Systematic review and meta-analysis of opioid antagonists for smoking cessation

New medications development for smoking cessation

Diseases associated with nicotine dependence in the form of habitual tobacco use are a major cause of premature death in the United States. The majority of tobacco smokers will relapse within the first month of attempted abstinence. Smoking cessation agents increase the likelihood that smokers can achieve long-term abstinence. Nevertheless, currently available smoking cessation agents have limited utility and fail to prevent relapse in the majority of smokers. Pharmacotherapy is therefore an effective strategy to aid smoking cessation efforts but considerable risk of relapse persists even when the most efficacious medications currently available are used. The past decade has seen major breakthroughs in our understanding of the molecular, cellular, and systems-level actions of nicotine in the brain that contribute to the development and maintenance of habitual tobacco use. In parallel, large-scale human genetics studies have revealed allelic variants that influence vulnerability to tobacco use disorder. These advances have revealed targets for the development of novel smoking cessation agents. Here, we summarize current efforts to develop smoking cessation therapeutics and highlight opportunities for future efforts.

Neurological Effects of Combining Low Toxic Dose of Tramadol and Nicotine: An Animal Model Evidence of Endoplasmic Reticulum Stress

Tramadol abuse is a common problem in the Middle East in conjunction with smoking. The current study applied immunohistochemistry, western blot, real-time PCR, and ELISA to test the combination toxicity. Low toxic doses of tramadol induced animal brain cortex inflammation and hippocampus injury. Adding nicotine reverted hippocampus pathological changes without triggering marked brain injury. The expression of CHOP protein with real-time PCR showed mild endoplasmic reticulum stress (ER) in rat's brain. Histological, immunohistochemical, and western blotting analysis of CHOP (CCAAT-enhancer-binding protein homologous protein) and BIP (immunoglobulin heavy chain-binding protein) chaperones demonstrated endoplasmic reticulum stress in the brains of animals. Furthermore, the levels of apoptosis and autophagy markers demonstrated a mild reaction. The blood level of serotonin was high in all study groups, with a marked increase in the combined one. The high serotonin levels in the blood can be critical and associated with a high risk of serious withdrawal and pathological consequences. Serotonin receptor blockers such as olanzapine may increase systemic serotonin levels and need further investigation to utterly pinpoint their roles in managing mood disorders. In conclusion, the combination of tramadol and nicotine is less harmful than expected. However, serious withdrawal effects can occur as a result of high systemic serotonin effects.

Elucidating the reinforcing effects of nicotine: a tribute to Nadia Chaudhri

Nadia Chaudhri worked with us as a graduate student in the Center for Neuroscience at the University of Pittsburgh from 1999 until she earned her PhD in 2005, a time that coincided with the discovery in our lab of the dual reinforcing actions of nicotine, a concept that she played an important role in shaping. The research that was described in her doctoral thesis is among the foundational pillars of the now well-accepted notion that nicotine acts as both a primary reinforcer and an amplifier of other reinforcer stimuli. This reinforcement-enhancing action of nicotine is robust and likely to be a powerful driver of nicotine use. Below, we discuss the evidence that these two actions of nicotine - primary reinforcement and reinforcement enhancement - are distinct and dissociable, a finding that Nadia was closely associated with. We go on to address two other topics that greatly interested Nadia during that time, the generalizability of the reinforcement-enhancing action of nicotine to multiple classes of reinforcing stimuli and potential sex differences in the dual reinforcing actions of nicotine. The research has greatly expanded since Nadia's involvement, but the core ideas that she helped to develop remain central to the concept of the dual reinforcing actions of nicotine and its importance for understanding the drivers of nicotine use.

Pharmacotherapy in Tobacco Cessation: A Narrative Review

A chronic, recurring illness, known as nicotine addiction and dependence, is defined by a person's dependence on the substance up to the extent that their normal day-to-day activities are compromised in the absence of the substance. This paper will highlight first-line smoking cessation treatments, such as nicotine replacement therapy (NRT), bupropion, and varenicline, and second-line medications, such as clonidine, nortriptyline, anxiolytics, mecamylamine, naltrexone, and NicVAX (Nabi Biopharmaceuticals, Rockville, MD, USA). NRT offers many options for nicotine delivery methods, comprising nicotine gum, rapid-release gum, lozenges, transdermal patches, high-dose nicotine patches, oral inhalers, nasal sprays, electronic nicotine delivery systems (ENDS), and sublingual tablets. Pharmacotherapies for quitting tobacco should lessen withdrawal symptoms and stop nicotine's reinforcing effects without having too many side effects.

F, Deng X, Wang Y, Wang Z, Wu Y, Xu M, Yang C, Li X, Yang K. Pharmacological interventions on smoking cessation: A systematic review and network meta-analysis

Objective: A network meta-analysis based on randomized controlled trials was conducted to investigate the effects of pharmacological interventions on smoking cessation.

Methods: English databases were searched to obtain randomized controlled trials reporting the effect of pharmacological interventions on smoking cessation. The risk of bias for the included trials was assessed using Cochrane Handbook tool. Stata 15.1 software was used to perform network meta-analysis, and GRADE approach was used to assess the evidence credibility on the effects of different interventions on smoking cessation.

Results: A total of 159 studies involving 60,285 smokers were included in the network meta-analysis. The analysis involved 15 interventions and which yielded 105 pairs of comparisons. Network meta-analysis showed that varenicline was more helpful for smoking cessation than other monotherapies, such as nicotine replacement therapy [Odds Ratio (OR) = 1.42, 95% confidence interval (CI) (1.16, 1.73)] and bupropion [OR = 1.52, 95% CI (1.22, 1.89)]. Furthermore, combined interventions were superior to monotherapy in achieving smoking cessation, such as varenicline plus bupropion over bupropion [OR = 2.00, 95% CI (1.11, 3.61)], varenicline plus nicotine replacement therapy over nicotine replacement therapy [OR = 1.84, 95% CI (1.07, 3.18)], and nicotine replacement therapy plus mecamylamine over naltrexone [OR = 6.29, 95% CI (1.59, 24.90)]. Finally, the surface under the cumulative ranking curve value indicated that nicotine replacement therapy plus mecamylamine had the greatest probability of becoming the best intervention.

Conclusion: Most pharmacological interventions demonstrated a benefit in smoking cessation compared with placebo, whether monotherapy or combination therapy. Moreover, confirmed evidence suggested that some combination treatments, such as varenicline plus bupropion and nicotine replacement therapy plus mecamylamine have a higher probability of being the best smoking cessation in

The Effects of Menstrual Cycle Hormones on Responses to Varenicline and Naltrexone Among Female Heavy Drinking Smokers

Aims

Women often experience poorer smoking cessation outcomes in comparison to men. Menstrual cycle phase and sex hormones may influence smoking behavior and alter response to opioid antagonist medications. Less is known about the effects of sex hormones in response to pharmacotherapy for female heavy drinking smokers.

Methods

This study is a secondary analysis of premenopausal female heavy drinking smokers who completed a 12-week randomized clinical trial comparing varenicline plus placebo versus varenicline plus naltrexone for smoking cessation and drinking reduction. Participants (n = 26; total observations = 66) provided saliva samples for assays of progesterone (P4) and estradiol (E2) post-randomization at Weeks 4, 8 and 12. We examined the effects of P4/E2 ratio and medication on smoking and drinking outcomes.

Results

For drinking outcomes, there was a significant interaction for percent days abstinent (b = 0.017, P = 0.05), suggesting that greater P4/E2 ratio is associated with greater percent days abstinent for women assigned to the varenicline plus naltrexone condition. There were no interaction effects for the remaining drinking outcomes (P’s ≥ 0.12). Results found no significant interaction effect of P4/E2 ratio and medication on smoking abstinence (P = 0.19).

Conclusion

Our results imply that when women show a greater P4/E2 ratio, typically observed during the luteal phase of the menstrual cycle, they experience an added benefit of naltrexone, versus placebo, for drinking outcomes as shown by greater percent days abstinent. Additional studies in larger samples are warranted as sex hormones offer important information above and beyond comparing women versus men.

The effects of naltrexone on retention in treatment and being opioid-free in opioid-dependent people: A systematic review and meta-analysis

BACKGROUND

Opioid dependency is a chronic relapsing disorder for which different therapeutically interventions have been developed. Naltrexone is a non-selective opioid antagonist that can be utilized for maintenance therapy in opioid dependency. In this systematic review, we aimed to evaluate the effects of naltrexone on retention in treatment and being opioid-free.

METHODS

We systematically searched PubMed and EMBASE databases up to February 5, 2022, using the following keywords: "Naltrexone," "Substance abuse," "Drug abuse," "Opiate-related disorder," and "Opioid dependence." Studies that included opiate-dependent individuals who were treated with naltrexone and assessed retention in treatment or being opioid-free were included. Two authors independently used the Cochrane risk-of-bias tool for quality assessment. A random effect model in Comprehensive Meta-Analysis software was used for the conduction of the meta-analysis. We performed subgroup analysis to evaluate the effects of naltrexone types on outcomes.

RESULTS

Eighteen studies, including 2,280 participants met our inclusion criteria. The duration of treatment ranged from 21 days to 24 months. The retention in treatment with naltrexone was 63% higher than controls (odds ratio (OR): 1.64 [95% confidence interval (CI), 0.78-3.44]. The OR for being opioid-free was 1.63 (95% CI, 0.57-4.72). Injectable naltrexone was significantly effective on retention in treatment (OR 1.86; 95% CI, 1.17-2.98).

CONCLUSIONS

We found that naltrexone could be useful for retention in treatment and being opioid-free, however, the findings were not significant. Further high-quality and large-scale observational studies are recommended.

The effects of pharmacological interventions on smoking cessation in people with alcohol dependence: A systematic review and meta-analysis of nine randomized controlled trials

BACKGROUND

Pharmacotherapies are widely used for smoking cessation. However, their efficacy for people with alcohol dependence remains unclear.

OBJECTIVE

This study aimed to explore the effects of pharmacotherapies on smoking cessation for people with alcohol dependence.

METHODS

Five electronic databases were searched in January 2021 for randomized controlled trials (RCTs) reporting the use of pharmacotherapies to promote smoking cessation in people with alcohol dependence. The risk of bias was assessed using the Cochrane tool. RevMan version 5.3 was used to perform meta-analyses of the changes in smoking behaviour, and the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of the evidence.

RESULTS

The search identified nine RCTs involving 908 smokers with alcohol dependence; eight were published in the USA and one in Canada. The risk of bias was low in three studies and unclear in the remaining six. The meta-analysis results showed that, compared with the placebo group, Varenicline had a significant effect on short-term smoking cessation (three RCTs, odds ratio [OR] = 6.27, 95% confidence interval [CI]: [2.49, 15.78], P < .05, very low certainty). Naltrexone had no significant effect on smoking cessation in short-term or long-term observations (three RCTs, OR = 0.99, 95% CI: [0.54, 1.81], P = .97, moderate certainty), and Topiramate had no significant effects (two RCTs, OR = 1.56, 95% CI: [0.67, 3.46], P > .05, low certainty). Only one trial reported that Bupropion did not affect smoking cessation.

CONCLUSION

Varenicline may promote smoking cessation in people with alcohol dependence. However, Naltrexone, Topiramate and Bupropion have no clear effect on increasing smoking abstinence among drinkers. The small number of studies and the low certainty of evidence indicate that the results should be interpreted cautiously.

Nicotine and Opioids: a Call for Co-treatment as the Standard of Care

The U.S. is in the midst of an opioid epidemic. At the same time, tobacco use remains the leading cause of preventable death and disability. While the shared biological underpinnings of nicotine and opioid addiction are well established, clinical implications for co-treatment of these two substance use disorders has not been emphasized in the literature, nor have researchers, clinicians, and policy makers adequately outlined pathways for incorporating co-treatment into existing clinical workflows. The current brief review characterizes the metabolic and neural mechanisms which mediate co-use of nicotine and opioids, and then outlines clinical and policy implications for concurrently addressing these two deadly epidemics. Screening, assessment, medication-assisted treatment (MAT), and tobacco-free policy are discussed. The evidence suggests that clinical care and policies that facilitate co-treatment are an expedient means of delivering healthcare to individuals that result in better health for the population while also meeting patients' substance abuse disorder recovery goals.

Current pharmacologic treatments for smoking cessation and new agents undergoing clinical trials

Smoking causes various diseases and is a major public health threat worldwide. Therefore, promoting smoking cessation is the most important intervention contributing to maintaining the health of smokers and nonsmokers and saving enormous financial expense. We reviewed existing and emerging smoking-cessation pharmacotherapies from the Cochrane Database of Systemic Reviews, PubMed, Ovid, and ClinicalTrials.gov databases. A literature review revealed that bupropion may be appropriate for patients interested in reducing smoking who dislike, or who have failed, nicotine-replacement therapy (NRT). Additionally, varenicline and NRT are efficacious first-line smoking cessation treatments and should be given to all individuals unless contraindicated.

The reviews of this paper are available via the supplementary material section.

Randomized Clinical Trials Investigating Innovative Interventions for Smoking Cessation in the Last Decade

Every year, billions of dollars are spent treating smoking and related conditions, yet smoking-related morbidity and mortality continue to rise. There are currently only three FDA-approved medications for smoking cessation: nicotine replacement therapy, bupropion, and varenicline. Although these medications increase abstinence rates, most individuals relapse following treatment. This chapter reviews clinical trials published within the past 10 years investigating novel smoking cessation pharmacotherapies. Among these pharmacotherapies, some showed promising results, such as cytisine and endocannabinoid modulators, whereas others failed to produce significant effects. More research is needed to develop drugs that produce higher rates of long-term abstinence and to determine which subgroups of patients benefit from a given treatment.

Therapeutic challenges for concurrent ethanol and nicotine consumption: naltrexone and varenicline fail to alter simultaneous ethanol and nicotine intake by female alcohol-preferring (P) rats

RATIONALE AND OBJECTIVES

Simultaneous alcohol and nicotine consumption occurs in the majority of individuals with alcohol use disorder (AUD) and nicotine dependence. Varenicline (Var) is used to assist in the cessation of nicotine use, while naltrexone (Nal) is the standard treatment for AUD. Despite evidence that ethanol (EtOH) and nicotine (NIC) co-use produces unique neuroadaptations, preclinical research has focused on the effects of pharmacotherapeutics on a single reinforcer. The current experiments examined the effects of Var and Nal on EtOH, NIC, or EtOH+NIC intake.

METHODS

Animals were randomly assigned to one of four drinking conditions of 24-h access to a three-bottle choice paradigm, one of which always contained water. Drinking conditions were water only, 0.07 and 0.14 mg/mL NIC (NIC only), 15% and 30% EtOH (EtOH only), or 15% and 30% EtOH with 0.14 mg/mL NIC (EtOH+NIC). The effects of Var (0, 1, or 2 mg/kg) or Nal (0, 1, or 10 mg/kg) injections on maintenance and relapse consumption were determined during four consecutive days.

RESULTS

Var reduced maintenance and relapse NIC intake but had no effect on EtOH or EtOH+NIC drinking. Conversely, Nal reduced EtOH maintenance and relapse drinking, but had no effect on NIC or EtOH+NIC drinking.

DISCUSSION

The results indicate the standard pharmacological treatments for nicotine dependence and AUD were effective at reducing consumption of the targeted reinforcer but neither reduced EtOH+NIC co-use/abuse. These findings suggest that co-abuse may promote unique neuroadaptations that require models of polysubstance abuse to develop pharmacotherapeutics to treat AUD and nicotine dependence.

Mechanisms and Clinical Features of Co-occurring Opioid and Nicotine Use

Purpose of review

To review the literature addressing shared pathophysiological and clinical features of opioid and nicotine use to inform etiology and treatment, and highlight areas for future research.

Recent findings

Opioid and nicotine use co-occur at an alarmingly high rate, and this may be driven in part by interactions between the opioid and cholinergic systems underlying drug reward and the transition to dependence. Pain, among other shared risk factors, is strongly implicated in both opioid and nicotine use and appears to play an important role in their co-occurrence. Additionally, there are important sex/gender considerations that require further study. Regarding treatment, smoking cessation can improve treatment outcomes in opioid use disorder, and pharmacological approaches that target the opioid and cholinergic systems may be effective for treating both classes of substance use disorders.

Summary

Understanding overlapping etiological and pathophysiological mechanisms of opioid and nicotine use can aid in understanding their co-occurrence and guiding their treatment.

Understanding the implications of the biobehavioral basis of nicotine addiction and its impact on the efficacy of treatment

INTRODUCTION

Tobacco use remains the leading cause of preventable death in the United States. There are efficacious behavioral and pharmacological options for smoking cessation including three FDA approved therapies - nicotine replacement therapy, varenicline and bupropion. Nevertheless, uptake of smoking cessation treatments continues to be poor and there is a need for novel smoking cessation treatments. Areas covered: This article reviews the biobehavioral basis of nicotine addiction, its implications for smoking cessation treatments, the various neurotransmitter systems involved in nicotine addictive effects, and their potential therapeutic value. Included are discussions around the role of genetic factors in predicting response to pharmacotherapy and what we know about appropriate application of pharmacotherapy and behavioral interventions for tobacco use disorder. The evidence for harm reduction measures in individuals who are not willing or able to quit smoking is also reviewed. Expert commentary: Many neurotransmitter system targets have been investigated as a result of our understanding of the underlying neurobiology of tobacco use disorder, and there remain important targets that have yet to be fully explored. rTMS or combination therapies are proposed as possible novel strategies to improve smoking cessation.

Current and Emerging Pharmacotherapies for Cessation of Tobacco Smoking

Tobacco use disorder is a chronic illness. With its high comorbidity rate, it is a major cause of years of life lost or years lived with disability; however, it is also considered the most preventable cause of death in developed countries. Since the development of nicotine replacement therapy (NRT) in 1978, treatment options have continued to evolve and expand. Despite this, currently available treatments remain insufficient, with less than 25% of smokers remaining abstinent 1 year after treatment. In this article, we review existing and emerging smoking cessation pharmacotherapies, with a special emphasis on the most promising agents that are currently being investigated. A search of the Cochrane Database of Systematic Reviews and the PubMed, Ovid, and ClinicalTrials.gov databases (August 2 to September 1, 2017) was undertaken for articles on smoking cessation pharmacotherapies, applying no language restrictions. More than 40 pharmacotherapies were reviewed including conventional pharmacotherapies-NRT, bupropion, and varenicline (all approved by the U.S. Food and Drug Administration as first-line treatment of smoking cessation)-and novel therapies: cytisine, N-acetylcysteine, cycloserine, memantine, baclofen, topiramate, galantamine, and bromocriptine. Studies of combination NRT and varenicline showed the greatest smoking cessation rates. Clonidine and nortriptyline are second-line treatments used when first-line treatments fail or are contraindicated, or by patient preference. Some novel therapies, especially acetylcholinesterase inhibitors, cytisine, and N-acetylcysteine, display promising results. Because the results of randomized clinical trials were reported using varied end points and outcome measures, direct comparisons between different pharmacotherapies cannot easily be evaluated. Additional high-quality randomized double-blind placebo-controlled trials with long-term follow-up, using validated sustained abstinence measures, are needed to find more effective smoking cessation aids.

The effectiveness of naltrexone combined with current smoking cessation medication to attenuate post smoking cessation weight gain: a literature review

Background

Smoking is the number one cause of preventable morbidity and mortality globally and although many countries have invested heavily in smoking cessation programs, 21% of the global population still smoke. Post cessation weight gain has been identified as a barrier to attempting cessation and is implicated in the high rates of relapse. Naltrexone has been touted as a possible solution to address post smoking cessation weight gain.

Results

The results from seven original studies assessing the effectiveness of naltrexone in combination with existing smoking cessation medications to attenuate post smoking cessation weight gain were obtained and critically reviewed. Five returned positive results and two returned results that were statistically insignificant. The positive results were seen more often in those identified as more likely to exhibit hedonic eating behaviour for example women and participants who were categorised as overweight or obese.

Conclusion

The evidence suggests further investigation in to a combination of naltrexone and approved smoking cessation medications is warranted and could provide a solution to attenuate post smoking cessation weight gain especially in women and those classified as overweight or obese. This may provide the tool required to remove a perceived barrier to smoking cessation and improve global statistics.

Endogenous opioid system: a promising target for future smoking cessation medications

BACKGROUND

Nicotine addiction continues to be a health challenge across the world. Despite several approved medications, smokers continue to relapse. Several human and animal studies have evaluated the role of the endogenous opioid system as a potential target for smoking cessation medications.

METHODS

In this review, studies that have elucidated the role of the mu (MORs), delta (DORs), and kappa (KORs) opioid receptors in nicotine reward, nicotine withdrawal, and reinstatement of nicotine seeking will be discussed. Additionally, the review will discuss discrepancies in the literature and therapeutic potential of the endogenous opioid system, and suggest studies to address gaps in knowledge with respect to the role of the opioid receptors in nicotine dependence.

RESULTS

Data available till date suggest that blockade of the MORs and DORs decreased the rewarding effects of nicotine, while activation of the MORs and DORs decreased nicotine withdrawal-induced aversive effects. In contrast, activation of the KORs decreased the rewarding effects of nicotine, while blockade of the KORs decreased nicotine withdrawal-induced aversive effects. Interestingly, blockade of the MORs and KORs attenuated reinstatement of nicotine seeking. In humans, MOR antagonists have shown benefits in select subpopulations of smokers and further investigation is required to realize their full therapeutic potential.

CONCLUSION

Future work must assess the influence of polymorphisms in opioid receptor-linked genes in nicotine dependence, which will help in both identifying individuals vulnerable to nicotine addiction and the development of opioid-based smoking cessation medications. Overall, the endogenous opioid system continues to be a promising target for future smoking cessation medications.

A gene-by-sex interaction for nicotine reward: evidence from humanized mice and epidemiology

It has been proposed that vulnerability to nicotine addiction is moderated by variation at the μ-opioid receptor locus (OPRM1), but results from human studies vary and prospective studies based on genotype are lacking. We have developed a humanized mouse model of the most common functional OPRM1 polymorphism rs1799971_A>G (A118G). Here we use this model system together with a cohort of German youth to examine the role of the OPRM1 A118G variation on nicotine reward. Nicotine reinforcement was examined in the humanized mouse model using i.v. self-administration. Male (n=17) and female (n=26) mice homozygous either for the major human A allele (AA) or the minor G allele (GG) underwent eight daily 2 h sessions of nicotine self-administration. Furthermore, male (n=104) and female (n=118) subjects homozygous for the A allele or carrying the G allele from the Mannheim Study of Children at Risk were evaluated for pleasurable and unpleasant experiences during their initial smoking experience. A significant sex-by-genotype effect was observed for nicotine self-administration. Male 118GG mice demonstrated higher nicotine intake than male 118AA mice, suggesting increased nicotine reinforcement. In contrast, there was no genotype effect in female mice. Human male G allele carriers reported increased pleasurable effects from their first smoking experience, as compared to male homozygous A, female G and female homozygous A allele carriers. The 118G allele appears to confer greater sensitivity to nicotine reinforcement in males, but not females.

Opioid Analgesics and Nicotine: More Than Blowing Smoke

Practitioners are highly likely to encounter patients with concurrent use of nicotine products and opioid analgesics. Smokers present with more severe and extended chronic pain outcomes and have a higher frequency of prescription opioid use. Current tobacco smoking is a strong predictor of risk for nonmedical use of prescription opioids. Opioid and nicotinic-cholinergic neurotransmitter systems interact in important ways to modulate opioid and nicotine effects: dopamine release induced by nicotine is dependent on facilitation by the opioid system, and the nicotinic-acetylcholine system modulates self-administration of several classes of abused drugs-including opioids. Nicotine can serve as a prime for the use of other drugs, which in the case of the opioid system may be bidirectional. Opioids and compounds in tobacco, including nicotine, are metabolized by the cytochrome P450 enzyme system, but the metabolism of opioids and tobacco products can be complicated. Accordingly, drug interactions are possible but not always clear. Because of these issues, asking about nicotine use in patients taking opioids for pain is recommended. When assessing patient tobacco use, practitioners should also obtain information on products other than cigarettes, such as cigars, pipes, smokeless tobacco, and electronic nicotine delivery systems (ENDS, or e-cigarettes). There are multiple forms of behavioral therapy and pharmacotherapy available to assist patients with smoking cessation, and opioid agonist maintenance and pain clinics represent underutilized opportunities for nicotine intervention programs.

Neural correlates of adherence to extended-release naltrexone pharmacotherapy in heroin dependence

Injectable extended-release naltrexone (XRNTX) presents an effective therapeutic strategy for opioid addiction, however its utility could be hampered by poor adherence. To gain a better insight into this phenomenon, we utilized blood oxygenation level-dependent functional magnetic resonance imaging (fMRI) in conjunction with a validated cue-induced craving procedure to examine neural correlates of XRNTX adherence. We operationalized treatment adherence as the number of monthly XRNTX injections (range: 0-3) administered to a group of fully detoxified heroin-dependent subjects (n=32). Additional outcomes included urine toxicology screening and self-reported tobacco use. The presented heroin-related visual cues reliably elicited heroin craving in all tested subjects. Nine, five, three and 15 of the participants, respectively, received zero, one, two and three XRNTX injections, predicted by the individual baseline fMRI signal change in response to the cues in the medial prefrontal cortex, a brain region involved in inhibitory self-control and emotional appraisal. The incidence of opioid-positive urines during the XRNTX therapy was low and remained about half the pre-treatment rate after the XRNTX ended. During the treatment, cigarette smoking behaviors followed patterns of opioid use, while cocaine consumption was increased with reductions in opioid use. The present data support the hypothesis that medial prefrontal cortex functions are involved in adherence to opioid antagonist therapy. A potential role of concurrent non-opioid addictive substances consumption during the XRNTX pharmacotherapy warrants further investigation. Our findings set the stage for further bio-behavioral investigations of the mechanisms of relapse prevention in opioid dependence.

Pharmacological Options for Smoking Cessation in Heavy-Drinking Smokers

There is a high prevalence of comorbid tobacco use and alcohol use disorder (AUD), affecting more than 6 million people in the US. Globally, tobacco and alcohol use rank fourth and fifth, respectively, for disability-adjusted life-years lost. Levels of alcohol use are higher in smokers than nonsmokers, and the prevalence of smoking is higher in heavy drinkers compared with nondrinkers. This relationship is driven by many different factors, including genetics, neurobiological mechanisms, conditioning processes, and psychosocial influences. Although this unique population tends to experience more negative health consequences, more severe AUD, and poorer response to treatment than those with either AUD or tobacco use disorder alone, there are currently no available treatment protocols tailored to this comorbid condition. In this review, we provide a comprehensive review of ongoing clinical research into smoking cessation options for heavy-drinking smokers (HDS) through an evaluation of the effect of promising novel pharmacotherapies as well as combination therapies, including varenicline, naltrexone, the combination of varenicline and naltrexone, and the combination of naltrexone and nicotine replacement therapy (NRT). These treatments are considered in light of the standard of care for smoking cessation, and seek to improve upon the available guidelines for this sizeable subgroup of smokers, namely those smokers who drink heavily.

A multifactoral analysis of 1452 patients for smoking sensation. An outpatient lab experience

Smoking habit is held responsible for several respiratory and metabolic diseases. Data from 1452 patients were recorded from our outpatient laboratory. The following parameters were recorded within several follow ups of our patients; smoking habit, respiratory functions, smoking cessation questionnaires, and administered drugs. The treatment administered to smokers throughout the period of inspection seems to also have a significant effect on dependence. In fact, varelicline causes a 50% reduction in smoking dependence in regards to nicotine substitutes (odds ratio: 0.48 (0.31-0,74), p=0.001) so displaying a substantial preponderance on the choice to fight smoking dependence.