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Terasaki D, Ellinwood A, White D. Quadruple pharmacotherapy for alcohol use disorder tolerable yet insufficient: a case report. Subst Abuse Treat Prev Policy 2024; 19:18. [PMID: 38424567 PMCID: PMC10905892 DOI: 10.1186/s13011-024-00599-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 02/16/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Combinations of alcohol use disorder (AUD) medications have been investigated, but few if any reports describe patients maintained on more than two options at the same time. CASE PRESENTATION We report a case of a middle-aged man hospitalized with gastrointestinal bleeding and acute kidney injury who had been maintained on four AUD medications (naltrexone, acamprosate, disulfiram, and gabapentin) and multiple psychiatric medications simultaneously as an outpatient. Direct quotations of his experiences with each AUD medication are included, revealing some deviations from what was prescribed as well as nuanced perceptions of effects. Overall, he tolerated the regimen well, but its AUD effects were insufficient to prevent several episodes of returning to alcohol use. He had very high hospital utilization. This prompted the initiation of an involuntary commitment, which began a period of at least six months of sobriety. CONCLUSIONS Quadruple pharmacotherapy for AUD may be well tolerated and supportive of recovery for an extended period of time. However, for our patient the regimen ultimately failed to prevent multiple episodes of returning to alcohol use and serious medical complications. In refractory cases like this, more intensive interventions such as involuntary commitment can be considered.
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Affiliation(s)
- Dale Terasaki
- Denver Health & Hospital Authority, 777 Bannock St, 80204, Denver, CO, USA.
| | | | - Dan White
- Denver Health & Hospital Authority, 777 Bannock St, 80204, Denver, CO, USA
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Tuchman FR, Hallgren KA, Richards DK, Aldridge A, Anton RK, Aubin HJ, Kranzler HR, Mann K, O’Malley SS, Witkiewitz K. Reductions in WHO risk drinking levels correlate with alcohol craving among individuals with alcohol use disorder. ALCOHOL, CLINICAL & EXPERIMENTAL RESEARCH 2024; 48:420-429. [PMID: 38149364 PMCID: PMC10922776 DOI: 10.1111/acer.15257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/26/2023] [Accepted: 12/14/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND Abstinence has historically been considered the preferred goal of alcohol use disorder (AUD) treatment. However, most individuals with AUD do not want to abstain and many are able to reduce their drinking successfully. Craving is often a target of pharmacological and behavioral interventions for AUD, and reductions in craving may signal recovery. Whether reductions in drinking during AUD treatment are associated with reductions in craving has not been well examined. METHODS We conducted secondary analyses of data from three AUD clinical trials (N's= 1327, 346, and 200). Drinking reductions from baseline to the end of treatment were measured as changes in World Health Organization (WHO) risk drinking levels; alcohol craving was measured using validated self-report measures. Regression analyses tested whether drinking reductions were associated with end-of-treatment craving reductions; moderation analyses tested whether associations between drinking reduction and end-of-treatment craving differed across AUD severity. RESULTS Reductions of at least 1 or at least 2 WHO risk drinking levels were associated with lower craving (all p's < 0.05). Results were substantively similar after removing abstainers at the end-of-treatment. Associations between drinking reductions and craving were generally not moderated by AUD severity. CONCLUSIONS Individuals with WHO risk drinking level reductions reported significantly lower craving, as compared to those who did not achieve meaningful reductions in drinking. The results demonstrate the utility of WHO risk drinking levels as AUD clinical trial endpoints and provide evidence that drinking reductions mitigate craving.
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Affiliation(s)
- Felicia R. Tuchman
- Department of Psychology, University of New Mexico, MSC 03-2220, Albuquerque, NM, USA
| | - Kevin A. Hallgren
- University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences, Seattle, WA, USA
| | - Dylan K. Richards
- Center on Alcohol, Substance use, And Addictions (CASAA), University of New Mexico, MSC11-6280, Albuquerque, NM, USA
| | - Arnie Aldridge
- Behavioral Health Financing, Economics and Evaluation Department, Research Triangle Institute (RTI) International, Durham, NC, USA
| | - Raymond K. Anton
- Psychiatry and Behavioral Sciences Department, Medical University of South Carolina, Charleston, SC, USA
| | - Henri-Jean Aubin
- AP-HP. Université Paris Saclay, French Institute of Health and Medical Research (INSERM), Paris, Île-de-France, FRANCE
| | - Henry R. Kranzler
- Center for Studies of Addiction, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Karl Mann
- Central Institute for Mental Health Mannheim, Heidelberg University, Heidelberg, DE
| | - Stephanie S. O’Malley
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Katie Witkiewitz
- Department of Psychology, University of New Mexico, MSC 03-2220, Albuquerque, NM, USA
- Center on Alcohol, Substance use, And Addictions (CASAA), University of New Mexico, MSC11-6280, Albuquerque, NM, USA
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Abstract
This paper is the forty-fifth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2022 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, USA.
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Terenius L, Oasa S, Sezgin E, Ma Y, Horne D, Radmiković M, Jovanović-Talisman T, Martin-Fardon R, Vukojevic V. Naltrexone blocks alcohol-induced effects on kappa-opioid receptors in the plasma membrane. RESEARCH SQUARE 2023:rs.3.rs-3091960. [PMID: 37503185 PMCID: PMC10371157 DOI: 10.21203/rs.3.rs-3091960/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Naltrexone (NTX), a homologue of the opiate antidote naloxone, is an orally active long-acting mu-opioid receptor (MOP) antagonist used in the treatment of opiate dependence. NTX is also found to relieve craving for alcohol and is one of the few FDA-approved drugs for alcohol use disorder (AUD). Reports that NTX blocks the actions of endogenous opioids released by alcohol are not convincing, suggesting that NTX interferes with alcohol actions by affecting opioid receptors. MOP and kappa-opioid receptor (KOP) are structurally related but functionally different. MOP is mainly located in interneurons activated by enkephalins while KOP is located in longer projections activated by dynorphins. While the actions of NTX on MOP are well established, the interaction with KOP and addiction is not well understood. We used sensitive fluorescence-based methods to study the influence of alcohol on KOP and the interaction between KOP and NTX. Here we report that alcohol interacts with KOP and its environment in the plasma membrane. These interactions are affected by NTX and are exerted both on KOP directly and on the plasma membrane (lipid) structures ("off-target"). The actions of NTX are stereospecific. Selective KOP antagonists, recently in early clinical trials for major depressive disorder, block the receptor but do not show the full action profile of NTX. The therapeutic effect of NTX treatment in AUD may be due to direct actions on KOP and the receptor environment.
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Kranzler HR, Hartwell EE. Medications for treating alcohol use disorder: A narrative review. ALCOHOL, CLINICAL & EXPERIMENTAL RESEARCH 2023; 47:1224-1237. [PMID: 37526592 DOI: 10.1111/acer.15118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/01/2023] [Accepted: 05/12/2023] [Indexed: 08/02/2023]
Abstract
Chronic heavy alcohol use impacts all major neurotransmitter systems and is associated with multiple medical, psychiatric, and social problems. Available evidence-based medications to treat alcohol use disorder (AUD) are underutilized in clinical practice. These medications promote abstinence or reduce alcohol consumption, though there are questions regarding their optimal dosage, length of treatment, and utility in combination with one another. Pharmacogenetic approaches, which use a patient's genetic make-up to inform medication selection, have garnered great interest but have yet to yield results robust enough to incorporate them in routine clinical care. This narrative review summarizes the evidence both for medications approved by the Food and Drug Administration (disulfiram, oral naltrexone, acamprosate, and extended-release naltrexone) and those commonly used off-label (e.g., gabapentin, baclofen, and topiramate) for AUD treatment. We discuss these drugs' mechanisms of action, clinical use, pharmacogenetic findings, and treatment recommendations. We conclude that the most consistent evidence supporting the pharmacotherapy of AUD is for the opioid antagonists, naltrexone and nalmefene (which is not approved in the United States), and topiramate. These medications demonstrate consistent small or moderate effects in reducing the frequency of drinking and/or heavy drinking. Lastly, we make suggestions for research needed to refine and expand the current literature on effective pharmacotherapy for AUD.
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Affiliation(s)
- Henry R Kranzler
- Department of Psychiatry, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Veterans Integrated Service Network 4, Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, Pennsylvania, USA
| | - Emily E Hartwell
- Department of Psychiatry, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Veterans Integrated Service Network 4, Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, Pennsylvania, USA
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Edinoff AN, Flanagan CJ, Sinnathamby ES, Pearl NZ, Jackson ED, Wenger DM, Cornett EM, Kaye AM, Kaye AD. Treatment of Acute Pain in Patients on Naltrexone: A Narrative Review. Curr Pain Headache Rep 2023; 27:183-192. [PMID: 37115486 DOI: 10.1007/s11916-023-01110-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE OF REVIEW The tissue damage and trauma associated with surgery almost always result in acute postoperative pain. The intensity of postoperative pain can range from mild to severe. Naltrexone is suitable for patients who do not wish to be on an agonist treatment such as methadone or buprenorphine. However, naltrexone has been shown to complicate postoperative pain management. RECENT FINDINGS Multiple studies have found that the use of naltrexone can increase the opioid requirement for postoperative pain control. Other modalities exist that can help outside of opioids such as ketamine, lidocaine/bupivacaine, duloxetine, and non-pharmacological management can help manage pain. Multimodal pain regiments should also be employed in patients. In addition to traditional methods for postoperative pain management, other methods of acute pain control exist that can help mitigate opioid dependence and help control pain in patients who use naltrexone for their substance use disorders.
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Affiliation(s)
- Amber N Edinoff
- Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.
- Louisiana Addiction Research Center, Shreveport, LA, 71103, USA.
| | - Chelsi J Flanagan
- School of Osteopathic Medicine, University of the Incarnate Word, San Antonio, TX, 78235, USA
| | - Evan S Sinnathamby
- School of Medicine, Louisiana State University Health Science Center at New Orleans, New Orleans, LA, 70112, USA
| | - Nathan Z Pearl
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
| | - Eric D Jackson
- University of Arizona College of Medicine- Phoenix, Phoenix, AZ, 85004, USA
| | - Danielle M Wenger
- University of Arizona College of Medicine- Phoenix, Phoenix, AZ, 85004, USA
| | - Elyse M Cornett
- Louisiana Addiction Research Center, Shreveport, LA, 71103, USA
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
| | - Adam M Kaye
- Thomas J. Long School of Pharmacy and Health Sciences, Department of Pharmacy Practice, University of the Pacific, Stockton, CA, 95211, USA
| | - Alan D Kaye
- Louisiana Addiction Research Center, Shreveport, LA, 71103, USA
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
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