correlation coefficients (rs ) were used to examine the strength of associations between study characteristics and placebo response. RESULTS For the end point measures of percent days abstinent and total abstinence, a negative relationship was evident between placebo response and treatment effect size in the naltrexone trials (rp = -0.55, p < 0.01 and rp = -0.20, p = 0.35, respectively) as well as in the acamprosate trials (rp = -0.45, p = 0.09 and rp = -0.56, p = 0.01, respectively). The placebo response for percent days abstinent was negatively correlated with mean age of participants (rs = -0.42, p = 0.05) across naltrexone trials and positively correlated with publication year (rs = 0.57, p = 0.03) across acamprosate trials. However, these 2 study characteristics were not significantly correlated with treatment effect size. CONCLUSIONS The placebo response varied considerably across trials and was negatively correlated with the treatment effect size. Additional studies are required to fully understand the complex nature of the placebo response and to evaluate approaches to minimize its effects.
Collapse
Affiliation(s)
- Raye Z Litten
- Division of Treatment and Recovery Research , National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland
| | | | | | | | | | | | | |
Collapse
|
24
|
Maisel NC, Blodgett JC, Wilbourne PL, Humphreys K, Finney JW. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful? Addiction 2013; 108:275-93. [PMID: 23075288 PMCID: PMC3970823 DOI: 10.1111/j.1360-0443.2012.04054.x] [Citation(s) in RCA: 252] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 02/14/2012] [Accepted: 08/09/2012] [Indexed: 12/11/2022]
Abstract
AIMS Although debates over the efficacy of oral naltrexone and acamprosate in treating alcohol use disorders tend to focus on their global efficacy relative to placebo or their efficacy relative to each other, the underlying reality may be more nuanced. This meta-analysis examined when naltrexone and acamprosate are most helpful by testing: (i) the relative efficacy of each medication given its presumed mechanism of action (reducing heavy drinking versus fostering abstinence) and (ii) whether different ways of implementing each medication (required abstinence before treatment, detoxification before treatment, goal of treatment, length of treatment, dosage) moderate its effects. METHODS A systematic literature search identified 64 randomized, placebo-controlled, English-language clinical trials completed between 1970 and 2009 focused on acamprosate or naltrexone. RESULTS Acamprosate had a significantly larger effect size than naltrexone on the maintenance of abstinence, and naltrexone had a larger effect size than acamprosate on the reduction of heavy drinking and craving. For naltrexone, requiring abstinence before the trial was associated with larger effect sizes for abstinence maintenance and reduced heavy drinking compared with placebo. For acamprosate, detoxification before medication administration was associated with better abstinence outcomes compared with placebo. CONCLUSIONS In treatment for alcohol use disorders, acamprosate has been found to be slightly more efficacious in promoting abstinence and naltrexone slightly more efficacious in reducing heavy drinking and craving. Detoxification before treatment or a longer period of required abstinence before treatment is associated with larger medication effects for acamprosate and naltrexone respectively.
Collapse
Affiliation(s)
- Natalya C. Maisel
- Center for Health Care Evaluation, VA Palo Alto Health Care System (152MPD), 795 Willow Rd., Menlo Park, CA 94025
| | - Janet C. Blodgett
- Center for Health Care Evaluation, VA Palo Alto Health Care System (152MPD), 795 Willow Rd., Menlo Park, CA 94025
| | - Paula L. Wilbourne
- Center for Health Care Evaluation, VA Palo Alto Health Care System (152MPD), 795 Willow Rd., Menlo Park, CA 94025
| | - Keith Humphreys
- Center for Health Care Evaluation, VA Palo Alto Health Care System (152MPD), 795 Willow Rd., Menlo Park, CA 94025,Stanford University Stanford School of Medicine, Department of Psychiatry & Behavioral Sciences, 401 N. Quarry Road, Stanford, CA 94305-5717
| | - John W. Finney
- Center for Health Care Evaluation, VA Palo Alto Health Care System (152MPD), 795 Willow Rd., Menlo Park, CA 94025,Stanford University Stanford School of Medicine, Department of Psychiatry & Behavioral Sciences, 401 N. Quarry Road, Stanford, CA 94305-5717
| |
Collapse
|
25
|
Samet S, Fenton MC, Nunes E, Greenstein E, Aharonovich E, Hasin D. Effects of independent and substance-induced major depressive disorder on remission and relapse of alcohol, cocaine and heroin dependence. Addiction 2013; 108:115-23. [PMID: 22775406 PMCID: PMC3767419 DOI: 10.1111/j.1360-0443.2012.04010.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Revised: 09/20/2011] [Accepted: 06/28/2012] [Indexed: 11/30/2022]
Abstract
AIMS Little is known about the differential effects of independent and substance-induced major depression on the longitudinal course of alcohol, cocaine and heroin disorders when studied prospectively. DESIGN Consecutively admitted in-patients, evaluated at baseline, 6-, 12- and 18-month follow-ups. SETTING Baseline evaluations in a short-stay in-patient urban community psychiatric hospital unit. PARTICIPANTS Adults (n = 250) with current DSM-IV cocaine, heroin and/or alcohol dependence at baseline. MEASUREMENTS The Psychiatric Research Interview for Substance and Mental Disorders (PRISM), used to evaluate independent and substance-induced major depression, alcohol, cocaine and heroin dependence, and other psychiatric disorders. Outcomes for each substance: (i) time (weeks) from hospital discharge to first use; (ii) time from discharge to onset of sustained (≥26 weeks) remission from dependence; (iii) time from onset of sustained remission to relapse. FINDINGS Substance-induced major depression significantly predicted post-discharge use of alcohol, cocaine and heroin (hazard ratios 4.7, 5.3 and 6.5, respectively). Among patients achieving stable remissions from dependence, independent major depression predicted relapse to alcohol and cocaine dependence (hazard ratios 2.3 and 2.7, respectively). CONCLUSIONS Substance-induced and independent major depressions were both related to post-discharge use of alcohol, cocaine and heroin. The findings suggest the importance of clinical attention to both types of depression in substance abusing patients.
Collapse
Affiliation(s)
- Sharon Samet
- School of Social Work, Columbia University, NewYork, NY, USA
| | - Miriam C. Fenton
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Edward Nunes
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, USA,New York State Psychiatric Institute, New York, NY, USA
| | | | - Efrat Aharonovich
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, USA,New York State Psychiatric Institute, New York, NY, USA
| | - Deborah Hasin
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA,Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, USA,New York State Psychiatric Institute, New York, NY, USA
| |
Collapse
|
26
|
Achat-Mendes C, Nic Dhonnchadha BÁ, Platt DM, Kantak KM, Spealman RD. Glycine transporter-1 inhibition preceding extinction training inhibits reacquisition of cocaine seeking. Neuropsychopharmacology 2012; 37:2837-45. [PMID: 22948980 PMCID: PMC3499725 DOI: 10.1038/npp.2012.155] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Cognitive enhancers that act by increasing glycine transmission might be useful adjuncts to cocaine-cue extinction training to deter relapse. The study investigated the effects of combining treatments of the glycine transporter-1 (GlyT-1) inhibitor, Org24598, with extinction training on the subsequent reacquisition of cocaine self-administration. Squirrel monkeys and rats were trained to self-administer cocaine under a second-order schedule of intravenous drug injection in which responding was maintained by cocaine injections and a cocaine-paired visual stimulus. During three weekly extinction sessions, saline was substituted for cocaine but responding still produced the cocaine-paired stimulus. Subjects were treated with Org24598 or vehicle, either before or after each extinction session. One week later, cocaine injections were restored, and reacquisition of cocaine self-administration was evaluated over 15 sessions. Compared with vehicle, administration of Org24598 (1.0 mg/kg in monkeys; 3.0 or 7.5 mg/kg in rats) before each extinction session significantly inhibited reacquisition of cocaine self-administration in each species. In contrast, administration of Org24598 (1.0 mg/kg in monkeys) following, rather than preceding, each extinction session did not affect reacquisition compared with vehicle. When extinction training was replaced by cocaine self-administration or abstinence control conditions, treatment with the same doses of Org24598 resulted in reacquisition that was significantly more rapid than the reacquisition observed when Org24598 was administered before extinction training sessions. The results support the potential clinical utility of GlyT-1 inhibitor pretreatments combined with cocaine-cue extinction training to inhibit relapse.
Collapse
Affiliation(s)
- Cindy Achat-Mendes
- Division of Neuroscience, New England Primate Research Center, Harvard Medical School, Southborough, MA, USA.
| | | | - Donna M Platt
- Division of Neuroscience, New England Primate Research Center, Harvard Medical School, Southborough, MA, USA
| | | | - Roger D Spealman
- Division of Neuroscience, New England Primate Research Center, Harvard Medical School, Southborough, MA, USA
| |
Collapse
|
27
|
White MA, Grilo CM, O'Malley SS, Potenza MN. Clinical case discussion: binge eating disorder, obesity and tobacco smoking. J Addict Med 2012; 4:11-9. [PMID: 20436923 DOI: 10.1097/adm.0b013e3181ce38c8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Marney A White
- Department of Psychiatry, Yale University School of Medicine
| | | | | | | |
Collapse
|
28
|
Gearhardt AN, White MA, Potenza MN. Binge eating disorder and food addiction. ACTA ACUST UNITED AC 2012; 4:201-7. [PMID: 21999695 DOI: 10.2174/1874473711104030201] [Citation(s) in RCA: 194] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 03/23/2011] [Accepted: 04/28/2011] [Indexed: 01/28/2023]
Abstract
Binge eating disorder (BED) shares many characteristics with addictive behaviors (e.g., diminished control, continued use despite negative consequences), and a body of scientific literature is building to support addiction conceptualizations of problematic eating. Despite similarities, BED and "food addiction" may represent unique yet overlapping conditions. Although the exploration of food addiction is relatively new, understanding the relationship between food addiction and BED may be informative in understanding the mechanisms underlying the development and maintenance of problematic eating. In the following paper, we 1) examine the theoretical similarities and differences between BED and addiction, 2) review recent empirical evidence that speak to the relationship between BED and food addiction and 3) discuss the implications of associations between BED and food addiction with respect to clinical interventions.
Collapse
|
29
|
Mason BJ, Lehert P. Acamprosate for alcohol dependence: a sex-specific meta-analysis based on individual patient data. Alcohol Clin Exp Res 2011; 36:497-508. [PMID: 21895717 DOI: 10.1111/j.1530-0277.2011.01616.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND It is unknown whether women derive comparable benefits and have a similar safety and tolerability profile as men from acamprosate, a widely prescribed drug for the maintenance of abstinence in alcohol dependence. The objective of this study was to assess sex-specific differences in the efficacy, safety, and tolerability of acamprosate in the treatment of women and men with alcohol dependence. METHODS A sex-specific meta-analysis was conducted based on individual patient data (IPD). Data were obtained from double-blind, randomized controlled trials with quantitative drinking measures in patients with alcohol dependence receiving oral acamprosate or placebo. Sources included PubMed, PsychInfo, and Cochrane electronic databases; reference lists from retrieved articles and presentations at professional meetings; and direct access to authors and companies who provided IPD. RESULTS Individual records were obtained from 1,317 women and 4,794 men who participated in 22 eligible studies conducted in 18 countries. IPD meta-analyses found a significant beneficial effect of acamprosate relative to placebo across all 4 efficacy end points: an incremental gain of 10.4% (95% CI 7.1 to 13.7, p < 0.001) in percentage of abstinent days, an incremental gain of 11.0% (7.4 to 14.6, p < 0.001) in percentage of no heavy drinking days, an odds ratio of 1.9 (1.6 to 2.2, p < 0.001) for rate of complete abstinence, and an odds ratio of 1.9 (1.6 to 2.3, p < 0.001) for rate of no heavy drinking, over the study duration. Acamprosate was also associated with significantly higher rates of treatment completion (p = 0.004) and medication compliance (p < 0.001) than placebo. Men and women did not differ on any measure of acamprosate efficacy, safety, or tolerability. CONCLUSIONS This sex-specific IPD meta-analysis provides evidence that acamprosate has a significant effect compared with placebo in improving rates of abstinence and no heavy drinking in both women and men with alcohol dependence. Further, acamprosate was associated with significantly higher rates of treatment completion and medication compliance than placebo among both women and men and had a comparable safety and tolerability profile.
Collapse
Affiliation(s)
- Barbara J Mason
- Pearson Center for Alcoholism and Addiction Research, Committee on the Neurobiology of Addictive Disorders, The Scripps Research Institute, La Jolla, California 92037, USA.
| | | |
Collapse
|
30
|
Abstract
OBJECTIVE To summarize published data on pharmacologic treatments for alcohol dependence alone and in combination with brief psychosocial therapies that may be feasible for primary care and specialty medical settings. METHODS We conducted electronic searches of published original research articles and reviews in MEDLINE, SCOPUS, CINAHL, Embase, and PsychINFO. In addition, hand searches of reference lists of review articles, supplemental searches of internet references and contacts with experts in the field were conducted. Randomized controlled studies published between January 1960 and August 2010 that met our inclusion/exclusion criteria were included. RESULTS A total of 85 studies, representing 18,937 subjects, met our criteria for inclusion. The evidence base for oral naltrexone (6% more days abstinent than placebo in the largest study) and topiramate (prescribed off-label) (e.g., 26.2% more days abstinent than placebo in a recent study) is positive but modest. Acamprosate shows modest efficacy with recently abstinent patients, with European studies showing better results than U.S. ones. The evidence-base for disulfiram is equivocal. Depot naltrexone shows efficacy (25% greater reduction in rate of heavy drinking vs. placebo, in one of the largest studies) in a limited number of studies. Some studies suggest that patients do better with extensive psychosocial treatments added to medications while others show that brief support can be equally effective. CONCLUSIONS Although treatment effects are modest, medications for alcohol dependence, in conjunction with either brief support or more extensive psychosocial therapy, can be effective in primary and specialty care medical settings.
Collapse
Affiliation(s)
- Peter M Miller
- Center for Drug and Alcohol Programs, Medical University of South Carolina, Charleston, SC 29425, USA.
| | | | | |
Collapse
|
31
|
Greenfield SF, Pettinati HM, O'Malley S, Randall PK, Randall CL. Gender differences in alcohol treatment: an analysis of outcome from the COMBINE study. Alcohol Clin Exp Res 2010; 34:1803-12. [PMID: 20645934 DOI: 10.1111/j.1530-0277.2010.01267.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Relatively few studies have examined gender differences in the effectiveness of specific behavioral or pharmacologic treatment of alcohol dependence. The aim of this study is to assess whether there were gender differences in treatment outcomes for specific behavioral and medication treatments singly or in combination by conducting a secondary analysis of public access data from the national, multisite NIAAA-sponsored COMBINE study. METHODS The COMBINE study investigated alcohol treatment among 8 groups of patients (378 women, 848 men) who received medical management (MM) with 16 weeks of placebo, naltrexone (100 mg/day), acamprosate (3 g/day), or their combination with or without a specialist-delivered combined behavioral intervention. We examined efficacy measures separately for men and women, followed by an overall analysis that included gender and its interaction with treatment condition in the analyses. These analyses were performed to confirm whether the findings reported in the parent trial were also relevant to women, and to more closely examine secondary outcome variables that were not analyzed previously for gender effects. RESULTS Compared to men, women reported a later age of onset of alcohol dependence by approximately 3 years, were significantly less likely to have had previous alcohol treatment, and drank fewer drinks per drinking day. Otherwise, there were no baseline gender differences in drinking measures. Outcome analyses of 2 primary (percent days abstinent and time to first heavy drinking day) and 2 secondary (good clinical response and percent heavy drinking days) drinking measures yielded the same overall pattern in each gender as that observed in the parent COMBINE study report. That is, only the naltrexone by behavioral intervention interaction reached or approached significance in women as well as in men. There was a naltrexone main effect that was significant in both men and women in reduction in alcohol craving scores with naltrexone-treated subjects reporting lower craving than placebo-treated subjects. CONCLUSIONS This gender-focused analysis found that alcohol-dependent women responded to naltrexone with COMBINE's Medical Management, similar to the alcohol-dependent men, on a wide range of outcome measures. These results suggest that clinicians can feel comfortable prescribing naltrexone for alcohol dependence in both men and women. In this study, it is also notable that fewer women than men reported receiving any alcohol treatment prior to entry into the COMBINE study. Of note, women tend to go to primary health care more frequently than to specialty substance abuse programs for treatment, and so the benefit we confirm for women of the naltrexone and MM combination has practical implications for treating alcohol-dependent women.
Collapse
|
32
|
Gueorguieva R, Wu R, Donovan D, Rounsaville BJ, Couper D, Krystal JH, O’Malley SS. Naltrexone and combined behavioral intervention effects on trajectories of drinking in the COMBINE study. Drug Alcohol Depend 2010; 107:221-9. [PMID: 19969427 PMCID: PMC2821955 DOI: 10.1016/j.drugalcdep.2009.10.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Revised: 10/28/2009] [Accepted: 10/28/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE COMBINE is the largest study of pharmacotherapy for alcoholism in the United States to date, designed to answer questions about the benefits of combining behavioral and pharmacological interventions. Trajectory-based analyses of daily drinking data allowed identification of distinct drinking trajectories in smaller studies and demonstrated significant naltrexone effects even when primary analyses on summary drinking measures were unsuccessful. The objective of this study was to replicate and refine trajectory estimation and to assess effects of naltrexone, acamprosate and therapy on the probabilities of following particular trajectories in COMBINE. It was hypothesized that different treatments may affect different trajectories of drinking. METHODS We conducted exploratory analyses of daily indicators of any drinking and heavy drinking using a trajectory-based approach and assessed trajectory membership probabilities and odds ratios for treatment effects. RESULTS We replicated the trajectories ("abstainer", "sporadic drinker", "consistent drinker") established previously in smaller studies. However, greater numbers of trajectories better described the heterogeneity of drinking over time. Naltrexone reduced the chance to follow a "nearly daily" trajectory and Combined Behavioral Intervention (CBI) reduced the chance to be in an "increasing to nearly daily" trajectory of any drinking. The combination of naltrexone and CBI increased the probability of membership in a trajectory in which the frequency of any drinking declined over time. Trajectory membership was associated with different patterns of treatment compliance. CONCLUSION The trajectory-analyses identified specific patterns of drinking that were differentially influenced by each treatment and provided support for hypotheses about the mechanisms by which these treatments work.
Collapse
Affiliation(s)
- Ralitza Gueorguieva
- Yale University School of Public Health and School of Medicine, New Haven, CT 06520, USA.
| | - Ran Wu
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06519, USA
| | - Dennis Donovan
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA 98105, USA
| | - Bruce J. Rounsaville
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06519, USA
| | - David Couper
- Department of Biostatistics, The University of North Carolina at Chapel Hill, NC 27514, USA
| | - John H. Krystal
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06519, USA,VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Stephanie S. O’Malley
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06519, USA
| |
Collapse
|
33
|
Fox HC, Hong KIA, Siedlarz KM, Bergquist K, Anderson G, Kreek MJ, Sinha R. Sex-specific dissociations in autonomic and HPA responses to stress and cues in alcohol-dependent patients with cocaine abuse. Alcohol Alcohol 2009; 44:575-85. [PMID: 19793926 DOI: 10.1093/alcalc/agp060] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
AIMS Chronic alcohol and drug dependence leads to neuroadaptations in hypothalamic-pituitary-adrenal (HPA) and sympathetic adrenal medullary (SAM) stress systems, which impact response sensitivity to stress and alcohol cue and facilitates risk of relapse. To date, gender variations in these systems have not been fully assessed in abstinent alcohol-dependent individuals who also met criteria for cocaine abuse. METHODS Forty-two (21 M/21 F) early abstinent treatment-seeking substance-abusing (SA) men and women and 42 (21 M/21 F) healthy control (HC) volunteers were exposed to three 5-min guided imagery conditions (stress, alcohol/drug cue, neutral relaxing), presented randomly, one per day across three consecutive days. Alcohol craving and anxiety ratings were obtained as well as measures of heart rate (HR), blood pressure, plasma ACTH, cortisol, norepinephrine (NE) and epinephrine (EPI). RESULTS SA males showed increased ACTH and EPI basal tone compared with HC males and SA females. However, they demonstrated no increase in ACTH and cortisol levels following stress and alcohol cue imagery exposure compared to the neutral condition. SA females demonstrated a typically increased stress response in both measures. In addition, SA males showed no increase in cardiovascular response to either stress or cue, and no increase in catecholamine response to cue compared with their response to neutral imagery. Again, this dampening was not observed in HC males who produced significantly higher levels of cue-related HR and EPI, and significantly higher stress-related DBP. In contrast, SA females showed an enhanced ACTH and cortisol response to stress and cue compared with neutral imagery and this was not observed in the HC females. They also demonstrated a reduced increase in NE and EPI compared with both SA males and HC females as well as reduced HR compared with HC females. CONCLUSIONS While SA males showed a generalized suppression of HPA, SAM system and cardiovascular markers following both stress and cue, SA women demonstrated a selective sympatho-adrenal suppression to stress only and an enhanced HPA response to both stress and cue. These gender variations are discussed in terms of their potential impact on relapse vulnerability and treatment outcome.
Collapse
Affiliation(s)
- Helen C Fox
- Yale Stress Center, Yale University School of Medicine, New Haven, CT 06519, USA
| | | | | | | | | | | | | |
Collapse
|
34
|
Sysko R, Hildebrandt T. Cognitive-behavioural therapy for individuals with bulimia nervosa and a co-occurring substance use disorder. EUROPEAN EATING DISORDERS REVIEW 2009; 17:89-100. [PMID: 19130465 DOI: 10.1002/erv.906] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
A significant percentage of individuals with bulimia nervosa (BN) also can be diagnosed with a co-occurring substance use disorder (SUD). Although studies have addressed the frequency of overlap between the disorders, etiology and shared personality traits, limited research is available about the treatment of these comorbid patients. Adapting cognitive-behaviour therapy (CBT) to serve as an integrated treatment for patients with both BN and a SUD is a viable option, as studies of CBT suggest that this form of treatment is efficacious for both disorders independently. The shared strategies in CBT for BN and SUDs facilitate the development of a combined treatment for individuals with both disorders with the addition of modules designed to address some common features of these disorders, such as motivation, difficulty with interpersonal relationships, reward sensitivity and impulsivity. Future research should begin to evaluate the efficacy of an integrated CBT in treating individuals with BN and a SUD.
Collapse
Affiliation(s)
- Robyn Sysko
- Columbia University, The New York State Psychiatric Institute, New York, NY 10032, USA.
| | | |
Collapse
|
35
|
Chen X, Lunn S, Deveaux L, Li X, Brathwaite N, Cottrell L, Stanton B. A cluster randomized controlled trial of an adolescent HIV prevention program among Bahamian youth: effect at 12 months post-intervention. AIDS Behav 2009; 13:499-508. [PMID: 19116781 DOI: 10.1007/s10461-008-9511-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Accepted: 12/08/2008] [Indexed: 11/26/2022]
Abstract
Behavioral interventions based on the Protection Motivation Theory (PMT) have been demonstrated to reduce HIV risk behavior among mid- and older adolescents in different settings across the globe but have not been evaluated among Caribbean nations and have received limited evaluation among pre-adolescents. To determine (1) the effectiveness among pre-adolescents in The Bahamas of a PMT-based HIV prevention program "Focus on Youth in the Caribbean" (FOYC) and (2) the role of the targeted PMT constructs in intervention effect. 1,360 sixth grade youth (10-11 years of age) from 15 urban schools in New Providence, The Bahamas were randomized by school to receive either FOYC or a control condition. Data collected at baseline, 6 and 12 months post intervention were analyzed. A five-step scheme was used to assess sexual behavior progression, ranging from "1" = "a virgin without intention to have sex" to "5" = "having sex without a condom". Group-based trajectory analysis was utilized in assessing the program effect. Two sexual behavior progression patterns were detected: slow progressors and quick progressors. Receiving FOYC reduced the likelihood for adolescents to become quick progressors (adjusted OR = 0.77, 95% CI: 0.64-1.00). The observed effectiveness was especially impacted by a subset of the targeted PMT constructs. FOYC effectively delays sexual risk among Bahamian pre-adolescents. The group-based trajectory analysis provides an analytical approach for assessing interventions among adolescents with low rates and diverse progression patterns of sexual activity.
Collapse
Affiliation(s)
- Xinguang Chen
- Department of Pediatrics, Pediatric Prevention Research Center, Wayne State University School of Medicine, 4201 St. Antoine Street, UHC-6D, Detroit, MI, USA.
| | | | | | | | | | | | | |
Collapse
|
36
|
New insights into the efficacy of naltrexone based on trajectory-based reanalyses of two negative clinical trials. Biol Psychiatry 2007; 61:1290-5. [PMID: 17224132 PMCID: PMC1952242 DOI: 10.1016/j.biopsych.2006.09.038] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2006] [Revised: 09/19/2006] [Accepted: 09/19/2006] [Indexed: 11/26/2022]
Abstract
BACKGROUND The heterogeneity of clinical findings in studies evaluating the efficacy of naltrexone in the treatment of alcohol dependence has led to growing efforts to explore novel approaches to data analysis. The objective of this study was to identify distinct trajectories of daily drinking over time in two negative clinical trials and to determine whether naltrexone affected the probability to follow a particular trajectory. METHODS The Veterans Affairs (VA) Cooperative Study #425 and the Women's Naltrexone Study failed to demonstrate efficacy on primary outcome variables. Separately for each study, we analyzed daily indicators of any drinking and heavy drinking using a semiparametric group-based approach. RESULTS We estimated three distinct trajectories of daily drinking (both any and heavy drinking) which we described as "abstainer," "sporadic drinker," and "consistent drinker." Naltrexone doubled the odds of following the abstainer trajectory instead of the consistent drinker trajectory but did not significantly change the odds of following the abstainer trajectory as contrasted with the sporadic drinker trajectory. CONCLUSIONS Naltrexone may have a clinically meaningful effect for alcohol-dependent patients with a high chance of consistent drinking, even in studies where it failed to show efficacy in planned analyses.
Collapse
|