Nalmefene for treatment of alcohol dependence

Approaching Alcohol Use Disorder After Liver Transplantation for Acute Alcoholic Hepatitis

Severe alcoholic hepatitis portends a high risk of mortality without liver transplantation. Transplant outcomes in patients with severe alcoholic hepatitis exhibit a strong inverse association with post-transplant alcohol relapse. The ingredients most central to ameliorating alcohol relapse risk may include destigmatized post-transplant alcohol monitoring, a nonpunitive clinician-patient partnership, and multimodal therapies to maintain abstinence and mitigate high-risk drinking. We here review the core principles of post-liver transplant management specific to alcohol use disorder.

Psychotic Decompensation During Nalmefene Treatment in a Patient With Schizoaffective Disorder: A Case Report

Objective: Nalmefene is a kappa-opioid receptor agonist/antagonist which is currently prescribed to reduce heavy drinking days. Adverse events (AEs) have previously been described in trials, but these trials excluded patients with psychiatric comorbidities. This is important as psychiatric disorders are frequently associated with alcohol use disorders; therefore, the specific AEs in this population should be investigated. Methods: Here, we describe the case of a patient with diagnosed alcohol use disorder and schizoaffective disorder who received treatment with nalmefene. Results: The patient showed decompensation of psychotic symptoms after two doses of medication, consisting of auditory hallucinations, delusions, and ideas of persecution. The symptoms improved two days after treatment discontinuation. Conclusions: This case indicates that the AEs of nalmefene should be specifically investigated in patients with psychiatric disorders.

Weak evidence on nalmefene creates dilemmas for clinicians and poses questions for regulators and researchers

BACKGROUND AND AIMS

Nalmefene has been approved in Europe for the treatment of alcohol dependence and subsequently recommended by the UK National Institute for Health and Care Excellence (NICE). This study examines critically the evidence base underpinning both decisions and the issues arising.

METHODS

Published studies of nalmefene were identified through a systematic search, with documents from the European Medicines Agency, the NICE appraisal and public clinical trial registries also examined to identify methodological issues.

RESULTS

Efficacy data used to support the licensing of nalmefene suffer from risk of bias due to lack of specification of a priori outcome measures and sensitivity analyses, use of post-hoc sample refinement and the use of inappropriate comparators. Despite this, evidence for the efficacy of nalmefene in reducing alcohol consumption in those with alcohol dependence is, at best, modest, and of uncertain significance to individual patients. The relevance of existing trial data to routine primary care practice is doubtful.

CONCLUSIONS

Problems with the registration, design, analysis and reporting of clinical trials of nalmefene did not prevent it being licensed and recommended for treating alcohol dependence. This creates dilemmas for primary care clinicians and commissioning organisations where nalmefene has been heavily promoted, and poses wider questions about the effectiveness of the medicines regulation system and how to develop the alcohol treatment evidence base.

Clinical experience about an unexpected adverse event during nalmefene treatment in two patients with alcohol use disorder

WHAT IS KNOWN AND OBJECTIVE

Nalmefene, a new opioid system regulator, has recently been approved for the treatment of alcohol dependence, primarily for reducing heavy drinking days.

CASES DESCRIPTION

Two patients with a diagnosis of alcohol use disorder were treated with nalmefene. Both patients developed fatigue and deep sleepiness after 2 days of treatment. Only after 1 day of drug discontinuation, symptoms normalized.

WHAT IS NEW AND CONCLUSION

We have analysed symptoms' development before and after treatment discontinuation and the possible association with nalmefene therapy. This case should pinpoint our attention on this adverse event for a careful choice of anticraving therapy in patients with severe alcohol use disorder.

Craving Typology Questionnaire (CTQ): a scale for alcohol craving in normal controls and alcoholics

INTRODUCTION

Craving is commonly thought to play a crucial role both in the transition from controlled drinking to alcohol dependence and in the mechanism underlying relapse. However there is no consensus on its definition, and on its correct assessment. Another significant hindrance is that craving is almost certainly a multi-faceted construct. To this respect a three pathway psychobiological model able to differentiate craving into a reward, relief, and obsessive component has been suggested.

METHODS

CTQ was administered to 547 control subjects and to 100 alcohol dependent patients. The dimensional structure of the questionnaire, through the principal component analysis, the reliability and the threshold values were evaluated in both the control and clinical sample.

RESULTS

The results showed and confirmed that the CTQ is composed of three dimensions. Cronbach's alpha coefficients suggest that the questionnaire is reliable. Alcohol-dependent subjects had a significantly higher mean score as compared to the normative sample in both Reward, Relief, Obsessive craving. Younger age correlated with higher scores on Reward craving (r=0.38; p<0.001) and males reported significantly higher scores than women on Reward craving (t=4.36; p<0.001).

DISCUSSION

CTQ showed to be a reliable and valid questionnaire to distinguish a normative sample from pathological individuals. The average scores obtained represent the first normative data available for this questionnaire. Identifying a craving type may represent an important predicting or matching variable for anti-craving psychotropics. More research is needed with respect to CTQ's external validity, i.e. correlations with phenotypic, endophenotypic and genetic indicators of relief, reward and obsessive drinking.

Efficacy and safety of pregabalin in the treatment of alcohol and benzodiazepine dependence

INTRODUCTION

Both alcohol and benzodiazepine dependence (AD, BD) are severe and chronic conditions with devastating physical and mental health effects. The relative scarcity and controversial evidential status of available pharmacological interventions for the treatment of patients' acute withdrawal syndrome and/or relapse prevention call for the clinical investigation of novel safe and efficacious agents.

AREAS COVERED

We review published studies of pregabalin as monotherapy in the treatment of AD and BD in more than 450 patients. Available evidence includes four RCTs, two in AD with active comparator drugs (naltrexone, tiapride, and lorazepam) and one placebo-controlled, and one placebo-controlled in BD. We also review other available studies on pregabalin's potential to reduce benzodiazepine consumption, its side effects, especially cognitive, as well as extant reports on its liability for abuse.

EXPERT OPINION

Available evidence suggests that monotherapy with pregabalin, within the dosage range of 150 - 600 mg/d, is a promising "novel" option for the safe and efficacious relapse prevention of both AD and BD. However, its efficacy as monotherapy in the acute treatment of AD withdrawal syndrome is still controversial. Clinicians should be cautious in prescribing pregabalin to patients with a history of multiple substance recreational use, and monitor its effects on cognition at dosages above 450 mg/d. Further, well-designed clinical research is still needed for the eventual consolidation of pregabalin's place in the treatment of AD and BD.

Advancing addiction treatment: what can we learn from animal studies?

Substance addiction is a maladaptive behavior characterized by compulsive and uncontrolled self-administration of a substance (drug). Years of research indicate that addictive behavior is the result of complex interactions between the drug, the user, and the environment in which the drug is used; therefore, addiction cannot simply be attributed to the neurobiological actions of a drug. However, despite the obvious complexity of addictive behavior, animal models have both advanced understanding of addiction and contributed importantly to the development of medications to treat this disease. We briefly review recent animal models used to study drug addiction and the contribution of data generated by these animal models for the clinical treatment of addictive disorders.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of substance use and related disorders. Part 2: Opioid dependence

OBJECTIVES

To develop evidence-based practice guidelines for the pharmacological treatment of opioid abuse and dependence.

METHODS

An international task force of the World Federation of Societies of Biological Psychiatry (WFSBP) developed these practice guidelines after a systematic review of the available evidence pertaining to the treatment of opioid dependence. On the basis of the evidence, the Task Force reached a consensus on practice recommendations, which are intended to be clinically and scientifically meaningful for physicians who treat adults with opioid dependence. The data used to develop these guidelines were extracted primarily from national treatment guidelines for opioid use disorders, as well as from meta-analyses, reviews, and publications of randomized clinical trials on the efficacy of pharmacological and other biological treatments for these disorders. Publications were identified by searching the MEDLINE database and the Cochrane Library. The literature was evaluated with respect to the strength of evidence for efficacy, which was categorized into one of six levels (A-F).

RESULTS

There is an excellent evidence base supporting the efficacy of methadone and buprenorphine or the combination of buprenorphine and naloxone for the treatment of opioid withdrawal, with clonidine and lofexidine as secondary or adjunctive medications. Opioid maintenance with methadone and buprenorphine is the best-studied and most effective treatment for opioid dependence, with heroin and naltrexone as second-line medications.

CONCLUSIONS

There is enough high quality data to formulate evidence-based guidelines for the treatment of opioid abuse and dependence. This task force report provides evidence for the efficacy of a number of medications to treat opioid abuse and dependence, particularly the opioid agonists methadone or buprenorphine. These medications have great relevance for clinical practice.