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Buzzi B, AlSharari SD, Walentiny DM, Damaj MI. Nelotanserin, a selective 5-HT2A receptor inverse agonist, attenuates aspects of nicotine withdrawal but not reward in mice. Behav Brain Res 2024; 467:115019. [PMID: 38677331 DOI: 10.1016/j.bbr.2024.115019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 04/29/2024]
Abstract
Nicotine smoking contributes to many preventable disabilities, diseases and deaths. Targeting nicotine reward and withdrawal is a basis for the majority of smoking cessation pharmacotherapies. Due to the emergence of interest in 5-HT2A receptor modulators for numerous psychiatric disorders, we investigated the effect of nelotanserin, a 5-HT2A receptor inverse agonist, on nicotine reward and withdrawal in ICR mice. In nicotine-dependent mice, nelotanserin dose-dependently reduced somatic signs of nicotine withdrawal and thermal hyperalgesia as measured in the hot plate test. However, nelotanserin had no effect on anxiety-like behavior and failed to reduce nicotine reward as measured in the conditioned place preference test. Our results suggest that inverse agonism of the 5-HT2A receptor may be a feasible novel mechanism for smoking cessation by reducing both physical withdrawal and thermal hyperalgesia associated with nicotine abstinence but may require complementary pharmacotherapies targeting affective and reward-associated decrements to improve cessation outcomes.
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Affiliation(s)
- Belle Buzzi
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA.
| | - Shakir D AlSharari
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia
| | - David M Walentiny
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA
| | - M Imad Damaj
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA
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Greenwald MK, Sogbesan T, Moses TEH. Relationship between opioid cross-tolerance during buprenorphine stabilization and return to opioid use during buprenorphine dose tapering. Psychopharmacology (Berl) 2024; 241:1151-1160. [PMID: 38326506 DOI: 10.1007/s00213-024-06549-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/31/2024] [Indexed: 02/09/2024]
Abstract
RATIONALE Opioid injection drug use (IDU) has been linked to a more severe pattern of use (e.g. tolerance, overdose risk) and shorter retention in treatment, which may undermine abstinence attempts. OBJECTIVES This secondary data analysis of four human laboratory studies investigated whether current opioid IDU modulates subjective abuse liability responses to high-dose hydromorphone during intermediate-dose buprenorphine stabilization (designed to suppress withdrawal but allow surmountable agonist effects), and whether hydromorphone response magnitude predicts latency of return to opioid use during buprenorphine dose-tapering. METHODS Regular heroin users not currently seeking treatment (n = 54; 29 current injectors, 25 non-injectors) were stabilized on 8-mg/day sublingual buprenorphine and assessed for subjective responses (e.g. 'liking', craving) to hydromorphone 24-mg intramuscular challenge (administered 16-hr post-buprenorphine) under randomized, double-blinded, controlled conditions. A subgroup (n = 35) subsequently completed a standardized 3-week outpatient buprenorphine dose-taper, paired with opioid-abstinent contingent reinforcement, and were assessed for return to opioid use based on thrice-weekly urinalysis and self-report. RESULTS During buprenorphine stabilization, IDU reported lower 'liking' of buprenorphine and post-hydromorphone peak 'liking', 'good effect' and 'high' compared to non-IDU. Less hydromorphone peak increase-from-baseline in 'liking' (which correlated with less hydromorphone-induced craving suppression) predicted significantly faster return to opioid use during buprenorphine dose-tapering. CONCLUSIONS In these buprenorphine-stabilized regular heroin users, IDU is associated with attenuated 'liking' response (more cross-tolerance) to buprenorphine and to high-dose hydromorphone challenge and, in turn, this cross-tolerance (but not IDU) predicts faster return to opioid use. Further research should examine mechanisms that link cross-tolerance to treatment response.
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Affiliation(s)
- Mark K Greenwald
- Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Tolan Park Medical Building, 3901 Chrysler Service Drive, Suite 2A, Detroit, MI, 48201, USA.
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Karin KN, Mustafa MA, Poklis JL, Buzzi B, Schlosburg JE, Parker L, Damaj MI, Lichtman AH. N-oleoyl alanine attenuates nicotine reward and spontaneous nicotine withdrawal in mice. Drug Alcohol Depend 2024; 259:111276. [PMID: 38676968 DOI: 10.1016/j.drugalcdep.2024.111276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 02/19/2024] [Accepted: 03/25/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND As nicotine dependence represents a longstanding major public health issue, new nicotine cessation pharmacotherapies are needed. Administration of N-oleoyl glycine (OlGly), an endogenous lipid signaling molecule, prevents nicotine-induced conditioned place preference (CPP) through a peroxisome proliferator-activated receptor-alpha (PPARα) dependent mechanism, and also ameliorated withdrawal signs in nicotine-dependent mice. Pharmacological evidence suggests that the methylated analog of OlGly, N-oleoyl alanine (OlAla), has an increased duration of action and may offer translational benefit. Accordingly, OlAla was assessed in nicotine CPP and dependence assays as well as its pharmacokinetics compared to OlGly. METHODS ICR female and male mice were tested in nicotine-induced CPP with and without the PPARα antagonist GW6471. OlAla was also assessed in nicotine-dependent mice following removal of nicotine minipumps: somatic withdrawal signs, thermal hyper-nociception and altered affective behavior (i.e., light/dark box). Finally, plasma and brain were collected after administration of OlGly or OlAla and analyzed by high-performance liquid chromatography tandem mass spectrometry. RESULTS OlAla prevented nicotine-induced CPP, but this effect was not blocked by GW6471. OlAla attenuated somatic and affective nicotine withdrawal signs, but not thermal hyper-nociception in nicotine-dependent mice undergoing withdrawal. OlAla and OlGly showed similar time-courses in plasma and brain. CONCLUSIONS The observation that both molecules showed similar pharmacokinetics argues against the notion that OlAla offers increased metabolic stability. Moreover, while these structurally similar lipids show efficacy in mouse models of reward and dependence, they reduce nicotine reward through distinct mechanisms.
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Affiliation(s)
- Kimberly N Karin
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Mohammed A Mustafa
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Justin L Poklis
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Belle Buzzi
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Joel E Schlosburg
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Linda Parker
- Department of Psychology, University of Guelph, Guelph, Ontario, Canada
| | - M Imad Damaj
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Aron H Lichtman
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA 23298, USA; Department of Medicinal Chemistry, Virginia Commonwealth University, Richmond, VA 23298, USA.
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Kale MB, Chandurkar PA, Taksande BG, Aglawe MM, Rahangdale SR, Upaganlawar AB, Kopalli SR, Umekar MJ, Wankhede NL. Agmatine alleviates ethanol withdrawal-associated cognitive impairment and neurochemical imbalance in rats. Neurosci Lett 2024; 832:137804. [PMID: 38692559 DOI: 10.1016/j.neulet.2024.137804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/25/2024] [Accepted: 04/28/2024] [Indexed: 05/03/2024]
Abstract
The present study aimed to investigate the role of agmatine in the neurobiology underlying memory impairment during ethanol withdrawal in rats. Sprague-Dawley rats were subjected to a 21-day chronic ethanol exposure regimen (2.4 % w/v ethanol for 3 days, 4.8 % w/v for the next 4 days, and 7.2 % w/v for the following 14 days), followed by a withdrawal period. Memory impairment was assessed using the passive avoidance test (PAT) at 24, 48, and 72 h post-withdrawal. The ethanol-withdrawn rats displayed a significant decrease in step-through latency in the PAT, indicative of memory impairment at 72 h post-withdrawal. However, administration of agmatine (40 µg/rat) and its modulators (L-arginine, arcaine, and amino-guanidine) significantly increases the latency time in the ethanol-withdrawn rats, demonstrating the attenuation of memory impairment. Further, pretreatment with imidazoline receptor agonists enhances agmatine's effects, while antagonists block them, implicating imidazoline receptors in agmatine's actions. Neurochemical analysis in ethanol-withdrawn rats reveals dysregulated glutamate and GABA levels, which was attenuated by agmatine and its modulators. By examining the effects of agmatine administration and modulators of endogenous agmatine, the study aimed to shed light on the potential therapeutic implications of agmatinergic signaling in alcohol addiction and related cognitive deficits. Thus, the present findings suggest that agmatine administration and modulation of endogenous agmatine levels hold potential as therapeutic strategies for managing alcohol addiction and associated cognitive deficits. Understanding the neurobiology underlying these effects paves the way for the development of novel interventions targeting agmatinergic signaling in addiction treatment.
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Affiliation(s)
- Mayur B Kale
- Division of Neuroscience, Smt. Kishoritai Bhoyar College of Pharmacy, Kamptee, Nagpur, Maharashtra 441002, India; SNJB's Shriman Sureshdada Jain College of Pharmacy, Neminagar, Chandwad, Nashik, Maharashtra 423101, India.
| | - Pranali A Chandurkar
- Division of Neuroscience, Smt. Kishoritai Bhoyar College of Pharmacy, Kamptee, Nagpur, Maharashtra 441002, India.
| | - Brijesh G Taksande
- Division of Neuroscience, Smt. Kishoritai Bhoyar College of Pharmacy, Kamptee, Nagpur, Maharashtra 441002, India.
| | - Manish M Aglawe
- Division of Neuroscience, Smt. Kishoritai Bhoyar College of Pharmacy, Kamptee, Nagpur, Maharashtra 441002, India.
| | - Sandip R Rahangdale
- Division of Neuroscience, Smt. Kishoritai Bhoyar College of Pharmacy, Kamptee, Nagpur, Maharashtra 441002, India.
| | - Aman B Upaganlawar
- SNJB's Shriman Sureshdada Jain College of Pharmacy, Neminagar, Chandwad, Nashik, Maharashtra 423101, India.
| | - Spandana R Kopalli
- Department of Integrated Bioscience and Biotechnology, Sejong University, Gwangjin-gu, Seoul 05006, Republic of Korea.
| | - Milind J Umekar
- Division of Neuroscience, Smt. Kishoritai Bhoyar College of Pharmacy, Kamptee, Nagpur, Maharashtra 441002, India.
| | - Nitu L Wankhede
- Division of Neuroscience, Smt. Kishoritai Bhoyar College of Pharmacy, Kamptee, Nagpur, Maharashtra 441002, India; SNJB's Shriman Sureshdada Jain College of Pharmacy, Neminagar, Chandwad, Nashik, Maharashtra 423101, India.
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Rezaei Moghadam M, Khoshrou A, Kakhki S, Hosseini SH, Shirinzadeh Feizabadi A, Beheshti F. Folic Acid Ameliorates Anxiety- and Depressive-Like Behavior Induced by Nicotine Withdrawal Through Restoration of Behavioral and Biochemical Alterations in Adolescent Male Rats. Nicotine Tob Res 2024; 26:733-741. [PMID: 37975546 DOI: 10.1093/ntr/ntad227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 10/24/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND The present study aimed to assess the efficacy of folic acid (FA) on withdrawal following nicotine (Nic) administration in adolescent male rats. AIMS AND METHODS Adolescent male rats were divided into two groups: (1) vehicle and (2) Nic (Nic-2 mg/kg), and were under treatment from 21 to 42 days of age. After that, they continued the experiment without treatment and returned to a regular diet, except for one of those who received Nic. The rats were divided into four groups where they were treated with different doses of FA (5, 10, and 15 mg/kg) and bupropion (Bup) by oral gavage, and the final group included normal rats that received only FA (15 mg/kg) from 42 days of age for three weeks during which withdrawal occurred. RESULTS Results showed that adolescent Nic exposure exacerbated the behavioral indices of anxiety- and depression-like behaviors, while FA attenuated the effects of Nic withdrawal on anxiety and depression as well as Bup. In support, the biochemical results demonstrated a balance between oxidant and antioxidant mediators in addition to the increase and decrease of serotonin and monoamine oxidase (MAO) activity in cortical tissue. TNF-α as an inflammatory agent was decreased, whereas IL-10 as an anti-inflammatory parameter was increased. CONCLUSIONS The present findings suggest anxiety and depression caused by Nic withdrawal were attenuated by FA more likely through the reduction activity of MAO, the important enzyme responsible for serotonin metabolism along with balance between oxidant/antioxidant and pro-inflammatory/anti-inflammatory mediators. However, various mechanisms might be involved, which requires further investigation. IMPLICATIONS Nic withdrawal-induced depression and anxiety like behavior in rats followed by neuro-oxidative damage and neuro-inflammation. FA supplementation as well as Bup improved cognitive disorders induced by Nic withdrawal by increasing neuro-inflammation and neuro-oxidative damage.
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Affiliation(s)
- Mikael Rezaei Moghadam
- Student Research Committee, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
| | - Alireza Khoshrou
- Student Research Committee, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Samaneh Kakhki
- Department of Clinical Biochemistry, School of Paramedical Sciences, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
- Neuroscience Research Center, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
| | - Seyed Hossein Hosseini
- Student Research Committee, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
| | - Atefeh Shirinzadeh Feizabadi
- Department of Medical Anesthesiology, School of Paramedical Sciences, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
| | - Farimah Beheshti
- Neuroscience Research Center, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
- Departments of Physiology, School of Paramedical Sciences, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
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Klein SS, Fine JS, Smith SW. Response to: "Eliminating the benzos: A benzodiazepine-sparing approach to preventing and treating alcohol withdrawal syndrome". J Trauma Acute Care Surg 2024; 96:e42-e43. [PMID: 38229217 DOI: 10.1097/ta.0000000000004264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Affiliation(s)
- Samantha S Klein
- Division of Medical Toxicology Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, New York
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Chambers A, Patton J, Wills BK. Precipitated opioid withdrawal in a patient started on olanzapine/samidorphan. Am J Emerg Med 2024; 79:230.e1-230.e2. [PMID: 38556414 DOI: 10.1016/j.ajem.2024.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 03/13/2024] [Accepted: 03/20/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Olanzapine/Samidorphan (Lybalvi®) is a novel oral agent for the treatment of schizophrenia and bipolar I disorder. It was designed to reduce weight gain associated with olanzapine. Samidorphan is an analog of naltrexone, initially intended to treat substance use disorders by antagonizing mu, delta, and kappa opioid receptors. CASE REPORT We present the case of a 36-year-old who took their first dose of olanzapine/samidorphan shortly before calling for emergency services. The patient took diphenhydramine and an epinephrine autoinjector for what they thought was an allergic reaction but continued to have symptoms. EMS reported involuntary muscle movements thought to be due to dystonia from olanzapine. In the ED, they experienced generalized muscle spasms lasting for several seconds and diaphoresis. Initially, the staff treated for a presumed dystonic reaction to olanzapine and administered diphenhydramine 25 mg IV, diazepam 2 mg IV, midazolam 5 mg IV, and benztropine 1 mg IV without improvement. It was later determined that the patient took 16 mg of buprenorphine SL daily. With this information, precipitated opioid withdrawal was felt to be the likely cause of symptoms. The patient received 16 mg of buprenorphine for an initial Clinical Opiate Withdrawal Scale (COWS) score of 11 with repeat COWS of 6. Why should an emergency physician be aware of this? Initiating olanzapine/samidorphan in the setting of chronic opioid therapy may result in precipitated opioid withdrawal. Additional SL buprenorphine may be a reasonable treatment modality.
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Affiliation(s)
- Andrew Chambers
- Virginia Poison Center, Division of Clinical Toxicology, United States of America; Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA, United States of America
| | - Jessica Patton
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA, United States of America.
| | - Brandon K Wills
- Virginia Poison Center, Division of Clinical Toxicology, United States of America; Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA, United States of America
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Shulman M, Greiner MG, Tafessu HM, Opara O, Ohrtman K, Potter K, Hefner K, Jelstrom E, Rosenthal RN, Wenzel K, Fishman M, Rotrosen J, Ghitza UE, Nunes EV, Bisaga A. Rapid Initiation of Injection Naltrexone for Opioid Use Disorder: A Stepped-Wedge Cluster Randomized Clinical Trial. JAMA Netw Open 2024; 7:e249744. [PMID: 38717773 PMCID: PMC11079685 DOI: 10.1001/jamanetworkopen.2024.9744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/05/2024] [Indexed: 05/12/2024] Open
Abstract
Importance Injectable extended-release (XR)-naltrexone is an effective treatment option for opioid use disorder (OUD), but the need to withdraw patients from opioid treatment prior to initiation is a barrier to implementation. Objective To compare the effectiveness of the standard procedure (SP) with the rapid procedure (RP) for XR-naltrexone initiation. Design, Setting, and Participants The Surmounting Withdrawal to Initiate Fast Treatment with Naltrexone study was an optimized stepped-wedge cluster randomized trial conducted at 6 community-based inpatient addiction treatment units. Units using the SP were randomly assigned at 14-week intervals to implement the RP. Participants admitted with OUD received the procedure the unit was delivering at the time of their admission. Participant recruitment took place between March 16, 2021, and July 18, 2022. The last visit was September 21, 2022. Interventions Standard procedure, based on the XR-naltrexone package insert (approximately 5-day buprenorphine taper followed by a 7- to 10-day opioid-free period and RP, defined as 1 day of buprenorphine at minimum necessary dose, 1 opioid-free day, and ascending low doses of oral naltrexone and adjunctive medications (eg, clonidine, clonazepam, antiemetics) for opioid withdrawal. Main Outcomes and Measures Receipt of XR-naltrexone injection prior to inpatient discharge (primary outcome). Secondary outcomes included opioid withdrawal scores and targeted safety events and serious adverse events. All analyses were intention-to-treat. Results A total of 415 participants with OUD were enrolled (mean [SD] age, 33.6 [8.48] years; 205 [49.4%] identified sex as male); 54 [13.0%] individuals identified as Black, 91 [21.9%] as Hispanic, 290 [69.9%] as White, and 22 [5.3%] as multiracial. Rates of successful initiation of XR-naltrexone among the RP group (141 of 225 [62.7%]) were noninferior to those of the SP group (68 of 190 [35.8%]) (odds ratio [OR], 3.60; 95% CI, 2.12-6.10). Withdrawal did not differ significantly between conditions (proportion of days with a moderate or greater maximum Clinical Opiate Withdrawal Scale score (>12) for RP vs SP: OR, 1.25; 95% CI, 0.62-2.50). Targeted safety events (RP: 12 [5.3%]; SP: 4 [2.1%]) and serious adverse events (RP: 15 [6.7%]; SP: 3 [1.6%]) were infrequent but occurred more often with RP than SP. Conclusions and Relevance In this trial, the RP of XR-naltrexone initiation was noninferior to the standard approach and saved time, although it required more intensive medical management and safety monitoring. The results of this trial suggest that rapid initiation could make XR-naltrexone a more viable treatment for patients with OUD. Trial Registration ClinicalTrials.gov Identifier: NCT04762537.
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Affiliation(s)
- Matisyahu Shulman
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York
| | - Miranda G. Greiner
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York
| | | | - Onumara Opara
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York
| | - Kaitlyn Ohrtman
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York
| | - Kenzie Potter
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York
| | | | | | | | - Kevin Wenzel
- Department of Psychiatry, Johns Hopkins University School of Medicine and Maryland Treatment Centers, Baltimore, Maryland
| | - Marc Fishman
- Department of Psychiatry, Johns Hopkins University School of Medicine and Maryland Treatment Centers, Baltimore, Maryland
| | - John Rotrosen
- Department of Psychiatry, New York University Grossman School of Medicine, New York, New York
| | - Udi E. Ghitza
- National Institute on Drug Abuse, Bethesda, Maryland
| | - Edward V. Nunes
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York
| | - Adam Bisaga
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York
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Moshiri M, Chaeideh B, Ebrahimi M, Dadpour B, Ghodsi A, Haghighizadeh A, Etemad L. Buprenorphine induced opioid withdrawal syndrome relieved by adjunctive Magnesium: A clinical trial. J Subst Use Addict Treat 2024; 160:209307. [PMID: 38309436 DOI: 10.1016/j.josat.2024.209307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 12/20/2023] [Accepted: 01/24/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Precipitated opioid withdrawal syndrome (OWS) is a severe and intolerable situation that may occur by a pharmaceutical agent. Reactivation of inhibited N-methyl-d-aspartate (NMDA) receptor in person with prolonged opioid use can led to severe OWS. We conducted a double-blind, randomized clinical trial to assess the effect of magnesium sulfate (MGSO4) as an NMDA receptor antagonist on OWS. MATERIALS AND METHODS The study randomly divided forty patients with precipitated OWS due to partial agonist (buprenorphine) use referred to the emergency unit of Toxicology Department of Mashhad University of Medical Sciences, Iran; into two groups. The control group received conventional therapies, including clonidine 0.1 mg tablet each hour, intravenous infusion of 10 mg diazepam every 30 min, and IV paracetamol (Acetaminophen) 1 g, while the intervention group received 3 g of MGSO4 in 20 min and then 10 mg/kg/h up to 2 h, in addition to the conventional treatment. The clinical opiate withdrawal scale (COWS) evaluated OWS at the start of the treatment, 30 min, and 2 h later. RESULTS Both groups had similar demographic, opiate types, and COWS severity at the start of the intervention. COWS was lower in the intervention than the control group at 30 min (11.20 ± 2.86 and 14.65 ± 2.36, respectively, P = 0.002) and at 2 h (3.2 ± 1.61 and 11.25 ± 3.27, respectively, P < 0.001) after treatment. The intervention group received lesser doses of clonidine (0.12 ± 0.51 and 0.17 ± 0.45 mg, P = 0.003) and Diazepam (13.50 ± 5.87, 24.0 ± 6.80 mg, P = 0.001) than the control group. Serum magnesium levels raised from 1.71 ± 0.13 mmol/L to 2.73 ± 0.13 mmol/L in the intervention group. CONCLUSION Magnesium can significantly reduce the severity of OWS. Additional studies are required to confirm these results.
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Affiliation(s)
- Mohammad Moshiri
- Medical Toxicology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Clinical Toxicology and Poisoning, Imam Reza (p) Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Mohsen Ebrahimi
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bita Dadpour
- Medical Toxicology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Clinical Toxicology and Poisoning, Imam Reza (p) Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Alireza Ghodsi
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Atoosa Haghighizadeh
- Department of Pharmaceutical and Food Control, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Leila Etemad
- Medical Toxicology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.
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Lee CM, Dillon DG, Tahir PM, Murphy CE. Phenobarbital treatment of alcohol withdrawal in the emergency department: A systematic review and meta-analysis. Acad Emerg Med 2024; 31:515-524. [PMID: 37923363 PMCID: PMC11065966 DOI: 10.1111/acem.14825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/14/2023] [Accepted: 10/17/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE Despite frequent treatment of alcohol withdrawal syndrome (AWS) in the emergency department (ED), evidence for phenobarbital (PB) as an ED alternative therapy is mixed. We conducted a systematic review and meta-analysis comparing safety and efficacy of PB to benzodiazepines (BZDs) for treatment of AWS in the ED. METHODS We searched articles and references published in English in PubMed, Web of Science, and Embase from inception through May 2022. We included randomized trials and cohort studies comparing treatment with PB to BZD controls and excluded studies focused on non-AWS conditions. Review was conducted by two blinded investigators and a third author; eight of 59 (13.6%) abstracts met inclusion criteria for review and meta-analysis using a random-effects model. Treatment superiority was evaluated through utilization, pharmacologic, and clinical outcomes. Primary outcomes for meta-analysis were the proportion of patients (1) admitted to the intensive care unit (ICU), (2) admitted to the hospital, (3) readmitted to the ED after discharge, and (4) who experienced adverse events. RESULTS Eight studies (two randomized controlled trials, six retrospective cohorts) comprised data from 1507 patients in 2012 treatment encounters for AWS. All studies were included in meta-analysis for adverse events, seven for hospital admission, five for ICU admission, and three for readmission to the ED after discharge. Overall methodological quality was low-moderate, risk of bias moderate-high, and statistical heterogeneity moderate. Pooled relative risk of ICU admission for those treated with PB versus BZD was 0.92 (95% confidence interval [CI] 0.54-1.55). Risk for admission to the hospital was 0.98 (95% CI 0.89-1.07) and for any adverse event was 1.1 (95% CI 0.78-1.57); heterogeneity prevented meta-analysis for ED readmission. CONCLUSIONS The current literature base does not show that treatment with PB significantly reduces ICU admissions, hospital admissions, ED readmissions, or adverse events in ED patients with AWS compared with BZDs alone.
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Affiliation(s)
- Carmen M Lee
- Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, California
| | - David G Dillon
- Emergency Medicine at the University of California, Davis School of Medicine, Sacramento, California
| | - Peggy M Tahir
- Research and Copyright Librarian at the University of California, San Francisco Library, San Francisco, California
| | - Charles E Murphy
- Associate Physician Diplomate in Emergency Medicine at the University of California, San Francisco School of Medicine, San Francisco, California
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11
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Qu L, Ma XP, Simayi A, Wang XL, Xu GP. Comparative efficacy of various pharmacologic treatments for alcohol withdrawal syndrome: a systematic review and network meta-analysis. Int Clin Psychopharmacol 2024; 39:148-162. [PMID: 38170803 DOI: 10.1097/yic.0000000000000526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
This study was to compare multiple classes of medications and medication combinations to find alternatives or additives for patients not applicable to benzodiazepines (BZDs). We performed a network meta-analysis to assess the comparative effect of 11 pharmacologic treatments in patients with alcohol withdrawal syndrome. Forty-one studies were included, comprising a total sample size of 4187 participants. The pooled results from the randomized controlled trials showed that there was no significant difference in the Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar) reduction with other medications or medication combinations compared to BZDs. Compared to BZDs, the mean difference in ICU length of stay of anticonvulsants + BZDs was -1.71 days (95% CI = -2.82, -0.59). Efficacy rankings from cohort studies showed that anticonvulsant + BZDs were superior to other treatments in reducing CIWA-Ar scores and reducing the length of stay in the ICU. Synthesis results from randomized controlled trials indicate that there are currently no data suggesting that other medications or medication combinations can fully replace BZDs. However, synthetic results from observational studies have shown that BZDs are effective in the context of adjuvant anticonvulsant therapy, particularly with early use of gabapentin in combination with BZDs in the treatment of alcohol withdrawal syndrome, which represents a promising treatment option.
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Affiliation(s)
- Li Qu
- Department of Anesthesia, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang, China
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12
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Chang AJ, Mallat AF, Edwards MJ, Gabra JN, Cucci MD. Evaluation of pre-hospital cannabis exposure and hospital opioid utilization in a trauma population: A retrospective cohort. Injury 2024; 55:111305. [PMID: 38216357 DOI: 10.1016/j.injury.2023.111305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 12/07/2023] [Accepted: 12/27/2023] [Indexed: 01/14/2024]
Abstract
PURPOSE Cannabis utilization has increased over time for recreational and medical purposes due to its legalization or decriminalization. The effects of cannabis use on opioid utilization are not well understood. The primary objective was to evaluate the total opioid utilization, measured in morphine milligram equivalents (MME), in hospitalized trauma patients that tested positive for tetrahydrocannabinol (THC) on a urine drug screen (UDS). METHODS This was a retrospective, cohort study in a level 1 trauma center between 10/17/17 and 12/31/19. Adult trauma patients (aged 15 years and older) who had a UDS completed within 48 h of hospital arrival were eligible for inclusion. Patients were excluded for a hospitalization >14 days, death within 24 h, severe alcohol withdrawal, prescribed cannabinoids, high daily opioid use prior-to-arrival, or transitioned to hospice or palliative care. Group assignments were determined based on the presence or absence of THC on the UDS. RESULTS The analysis included 750 patients with 160 (21 %) THC positive patients. The population were primarily male (64.6 %), median age of 56 years [IQR 35-72], with blunt (93 %) injuries from motor vehicle crash or falls (79 %). The THC group was more likely to have other substances present, including amphetamines, benzodiazepines, opiates, and cocaine. The THC group had a higher median injury severity score (10 [IQR 5-17] vs. 9 [5-14], p = 0.0056), and maximum abbreviated injury score (3 [IQR 2-3] vs. 2 [IQR 2-3], p = 0.0009). The THC group had a total higher median opioid utilization during the hospitalization (155 [IQR 68-367] vs. 62 [IQR 13-175] MME; p < 0.0001), which included higher opioid use in the emergency department, floor, and intensive care unit. There were no significant differences in secondary outcomes except the THC group was more likely to receive an opioid prescription at discharge and more likely to require mechanical ventilation. Based on multivariable regression analyses, other variables were associated with increased opioid utilization. CONCLUSION Pre-existing THC exposure may be associated with an increased hospital opioid utilization in a trauma population. However, other variables may also play a role in opioid utilization.
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Affiliation(s)
- Alexander J Chang
- Cleveland Clinic Akron General, Department of Surgery, 1 Akron General Ave, Akron, OH, 44303, USA
| | - Ali F Mallat
- Executive Director, Acute Care Surgery, Cleveland Clinic Akron General, Acute Care Surgery, Digestive Diseases and Surgery Institute, 1 Akron General Ave., Akron, OH, 44307, USA
| | - Marc J Edwards
- Cleveland Clinic Akron General, Department of Research, 1 Akron General Ave., Akron, OH, 44307, USA
| | - Joseph N Gabra
- Cleveland Clinic Akron General, Department of Research, 1 Akron General Ave., Akron, OH, 44307, USA
| | - Michaelia D Cucci
- Cleveland Clinic Akron General, Department of Pharmacy, 1 Akron General Ave., Akron, OH, 44307, USA.
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13
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Strayer RJ. Current concepts in ketamine therapy in the emergency department. Emerg Med Pract 2024; 26:1-24. [PMID: 38639638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Ketamine has been in use since its development as a dissociative anesthetic in the 1960s, but it was largely confined to the operating theater or austere environments until used by emergency physicians to facilitate painful procedures in children. As the unique effects of ketamine across its dose-response curve were understood, new applications emerged. In low doses, ketamine has found an important role alongside or instead of opioids in the management of severe pain, and methods to slow its absorption allow higher, more effective doses while attenuating psychoperceptual effects. Ketamine's unique anesthetic properties have inspired its use as an induction agent for intubation without a paralytic and for the rapid, safe control of dangerously agitated patients. Emerging uses for ketamine in acute care include treatment for status epilepticus and alcohol withdrawal syndrome; however, its most important rising indication may be as an emergency treatment of depression and suicidality.
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Affiliation(s)
- Reuben J Strayer
- Emergency Medicine + Addiction Medicine, Maimonides Health, Brooklyn, NY
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14
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Punia K, Scott W, Manuja K, Campbell K, Balodis IM, MacKillop J. SAEM GRACE: Phenobarbital for alcohol withdrawal management in the emergency department: A systematic review of direct evidence. Acad Emerg Med 2024; 31:481-492. [PMID: 37589203 DOI: 10.1111/acem.14788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/19/2023] [Accepted: 07/02/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVES Alcohol withdrawal syndrome (AWS) is a commonly presenting condition in the emergency department (ED) and can have severe complications, including mortality. Benzodiazepines are first-line medications for treating AWS but may be unavailable or insufficient. This systematic review evaluates the direct evidence assessing the utility of phenobarbital for treating AWS in the ED. METHODS A systematic search was conducted and designed according to the patient-intervention-comparator-outcome (PICO) question: (P) adults (≥18 years old) presenting to the ED with alcohol withdrawal; (I) phenobarbital (including adjunctive); (C) benzodiazepines or no intervention; and (O) AWS complications, admission to a monitored setting, control of symptoms, adverse effects, and adjunctive medications. Two reviewers independently assessed articles for inclusion and conducted risk of bias assessments for included studies. RESULTS From 70 potentially relevant articles, seven studies met inclusion criteria: three retrospective cohort studies, two retrospective chart reviews, and two randomized controlled trials (RCTs), one examining phenobarbital monotherapy and one examining adjunctive phenobarbital. Across the retrospective cohort studies, treatment of AWS with phenobarbital resulted in lower odds of a subsequent ED visit. The retrospective chart reviews indicated that phenobarbital was associated with higher discharge rate compared to benzodiazepine-only treatments. For the two RCTs, phenobarbital did not differ significantly from benzodiazepine for most outcomes, although concomitant treatment with phenobarbital was associated with lower benzodiazepine use and intensive care unit admission. The heterogeneous designs and small number of studies prevented quantitative synthesis. CONCLUSIONS Relatively few studies provide direct evidence on the utility of phenobarbital for AWS in the ED, but the evidence that exists generally suggests that it is a reasonable and appropriate approach. Additional RCTs and other methodologically rigorous investigations are needed for more definitive direct evidence.
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Affiliation(s)
- Kiran Punia
- Department of Psychology, Neuroscience, and Behaviour, McMaster University, Ontario, Hamilton, Canada
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare Hamilton/McMaster University, Hamilton, Ontario, Canada
| | - William Scott
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kriti Manuja
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare Hamilton/McMaster University, Hamilton, Ontario, Canada
| | | | - Iris M Balodis
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare Hamilton/McMaster University, Hamilton, Ontario, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Centre for Medicinal Cannabis Research (CMCR), McMaster University, Hamilton, Ontario, Canada
| | - James MacKillop
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare Hamilton/McMaster University, Hamilton, Ontario, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Centre for Medicinal Cannabis Research (CMCR), McMaster University, Hamilton, Ontario, Canada
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15
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Marques LDS, Rocha YMD, Nascimento GAD, Santos SAAR, Vieira NCG, Moura LFWG, Alves DR, Silva WMBD, de Morais SM, de Oliveira KA, da Silva LMR, Sousa KKOD, Vieira-Neto AE, Coutinho HDM, Campos AR, Magalhães FEA. Potential of the Blue Calm® food supplement in the treatment of alcohol withdrawal-induced anxiety in adult zebrafish (Danio rerio). Neurochem Int 2024; 175:105706. [PMID: 38423391 DOI: 10.1016/j.neuint.2024.105706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/02/2024]
Abstract
Alcohol use disorder (AUD) is characterized by a set of behavioral, cognitive, nutritional, and physiological phenomena derived from the uncontrolled use of alcoholic beverages. There are cases in which AUD is associated with anxiety disorder, and when untreated, it requires careful pharmacotherapy. Blue Calm® (BC) is a food supplement indicated to aid restorative sleep, which has traces of medicinal plant extracts, as well as myo-inositol, magnesium bisglycinate, taurine, and L-tryptophan as its main chemical constituents. In this context, this study aimed to evaluate the potential of the BC in the treatment alcohol withdrawal-induced anxiety in adult zebrafish (aZF). Initially, BC was submitted to antioxidant activity against 2,2-diphenyl-1-picrylhydrazyl radical. Subsequently, the aZF (n = 6/group) were treated with BC (0.1 or 1 or 10 mg/mL; 20 μL; p.o.), and the sedative effect and acute toxicity (96 h) were evaluated. Then, the anxiolytic-like effect and the possible GABAergic mechanism were analyzed through the Light & Dark Test. Finally, BC action was evaluated for treating alcohol withdrawal-induced anxiety in aZF. Molecular docking was performed to evaluate the interaction of the major chemical constituents of BC with the GABAA receptor. BC showed antioxidant potential, a sedative effect, was not toxic, and all doses of BC had an anxiolytic-like effect and showed potential for the treatment of alcohol withdrawal-induced anxiety in aZF. In addition to the anxiolytic action, the main chemical constituents of BC were confirmed in the molecular docking, thus suggesting that BC is an anxiolytic that modulates the GABAergic system and has pharmacological potential for the treatment of alcohol withdrawal-induced anxiety.
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Affiliation(s)
- Luzia Débora S Marques
- Universidade Estadual do Ceará, Programa de Pós-Graduação em Nutrição e Saúde (PPGNS), Centro de Ciências da Saúde (CCS), Campus Do Itaperi, CEP 60.741-000, Fortaleza, CE, Brazil
| | - Yatagan M da Rocha
- Universidade Estadual do Ceará, Programa de Pós-Graduação em Nutrição e Saúde (PPGNS), Centro de Ciências da Saúde (CCS), Campus Do Itaperi, CEP 60.741-000, Fortaleza, CE, Brazil
| | - Gabriela A do Nascimento
- Universidade Estadual do Ceará, Programa de Pós-Graduação em Nutrição e Saúde (PPGNS), Centro de Ciências da Saúde (CCS), Campus Do Itaperi, CEP 60.741-000, Fortaleza, CE, Brazil
| | - Sacha Aubrey A R Santos
- Universidade de Fortaleza, Rede Nordeste de Biotecnologia (RENORBIO), Programa de Pós-Graduação em Ciências Médicas (PPGCM), Núcleo de Biologia Experimental (NUBEX), CEP 60.811-650, Fortaleza, Ceará, Brazil
| | - Natália Chaves G Vieira
- Universidade de Fortaleza, Rede Nordeste de Biotecnologia (RENORBIO), Programa de Pós-Graduação em Ciências Médicas (PPGCM), Núcleo de Biologia Experimental (NUBEX), CEP 60.811-650, Fortaleza, Ceará, Brazil
| | - Luiz Francisco Wemmenson G Moura
- Universidade de Fortaleza, Rede Nordeste de Biotecnologia (RENORBIO), Programa de Pós-Graduação em Ciências Médicas (PPGCM), Núcleo de Biologia Experimental (NUBEX), CEP 60.811-650, Fortaleza, Ceará, Brazil
| | - Daniela R Alves
- Universidade Estadual do Ceará, Programa de Pós-Graduação em Ciências Naturais (PPGCS), Centro de Ciências e Tecnologia (CCT), Laboratório de Análises Cromatográficas e Espectroscópicas (LACES), Campus do Itaperi, CEP 60714-903, Fortaleza, Ceará, Brazil
| | - Wildson Max B da Silva
- Universidade Estadual do Ceará, Programa de Pós-Graduação em Ciências Naturais (PPGCS), Centro de Ciências e Tecnologia (CCT), Laboratório de Análises Cromatográficas e Espectroscópicas (LACES), Campus do Itaperi, CEP 60714-903, Fortaleza, Ceará, Brazil
| | - Selene Maia de Morais
- Universidade Estadual do Ceará, Programa de Pós-Graduação em Ciências Naturais (PPGCS), Centro de Ciências e Tecnologia (CCT), Laboratório de Análises Cromatográficas e Espectroscópicas (LACES), Campus do Itaperi, CEP 60714-903, Fortaleza, Ceará, Brazil.
| | - Keciany A de Oliveira
- Universidade Estadual do Ceará, Programa de Pós-Graduação em Nutrição e Saúde (PPGNS), Centro de Ciências da Saúde (CCS), Campus Do Itaperi, CEP 60.741-000, Fortaleza, CE, Brazil
| | - Larissa Morais R da Silva
- Universidade Federal do Ceará, Programa de Pós-Graduação em Ciências e Tecnologia de Alimentos (PPGCTA), Laboratório de Microbiologia de Alimentos (LMA), Campos do Pici, CEP 60.356.000, Fortaleza, Ceará, Brazil.
| | - Kalina Kelma O de Sousa
- Universidade Estadual do Ceará, Laboratório de Bioprospecção de Produtos Naturais e Biotecnologia (LBPNB), Campus CECITEC, CEP 60.660-000, Tauá, Ceará, Brazil
| | - Antonio Eufrásio Vieira-Neto
- Universidade de Fortaleza, Rede Nordeste de Biotecnologia (RENORBIO), Programa de Pós-Graduação em Ciências Médicas (PPGCM), Núcleo de Biologia Experimental (NUBEX), CEP 60.811-650, Fortaleza, Ceará, Brazil
| | - Henrique Douglas Melo Coutinho
- Universidade Regional do Cariri - URCA, Programa de Pós-Graduação em Química Biológica (PPGQB), Laboratório de Microbiologia e Biologia Molecular (LMBM), CEP 63105-000, Crato, Ceará, Brazil.
| | - Adriana Rolim Campos
- Universidade de Fortaleza, Rede Nordeste de Biotecnologia (RENORBIO), Programa de Pós-Graduação em Ciências Médicas (PPGCM), Núcleo de Biologia Experimental (NUBEX), CEP 60.811-650, Fortaleza, Ceará, Brazil.
| | - Francisco Ernani Alves Magalhães
- Universidade Estadual do Ceará, Programa de Pós-Graduação em Nutrição e Saúde (PPGNS), Centro de Ciências da Saúde (CCS), Campus Do Itaperi, CEP 60.741-000, Fortaleza, CE, Brazil; Universidade de Fortaleza, Rede Nordeste de Biotecnologia (RENORBIO), Programa de Pós-Graduação em Ciências Médicas (PPGCM), Núcleo de Biologia Experimental (NUBEX), CEP 60.811-650, Fortaleza, Ceará, Brazil; Universidade Estadual do Ceará, Laboratório de Bioprospecção de Produtos Naturais e Biotecnologia (LBPNB), Campus CECITEC, CEP 60.660-000, Tauá, Ceará, Brazil.
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16
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Ronan MV, Ganatra RB, Saukkonen J. Establishing the safety of phenobarbital treatment of alcohol withdrawal syndrome on general medical wards: A retrospective cohort study. Alcohol 2024; 116:29-34. [PMID: 37979844 DOI: 10.1016/j.alcohol.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 10/17/2023] [Accepted: 10/25/2023] [Indexed: 11/20/2023]
Abstract
INTRODUCTION Concern about adverse effects from phenobarbital limits its use in treating alcohol withdrawal syndrome (AWS) on general medical wards. Benzodiazepines are the recommended treatment for inpatient management of AWS, yet a subset of patients have an inadequate response or experience complications of AWS despite treatment with benzodiazepines. Data supporting an alternative treatment are needed. We set out to estimate the rate of serious adverse events (SAEs) of phenobarbital treatment for AWS on general medical wards. METHODS Retrospective cohort study of all general medical ward patients hospitalized at a single tertiary urban VA Medical Center from October 2018-May 2021 who received phenobarbital for treatment of AWS. Primary outcomes were SAEs attributed to phenobarbital and treatment failure. SAEs were defined as ICU transfer or intubation for over-sedation, pneumonia, and death. Treatment failure was defined as progression of withdrawal resulting in seizure, ICU transfer, behavioral emergencies, or death. RESULTS During the study period, phenobarbital was administered in 29% (244) of all AWS hospitalizations. Among them, 93% had a history of AWS hospitalization and 68% had a history of complicated AWS. Fifty-three percent of patients met criteria for moderate, severe, or complicated withdrawal prior to phenobarbital initiation. The mean cumulative dose of phenobarbital per patient was 966.5 mg (13.6 mg/kg). SAEs occurred in 1 of 244 hospitalizations (0.4%): there were no intubations, ICU transfers for oversedation, or deaths due to phenobarbital or AWS. One case of pneumonia was possibly attributable to phenobarbital. Treatment failures (6 ICU transfers, 9 behavioral emergencies) were identified during 12 of 244 hospitalizations (4.9%). CONCLUSIONS SAEs and treatment failures were infrequent among 148 patients treated with phenobarbital across 244 hospitalizations with a mean cumulative dose of 966.5 mg per patient. Our findings suggest that phenobarbital is a safe alternative treatment of AWS in general medical ward patients.
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Affiliation(s)
- Matthew V Ronan
- Medical Service, GIM Section, VA Boston Healthcare System, West Roxbury, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Rahul B Ganatra
- Medical Service, GIM Section, VA Boston Healthcare System, West Roxbury, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Jussi Saukkonen
- Medical Service, Pulmonary and Critical Care Section, VA Boston Healthcare System, West Roxbury, MA, United States; Boston University School of Medicine, Boston, MA, United States
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Brickel KH, Hodge EK, Zavgorodnyaya D, Schroeder JM, Brown LH, Daley MJ. A Comparison of Injectable Diazepam and Lorazepam in the Goal-Directed Management of Severe Alcohol Withdrawal. Ann Pharmacother 2024; 58:453-460. [PMID: 37606361 DOI: 10.1177/10600280231194790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Benzodiazepines are the gold standard for treatment of alcohol withdrawal, yet the selection of a preferred benzodiazepine is limited due to a lack of comparative studies. OBJECTIVES The primary objective of this study was to compare the efficacy and safety of injectable lorazepam (LZP) and diazepam (DZP) in the treatment of severe alcohol withdrawal syndrome (AWS). METHODS Retrospective cohort study of adult patients admitted to an intensive care unit with a primary diagnosis of AWS. Subjects who received at least 12 LZP equivalent units (LEU) of injectable DZP or LZP within 24 hours of initiation of the severe AWS protocol were included. The primary outcome was time with Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) scores at goal over the first 24 hours of treatment. RESULTS A total of 191 patients were included (DZP n = 89, LZP n = 102). Time with CIWA-Ar scores at goal during the first 24 hours was similar between groups (DZP 12 hours [interquartile range, IQR, = 9-15] vs LZP 14 hours [IQR = 10-17]), P = 0.06). At 24 hours, LEU requirement was similar (DZP 40 [IQR = 22-78] vs LZP 32 [IQR = 18-56], P = 0.05). Drug cost at 24 hours was higher in the DZP group ($204.6 [IQR = 112.53-398.97] vs $8 [IQR = 4.5-14], P < 0.01). CONCLUSION AND RELEVANCE DZP or LZP are equally efficacious for the treatment of severe AWS. LZP may be preferred due to cost but both medications can be used interchangeably based on availability.
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Affiliation(s)
- Kendall H Brickel
- Department of Pharmacy, Dell Seton Medical Center, The University of Texas, Austin, TX, USA
| | - Emily K Hodge
- Department of Pharmacy, Dell Seton Medical Center, The University of Texas, Austin, TX, USA
| | - Daria Zavgorodnyaya
- Department of Pharmacy, Dell Seton Medical Center, The University of Texas, Austin, TX, USA
| | - John M Schroeder
- Department of Pharmacy, Dell Seton Medical Center, The University of Texas, Austin, TX, USA
| | - Lawrence H Brown
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas, Austin, TX, USA
| | - Mitchell J Daley
- Department of Pharmacy, Dell Seton Medical Center, The University of Texas, Austin, TX, USA
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas, Austin, TX, USA
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18
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Nurten A, Gören MZ, Tekin N, Kaşkal M, Enginar N. Assessing effects of tamoxifen on tolerance, dependence, and glutamate and glutamine levels in frontal cortex and hippocampus in chronic morphine treatment. Behav Brain Res 2024; 463:114897. [PMID: 38331101 DOI: 10.1016/j.bbr.2024.114897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 02/02/2024] [Accepted: 02/02/2024] [Indexed: 02/10/2024]
Abstract
Tamoxifen has been shown to reduce glutamate release from presynaptic glutamatergic nerves and reverse tolerance to morphine-induced respiratory depression. Changes in glutamatergic neurotransmission in the central nervous system contribute to morphine tolerance, dependence, and withdrawal. This study, therefore, evaluated effects of tamoxifen on development of analgesic tolerance and dependence, and brain glutamate and glutamine levels in chronic morphine administration. Mice implanted with placebo or morphine pellets were injected with tamoxifen (0.6-2 mg/kg) or vehicle twice daily for 3 days. Nociceptive response was evaluated in the hot plate and tail immersion tests, 4, 48 and 72 h post-implant, and following a challenge dose of morphine (10 mg/kg). Withdrawal signs were determined after naloxone (1 mg/kg) administration. Morphine increased nociceptive threshold which declined over time. At 72 h, acute morphine elicited tolerance to the analgesic effect in the hot plate test in vehicle or tamoxifen administered animals. In the tail immersion test, however, tolerance to morphine analgesia was observed in tamoxifen, but not vehicle, co-administration. Tamoxifen did not reduce withdrawal signs. In contrast to previous reports, glutamate and glutamine levels in the hippocampus and frontal cortex did not change in the morphine-vehicle group. Confirming previous findings, tamoxifen (2 mg/kg) decreased glutamate and glutamine concentrations in the hippocampus in animals with placebo pellets. Both doses of tamoxifen significantly changed glutamate and/or glutamine concentrations in both regions in morphine pellet implanted animals. These results suggest that tamoxifen has no effect on dependence but may facilitate tolerance development to the antinociception, possibly mediated at the spinal level, in chronic morphine administration.
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Affiliation(s)
- Asiye Nurten
- Department of Physiology, Faculty of Medicine, Istanbul Yeni Yuzyil University, Istanbul, Turkey
| | - M Zafer Gören
- Department of Medical Pharmacology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Nurdan Tekin
- Department of Medical Pharmacology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Mert Kaşkal
- Department of Medical Pharmacology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Nurhan Enginar
- Department of Medical Pharmacology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
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Jones BLH, Geier M, Neuhaus J, Coffin PO, Snyder HR, Soran CS, Knight KR, Suen LW. Withdrawal during outpatient low dose buprenorphine initiation in people who use fentanyl: a retrospective cohort study. Harm Reduct J 2024; 21:80. [PMID: 38594721 PMCID: PMC11005253 DOI: 10.1186/s12954-024-00998-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/02/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Buprenorphine is an effective treatment for opioid use disorder (OUD); however, buprenorphine initiation can be complicated by withdrawal symptoms including precipitated withdrawal. There has been increasing interest in using low dose initiation (LDI) strategies to reduce this withdrawal risk. As there are limited data on withdrawal symptoms during LDI, we characterize withdrawal symptoms in people with daily fentanyl use who underwent initiation using these strategies as outpatients. METHODS We conducted a retrospective chart review of patients with OUD using daily fentanyl who were prescribed 7-day or 4-day LDI at 2 substance use disorder treatment clinics in San Francisco. Two addiction medicine experts assessed extracted chart documentation for withdrawal severity and precipitated withdrawal, defined as acute worsening of withdrawal symptoms immediately after taking buprenorphine. A third expert adjudicated disagreements. Data were analyzed using descriptive statistics. RESULTS There were 175 initiations in 126 patients. The mean age was 37 (SD 10 years). 71% were men, 26% women, and 2% non-binary. 21% identified as Black, 16% Latine, and 52% white. 60% were unstably housed and 75% had Medicaid insurance. Substance co-use included 74% who used amphetamines, 29% cocaine, 22% benzodiazepines, and 19% alcohol. Follow up was available for 118 (67%) initiations. There was deviation from protocol instructions in 22% of these initiations with follow up. 31% had any withdrawal, including 21% with mild symptoms, 8% moderate and 2% severe. Precipitated withdrawal occurred in 10 cases, or 8% of initiations with follow up. Of these, 7 had deviation from protocol instructions; thus, there were 3 cases with follow up (3%) in which precipitated withdrawal occurred without protocol deviation. CONCLUSIONS Withdrawal was relatively common in our cohort but was mostly mild, and precipitated withdrawal was rare. Deviation from instructions, structural barriers, and varying fentanyl use characteristics may contribute to withdrawal. Clinicians should counsel patients who use fentanyl that mild withdrawal symptoms are likely during LDI, and there is still a low risk for precipitated withdrawal. Future studies should compare withdrawal across initiation types, seek ways to support patients in initiating buprenorphine, and qualitatively elicit patients' withdrawal experiences.
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Affiliation(s)
- Benjamin L H Jones
- Medical Student Center, UCSF School of Medicine, 533 Parnassus Avenue, S-245, San Francisco, CA, 94143, USA.
| | - Michelle Geier
- San Francisco Department of Public Health, 101 Grove Street, San Francisco, CA, 94102, USA
| | - John Neuhaus
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th Street, 2nd Floor, San Francisco, CA, 94158, USA
| | - Phillip O Coffin
- San Francisco Department of Public Health, 101 Grove Street, San Francisco, CA, 94102, USA
- Department of Medicine, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Hannah R Snyder
- Department of Family and Community Medicine, University of California San Francisco, 995 Potrero Avenue, San Francisco, CA, 94110, USA
| | - Christine S Soran
- Division of General Internal Medicine, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
- Division of Substance Abuse and Addiction Medicine, San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
| | - Kelly R Knight
- Department of Humanities and Social Sciences, University of California San Francisco, 490 Illinois Street, 7th Floor, San Francisco, CA, 94143, USA
| | - Leslie W Suen
- Department of Medicine, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
- Division of General Internal Medicine, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
- Division of Substance Abuse and Addiction Medicine, San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
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Stanciu CN, Ahmed S, Sarfraz Z, Nimavat N, Healey CJ, Grundmann O, Ballard JR, Henningfield J. Prevalence, Characteristics, and Reasons for Kratom Use among Psychiatrically Ill Inpatients Who Use Substances. J Dual Diagn 2024; 20:87-97. [PMID: 38153407 DOI: 10.1080/15504263.2023.2289456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
OBJECTIVE Despite kratom impacting neurobiological systems involved in psychiatric disorders, little is known about the prevalence of use among patients with severe psychopathologies. Here, we investigated the prevalence of kratom use, motives for use, and the clinical associations among inpatients with severe psychiatric disorders. METHODS A total of 578 patients, aged 18 to 65, were evaluated by New Hampshire Hospital's Addiction Services from January 1, 2020, to February 28, 2022. The study collected demographic information and used chi-square tests, multivariable logistic regression, and subgroup analyses with 95% confidence intervals to examine trends among kratom users. A receiver operating characteristic curve analysis was also conducted. All statistical tests were performed using IBM SPSS Version 28.0.1. RESULTS Of the patients assessed, 2.2% (n = 13) reported using kratom. The reasons for kratom use were managing withdrawal symptoms (15.4%), maintaining sobriety and reducing cravings for opioids (53.8%), improving focus and concentration (30.8%), alleviating low moods (38.5%), and managing pain (15.4%). Compared to non-kratom users, the only factor with a fair to good association with kratom use is postsecondary education (Area Under Curve, AUC = 0.77). CONCLUSIONS Prevalence of kratom use among patients with serious mental illness at our site aligns with that reported in the general population. Users often cite self-management of cravings and sobriety from opioids, as well as treatment of low mood states, as motivations for consumption. While observations suggest a possible association between kratom use and individuals with post-secondary education, multiple substance use, and experience of substance-induced psychosis or mood disorders, it is essential to interpret these links cautiously until further rigorous studies are carried out to substantiate these findings.
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Affiliation(s)
- Cornel N Stanciu
- Director of Addiction Services, New Hampshire Hospital, Concord, New Hampshire, USA
| | - Saeed Ahmed
- Department of Psychiatry, Rutland Regional Medical Center, Rutland, Vermont, USA
| | - Zouina Sarfraz
- Department of Research and Publications, Fatima Jinnah Medical University, Lahore, Pakistan
| | - Nirav Nimavat
- Community Medicine Department, B.K. Shah Medical Institute & Research Centre, Vadodara, India
| | | | - Oliver Grundmann
- Entrepreneurial Programs in Medicinal Chemistry, University of Florida, Gainesville, Florida, USA
| | - Jonathan R Ballard
- Chief Medical Officer, New Hampshire Department of Health and Human Services, Concord, New Hampshire, USA
| | - Jack Henningfield
- Pinney Associates, Inc., Bethesda, Maryland, USA
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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21
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Liu W, Wang Z, Wang W, Wang Z, Xing Y, Hölscher C. Liraglutide Reduces Alcohol Consumption, Anxiety, Memory Impairment, and Synapse Loss in Alcohol Dependent Mice. Neurochem Res 2024; 49:1061-1075. [PMID: 38267691 DOI: 10.1007/s11064-023-04093-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 12/02/2023] [Accepted: 12/22/2023] [Indexed: 01/26/2024]
Abstract
Glucagon-like peptide 1 (GLP-1) analogues have been commercialized for the management of type 2 diabetes. Recent studies have underscored GLP-1's role as a modulator of alcohol-related behavior. However, the role of the GLP-1 analogue liraglutide on alcohol-withdrawal responses have not been fully elucidated. Liraglutide binds to the G-protein-coupled receptor and activates an adenylyl cyclase and the associated classic growth factor signaling pathway, which acts growth factor-like and neuroprotective properties. The underlying neurobiological mechanisms of liraglutide on alcohol withdrawal remains unknown. This study endeavored to explore the effects of liraglutide on the emotion and memory ability of alcohol-withdrawal mice, and synaptic morphology in the medial prefrontal cortex (mPFC) and the hippocampus (HP), and thus affects the relapse-like drinking of alcohol-withdrawal mice. The alcohol-withdrawal group was reintroduced to a 20% v/v alcohol and water through the two-bottle choice for four consecutive days, a period referred to as alcohol re-drinking. Male C57BL/6J mice were exposed to a regimen of 20% alcohol and water for a duration of 6 weeks. This regimen established the two-bottle choice model of alcohol exposure. Learning capabilities, memory proficiency, and anxiety-like behavior were evaluated using the Morris water maze, open field, and elevated plus maze paradigms. Furthermore, synaptic morphology and the levels of synaptic transport-related proteins were assessed via Golgi staining and Western Blot analysis after a two-week alcohol deprivation period. Alcohol re-drinking of alcohol-withdrawal mice was also evaluated using a two-bottle choice paradigm. Our findings indicate that liraglutide can substantially decrease alcohol consumption and preference (p < 0.05) in the alcohol group and enhance learning and memory performance (p < 0.01), as well as alleviate anxiety-like behavior (p < 0.01) of alcohol-withdrawal mice. Alcohol consumption led to a reduction in dendritic spine density in the mPFC and HP, which was restored to normal levels by liraglutide (p < 0.001). Furthermore, liraglutide was found to augment the levels of synaptic transport-related proteins in mice subjected to alcohol withdrawal (p < 0.01). The study findings corroborate that liraglutide has the potential to mitigate alcohol consumption and ameliorate the memory impairments and anxiety induced by alcohol withdrawal. The therapeutic efficacy of liraglutide might be attributed to its role in counteracting synapse loss in the mPFC and HP regions and thus prevented relapse-like drinking in alcohol-withdrawal mice.
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Affiliation(s)
- Weizhen Liu
- Department of Physiology and Neurobiology, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, 450001, Henan, China
- The Academy of Medical Sciences of Zhengzhou University, Zhengzhou, 450001, Henan, China
| | - Ziliang Wang
- Department of Physiology and Neurobiology, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, 450001, Henan, China
- The Academy of Medical Sciences of Zhengzhou University, Zhengzhou, 450001, Henan, China
| | - Wang Wang
- Department of Physiology and Neurobiology, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, 450001, Henan, China
- The Academy of Medical Sciences of Zhengzhou University, Zhengzhou, 450001, Henan, China
| | - Zhiju Wang
- Department of Physiology and Neurobiology, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, 450001, Henan, China
| | - Ying Xing
- Department of Physiology and Neurobiology, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, 450001, Henan, China.
| | - Christian Hölscher
- Henan Academy of Innovation in Medical Science, XinZheng, 451100, Henan, China.
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Acheson LS, Clay S, McKetin R, Lintzeris N, Dunlop A, Brett J, Christmass M, Rodgers C, Shoptaw S, Farrell M, Ezard N, Siefried KJ. Participant experiences in a pilot study for methamphetamine withdrawal treatment: Implications for retention. Int J Drug Policy 2024; 126:104383. [PMID: 38479162 DOI: 10.1016/j.drugpo.2024.104383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 02/21/2024] [Accepted: 03/03/2024] [Indexed: 04/29/2024]
Abstract
INTRODUCTION There is little knowledge of the perspectives of people who use methamphetamine and have participated in clinical trials, and none for interventions not intended to address abstinence. A better understanding of these experiences could lead to more patient centred clinical trial design. This study seeks to understand the experiences of people who completed a clinical trial of lisdexamfetamine for the treatment of acute methamphetamine withdrawal. METHODS Thematic analysis of open-ended, semi-structured interviews with eight people who participated in an inpatient clinical trial of lisdexamfetamine for acute methamphetamine withdrawal. Interviews were conducted between days 3 and 6 of admission to an inner-city Sydney hospital. RESULTS Participants described how research procedures, the research setting, and the investigational product affected their experiences while enrolled in a clinical trial. Of particular importance to participants were transparent and low burden trial procedures, a welcoming trial environment, trusting relationships and effective communication, which were linked with the participants' subsequent decision to remain enrolled in the trial. DISCUSSION The experiences of participants in this clinical trial can be distilled into four meta-themes: agency, caring-trust, safety, and communication. Participants spontaneously linked these experiences with a capacity to remain enrolled in the study. By considering the experiences of trial participants in clinical trial design, researchers can improve the experiences of future trial participants and facilitate their choice to remain enrolled in clinical trials.
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Affiliation(s)
- Liam S Acheson
- The National Drug and Alcohol Research Centre (NDARC), University of New South Wales, 22-32 King St, Randwick, NSW 2031, Australia; Alcohol and Drug Service, St Vincent's Hospital Sydney, 390 Victoria St Darlinghurst, NSW 2010, Australia; The National Centre for Clinical Research on Emerging Drugs (NCCRED), c/o University of New South Wales, 22-32 King St, Randwick, NSW 2031, Australia.
| | - Simon Clay
- The National Drug and Alcohol Research Centre (NDARC), University of New South Wales, 22-32 King St, Randwick, NSW 2031, Australia
| | - Rebecca McKetin
- The National Drug and Alcohol Research Centre (NDARC), University of New South Wales, 22-32 King St, Randwick, NSW 2031, Australia
| | - Nicholas Lintzeris
- New South Wales Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Sydney, Australia; Drug and Alcohol Services, South East Sydney Local Health District, 591 S Dowling St, Surry Hills, NSW 2010, Australia; Specialty of Addiction Medicine, The University of Sydney, Camperdown, NSW 2050, Australia
| | - Adrian Dunlop
- New South Wales Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Sydney, Australia; Drug and Alcohol Clinical Services, Hunter New England Local Health District, Lookout Rd, New Lambton Heights, NSW 2305, Australia; School of Medicine and Public Health, University of Newcastle, University Dr, Callaghan, NSW 2308, Australia
| | - Jonathan Brett
- Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, 390 Victoria St Darlinghurst, NSW 2010, Australia; St. Vincent's Clinical School, The University of New South Wales, 390 Victoria St Darlinghurst, NSW 2010, Australia
| | - Michael Christmass
- Next Step Drug and Alcohol Services, 32 Moore St, East Perth, WA, 6004, United States; National Drug Research Institute, Curtin University, Kent St, Bentley WA 6102, United States
| | - Craig Rodgers
- Alcohol and Drug Service, St Vincent's Hospital Sydney, 390 Victoria St Darlinghurst, NSW 2010, Australia
| | - Steve Shoptaw
- Department of Family Medicine, University of California Los Angeles, Los Angeles, CA 90095, United States
| | - Michael Farrell
- The National Drug and Alcohol Research Centre (NDARC), University of New South Wales, 22-32 King St, Randwick, NSW 2031, Australia
| | - Nadine Ezard
- Alcohol and Drug Service, St Vincent's Hospital Sydney, 390 Victoria St Darlinghurst, NSW 2010, Australia; The National Centre for Clinical Research on Emerging Drugs (NCCRED), c/o University of New South Wales, 22-32 King St, Randwick, NSW 2031, Australia; New South Wales Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Sydney, Australia
| | - Krista J Siefried
- The National Drug and Alcohol Research Centre (NDARC), University of New South Wales, 22-32 King St, Randwick, NSW 2031, Australia; Alcohol and Drug Service, St Vincent's Hospital Sydney, 390 Victoria St Darlinghurst, NSW 2010, Australia; The National Centre for Clinical Research on Emerging Drugs (NCCRED), c/o University of New South Wales, 22-32 King St, Randwick, NSW 2031, Australia
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23
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Bell CM, Rech MA, Akuamoah-Boateng KA, Kasotakis G, McMurray JD, Moses BA, Mueller SW, Patel GP, Roberts RJ, Sakhuja A, Salvator A, Setliff EL, Droege CA. Ketamine in Critically Ill Patients: Use, Perceptions, and Potential Barriers. J Pharm Pract 2024; 37:351-363. [PMID: 36282867 DOI: 10.1177/08971900221134551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Objective: To evaluate practitioner use of ketamine and identify potential barriers to use in acutely and critically ill patients. To compare characteristics, beliefs, and practices of ketamine frequent users and non-users. Methods: An online survey developed by members of the Society of Critical Care Medicine (SCCM) Clinical Pharmacy and Pharmacology Section was distributed to physician, pharmacist, nurse practitioner, physician assistant and nurse members of SCCM. The online survey queried SCCM members on self-reported practices regarding ketamine use and potential barriers in acute and critically ill patients. Results: Respondents, 341 analyzed, were mostly adult physicians, practicing in the United States at academic medical centers. Clinicians were comfortable or very comfortable using ketamine to facilitate intubation (80.0%), for analgesia (77.9%), procedural sedation (79.4%), continuous ICU sedation (65.8%), dressing changes (62.4%), or for asthma exacerbation and status epilepticus (58.8% and 40.4%). Clinicians were least comfortable with ketamine use for alcohol withdrawal and opioid detoxification (24.7% and 23.2%). Most respondents reported "never" or "infrequently" using ketamine preferentially for continuous IV analgesia (55.6%) or sedation (61%). Responses were mixed across dosing ranges and duration. The most common barriers to ketamine use were adverse effects (42.6%), other practitioners not routinely using the medication (41.5%), lack of evidence (33.5%), lack of familiarity (33.1%), and hospital/institutional policy guiding the indication for use (32.3%). Conclusion: Although most critical care practitioners report feeling comfortable using ketamine, there are many inconsistencies in practice regarding dose, duration, and reasons to avoid or limit ketamine use. Further educational tools may be targeted at practitioners to improve appropriate ketamine use.
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Affiliation(s)
- Carolyn M Bell
- Department of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Megan A Rech
- Department of Pharmacy, Department of Emergency Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Kwame A Akuamoah-Boateng
- Department of Surgery: Division of Acute Care Surgical Services, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - George Kasotakis
- Department of Surgery, Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey D McMurray
- Department of Anesthesia, Medical University of South Carolina, Charleston, SC, USA
| | - Benjamin A Moses
- Department of Anesthesia: Division of Critical Care, University of Virginia Health, Charlottesville, VA, USA
| | - Scott W Mueller
- Department of Pharmacy, University of Colorado Health, Aurora, CO, USA
| | - Gourang P Patel
- Department of Pharmacy, University of Chicago Medical Center, Chicago, IL, USA
| | - Russel J Roberts
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Ankit Sakhuja
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Ann Salvator
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Erika L Setliff
- Department of Clinical Education Services, Atrium Health Cabarrus, Concord, NC, USA
| | - Christopher A Droege
- Department of Pharmacy Services, UC Health-University of Cincinnati Medical Center, Cincinnati, OH, USA
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Lebin JA, Bass ME, Heard K, Hoppe J, Jacknin G. A Retrospective Evaluation of Adjunctive Phenobarbital vs. Benzodiazepine Alone for the Treatment of Moderate Alcohol Withdrawal in the Emergency Department. J Emerg Med 2024; 66:e516-e522. [PMID: 38485572 DOI: 10.1016/j.jemermed.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/21/2023] [Accepted: 12/08/2023] [Indexed: 04/07/2024]
Abstract
BACKGROUND Phenobarbital has been used in the emergency department (ED) as both a primary and adjunctive medication for alcohol withdrawal, but previous studies evaluating its impact on patient outcomes are limited by heterogenous symptom severity. OBJECTIVES We compared the clinical outcomes of ED patients with moderate alcohol withdrawal who received phenobarbital, with or without benzodiazepines, with patients who received benzodiazepine treatment alone. METHODS This is a retrospective cohort study conducted at a single academic medical center utilizing chart review of ED patients with moderate alcohol withdrawal between 2015 and 2020. Patient encounters were classified into two treatment categories based on medication treatment: phenobarbital alone or in combination with benzodiazepines vs. benzodiazepines alone. Chi-square test or Fisher's exact was used to analyze categorical variables and the Student's t-test for continuous data. RESULTS Among the 287 encounters that met inclusion criteria, 100 received phenobarbital, compared with 187 that received benzodiazepines alone. Patients who received phenobarbital were provided significantly more lorazepam equivalents. There was a significant difference in the percentage of patient encounters that required admission to the hospital in the phenobarbital cohort compared with the benzodiazepine cohort (75% vs. 43.3%, p < 0.001). However, there was no difference in admission level of care to the floor (51.2% vs. 52.0%), stepdown (33.8% vs. 28%), or intensive care unit (15% vs. 20%), respectively. CONCLUSIONS Patients who received phenobarbital for moderate alcohol withdrawal were more likely to be admitted to the hospital, but there was no difference in admission level of care when compared with patients who received benzodiazepines alone. Patients who received phenobarbital were provided greater lorazepam equivalents in the ED.
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Affiliation(s)
- Jacob A Lebin
- Section of Medical Toxicology, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Megan E Bass
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy, Aurora, Colorado
| | - Kennon Heard
- Section of Medical Toxicology, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Jason Hoppe
- Section of Medical Toxicology, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Gabrielle Jacknin
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy, Aurora, Colorado
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Scicluna RL, Wilson BB, Thelaus SH, Arnold JC, McGregor IS, Bowen MT. Cannabidiol Reduced the Severity of Gastrointestinal Symptoms of Opioid Withdrawal in Male and Female Mice. Cannabis Cannabinoid Res 2024; 9:547-560. [PMID: 36577048 DOI: 10.1089/can.2022.0036] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Introduction: Opioid withdrawal is a powerful driver of drug-seeking behavior as relief from this aversive state through drug-taking is a strong negative reinforcer. There are currently limited treatment options available for opioid withdrawal and cannabidiol (CBD) has been identified as a potential novel therapeutic. This study explored the efficacy and dose dependency of CBD for reducing the severity of naloxone-precipitated and spontaneous oxycodone withdrawal (PW and SW, respectively) in male and female mice. Methods: Mice were administered saline or escalating doses of oxycodone, whereby 9, 17.8, 23.7, and 33 mg/kg oxycodone IP was administered twice daily on days 1-2, 3-4, 5-6, and 7-8, respectively. On the 9th day, a single 33 mg/kg dose of oxycodone (or saline) was administered. To precipitate withdrawal, on day 9, mice in the withdrawal conditions were administered an IP injection of 10 mg/kg naloxone 2 h after the final oxycodone injection and immediately before withdrawal testing. To elicit SW, a separate group of mice underwent withdrawal testing 24 h after their final oxycodone injection. Mice were treated with an IP injection of 0, 10, 30 or 100 mg/kg of CBD 60 min before testing. Withdrawal symptoms examined included gastrointestinal symptoms (fecal boli, diarrhea, and body weight loss), somatic symptoms (paw tremors), and negative affect (jumping). Results: A robust PW syndrome was observed in both male and female mice, whereas only male mice displayed an SW syndrome. CBD dose dependently reduced gastrointestinal symptoms during both PW and SW in male mice and during PW in female mice. CBD had no effect on PW- or SW-induced jumping in male mice. However, in female mice, the PW-induced increase in jumps was less pronounced in CBD-treated mice. The highest dose of CBD inhibited paw tremors during PW, but not SW, in male mice. Neither PW- nor SW-induced paw tremors were observed in female mice. Conclusions: The magnitude of effects on the gastrointestinal symptoms, their consistency across PW and SW, and both sexes, alongside the availability of CBD for clinical use, suggest further exploration of the potential for CBD to treat these symptoms could be justified.
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Affiliation(s)
- Rhianne L Scicluna
- Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia
- School of Psychology, Faculty of Science, The University of Sydney, Sydney, New South Wales, Australia
| | - Bianca B Wilson
- Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia
- School of Psychology, Faculty of Science, The University of Sydney, Sydney, New South Wales, Australia
| | - Samuel H Thelaus
- Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia
- School of Psychology, Faculty of Science, The University of Sydney, Sydney, New South Wales, Australia
| | - Jonathon C Arnold
- Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia
- School of Pharmacy, Discipline of Pharmacology, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, New South Wales, Australia
| | - Iain S McGregor
- Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia
- School of Psychology, Faculty of Science, The University of Sydney, Sydney, New South Wales, Australia
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael T Bowen
- Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia
- School of Psychology, Faculty of Science, The University of Sydney, Sydney, New South Wales, Australia
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26
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Quezada M, Ponce C, Berríos‐Cárcamo P, Santapau D, Gallardo J, De Gregorio C, Quintanilla ME, Morales P, Ezquer M, Herrera‐Marschitz M, Israel Y, Andrés‐Herrera P, Hipólito L, Ezquer F. Amelioration of morphine withdrawal syndrome by systemic and intranasal administration of mesenchymal stem cell-derived secretome in preclinical models of morphine dependence. CNS Neurosci Ther 2024; 30:e14517. [PMID: 37927136 PMCID: PMC11017443 DOI: 10.1111/cns.14517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/21/2023] [Accepted: 10/12/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Morphine is an opiate commonly used in the treatment of moderate to severe pain. However, prolonged administration can lead to physical dependence and strong withdrawal symptoms upon cessation of morphine use. These symptoms can include anxiety, irritability, increased heart rate, and muscle cramps, which strongly promote morphine use relapse. The morphine-induced increases in neuroinflammation, brain oxidative stress, and alteration of glutamate levels in the hippocampus and nucleus accumbens have been associated with morphine dependence and a higher severity of withdrawal symptoms. Due to its rich content in potent anti-inflammatory and antioxidant factors, secretome derived from human mesenchymal stem cells (hMSCs) is proposed as a preclinical therapeutic tool for the treatment of this complex neurological condition associated with neuroinflammation and brain oxidative stress. METHODS Two animal models of morphine dependence were used to evaluate the therapeutic efficacy of hMSC-derived secretome in reducing morphine withdrawal signs. In the first model, rats were implanted subcutaneously with mini-pumps which released morphine at a concentration of 10 mg/kg/day for seven days. Three days after pump implantation, animals were treated with a simultaneous intravenous and intranasal administration of hMSC-derived secretome or vehicle, and withdrawal signs were precipitated on day seven by i.p. naloxone administration. In this model, brain alterations associated with withdrawal were also analyzed before withdrawal precipitation. In the second animal model, rats voluntarily consuming morphine for three weeks were intravenously and intranasally treated with hMSC-derived secretome or vehicle, and withdrawal signs were induced by morphine deprivation. RESULTS In both animal models secretome administration induced a significant reduction of withdrawal signs, as shown by a reduction in a combined withdrawal score. Secretome administration also promoted a reduction in morphine-induced neuroinflammation in the hippocampus and nucleus accumbens, while no changes were observed in extracellular glutamate levels in the nucleus accumbens. CONCLUSION Data presented from two animal models of morphine dependence suggest that administration of secretome derived from hMSCs reduces the development of opioid withdrawal signs, which correlates with a reduction in neuroinflammation in the hippocampus and nucleus accumbens.
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Affiliation(s)
- Mauricio Quezada
- Center for Regenerative Medicine, Faculty of MedicineClínica Alemana‐Universidad del DesarrolloSantiagoChile
| | - Carolina Ponce
- Department of Neuroscience, Faculty of MedicineUniversidad de ChileSantiagoChile
| | - Pablo Berríos‐Cárcamo
- Center for Regenerative Medicine, Faculty of MedicineClínica Alemana‐Universidad del DesarrolloSantiagoChile
| | - Daniela Santapau
- Center for Regenerative Medicine, Faculty of MedicineClínica Alemana‐Universidad del DesarrolloSantiagoChile
| | - Javiera Gallardo
- Center for Regenerative Medicine, Faculty of MedicineClínica Alemana‐Universidad del DesarrolloSantiagoChile
| | - Cristian De Gregorio
- Center for Regenerative Medicine, Faculty of MedicineClínica Alemana‐Universidad del DesarrolloSantiagoChile
| | - María Elena Quintanilla
- Molecular and Clinical Pharmacology Program, Institute of Biomedical Science, Faculty of MedicineUniversidad de ChileSantiagoChile
| | - Paola Morales
- Department of Neuroscience, Faculty of MedicineUniversidad de ChileSantiagoChile
- Molecular and Clinical Pharmacology Program, Institute of Biomedical Science, Faculty of MedicineUniversidad de ChileSantiagoChile
| | - Marcelo Ezquer
- Center for Regenerative Medicine, Faculty of MedicineClínica Alemana‐Universidad del DesarrolloSantiagoChile
| | - Mario Herrera‐Marschitz
- Department of Neuroscience, Faculty of MedicineUniversidad de ChileSantiagoChile
- Molecular and Clinical Pharmacology Program, Institute of Biomedical Science, Faculty of MedicineUniversidad de ChileSantiagoChile
| | - Yedy Israel
- Molecular and Clinical Pharmacology Program, Institute of Biomedical Science, Faculty of MedicineUniversidad de ChileSantiagoChile
| | - Paula Andrés‐Herrera
- Department of Pharmacy and Pharmaceutical Technology and ParasitologyUniversity of ValenciaValenciaSpain
- University Institute of Biotechnology and Biomedicine (BIOTECMED)University of ValenciaValenciaSpain
| | - Lucia Hipólito
- Department of Pharmacy and Pharmaceutical Technology and ParasitologyUniversity of ValenciaValenciaSpain
- University Institute of Biotechnology and Biomedicine (BIOTECMED)University of ValenciaValenciaSpain
| | - Fernando Ezquer
- Center for Regenerative Medicine, Faculty of MedicineClínica Alemana‐Universidad del DesarrolloSantiagoChile
- Research Center for the Development of Novel Therapeutic Alternatives for Alcohol Use DisordersSantiagoChile
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Khatri SN, Sadek S, Kendrick PT, Bondy EO, Hong M, Pauss S, Luo D, Prisinzano TE, Dunn KE, Marusich JA, Beckmann JS, Hinds TD, Gipson CD. Xylazine suppresses fentanyl consumption during self-administration and induces a unique sex-specific withdrawal syndrome that is not altered by naloxone in rats. Exp Clin Psychopharmacol 2024; 32:150-157. [PMID: 37470999 PMCID: PMC10799160 DOI: 10.1037/pha0000670] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
Prescription and illicit opioid use are a public health crisis, with the landscape shifting to fentanyl use. Since fentanyl is 100-fold more potent than morphine, its use is associated with a higher risk of fatal overdose that can be remediated through naloxone (Narcan) administration. However, recent reports indicate that xylazine, an anesthetic, is increasingly detected in accidental fentanyl overdose deaths. Anecdotal reports suggest that xylazine may prolong the fentanyl "high," alter the onset of fentanyl withdrawal, and increase resistance to naloxone-induced reversal of overdose. To date, no preclinical studies have evaluated the impacts of xylazine on fentanyl self-administration (SA; 2.5 μg/kg/infusion) or withdrawal to our knowledge. We established a rat model of xylazine/fentanyl co-SA and withdrawal and evaluated outcomes as a function of biological sex. When administered alone, chronic xylazine (2.5 mg/kg, intraperitoneal) induced unique sex-specific withdrawal symptomatology, whereby females showed delayed onset of signs and a possible enhancement of sensitivity to the motor-suppressing effects of xylazine. Xylazine reduced fentanyl consumption in both male and female rats regardless of whether it was experimenter-administered or added to the intravenous fentanyl product (0.05, 0.10, and 0.5 mg/kg/infusion) when compared to fentanyl SA alone. Interestingly, this effect was dose-dependent when self-administered intravenously. Naloxone (0.1 mg/kg, subcutaneous injection) did not increase somatic signs of fentanyl withdrawal, regardless of the inclusion of xylazine in the fentanyl infusion in either sex; however, somatic signs of withdrawal were higher across time points in females after xylazine/fentanyl co-SA regardless of naloxone exposure as compared to females following fentanyl SA alone. Together, these results indicate that xylazine/fentanyl co-SA dose-dependently suppressed fentanyl intake in both sexes and induced a unique withdrawal syndrome in females that was not altered by acute naloxone treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
- Shailesh N. Khatri
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington KY
| | - Safiyah Sadek
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington KY
| | - Percell T. Kendrick
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington KY
| | - Emma O. Bondy
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington KY
| | - Mei Hong
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington KY
| | - Sally Pauss
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington KY
| | - Dan Luo
- Center for Pharmaceutical Research and Innovation, College of Pharmacy, University of Kentucky, Lexington, KY
| | - Thomas E. Prisinzano
- Center for Pharmaceutical Research and Innovation, College of Pharmacy, University of Kentucky, Lexington, KY
| | - Kelly E. Dunn
- Psychiatry and Behavioral Sciences Department, Johns Hopkins University, Baltimore, MD
| | - Julie A. Marusich
- Center for Drug Discovery, RTI International, Research Triangle Park, NC
| | | | - Terry D. Hinds
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington KY
| | - Cassandra D. Gipson
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington KY
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Stern SJ, D’Orazio JL, Work BD, Calcaterra SL, Thakrar AP. Point/counterpoint: Should full agonist opioid medications be offered to hospitalized patients for management of opioid withdrawal? J Hosp Med 2024; 19:339-343. [PMID: 38030816 PMCID: PMC10987259 DOI: 10.1002/jhm.13238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 10/22/2023] [Accepted: 11/04/2023] [Indexed: 12/01/2023]
Affiliation(s)
- Sam J. Stern
- Division of Hospital Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
- Lewis Katz School of Medicine, Center for Urban Bioethics, Philadelphia, Pennsylvania, USA
| | - Joseph L. D’Orazio
- Cooper Center for Healing, Camden, New Jersey, USA
- Department of Emergency Medicine, Division of Toxicology and Addiction Medicine, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Brian D. Work
- Division of Hospital Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
- Prevention Point Philadelphia, Philadelphia, Pennsylvania, USA
| | - Susan L. Calcaterra
- Division of General Internal Medicine and Hospital Medicine, University of Colorado, Aurora, Colorado, USA
| | - Ashish P. Thakrar
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Acheson LS, Gordon C, McKetin R, Brett J, Christmass M, Rodgers C, Lintzeris N, Dunlop A, Farrell M, Shoptaw S, Ezard N, Siefried KJ. Measuring Objective and Subjective Sleep during Lisdexamfetamine Treatment of Acute Methamphetamine Withdrawal: A Feasibility Study. Eur Addict Res 2024; 30:121-125. [PMID: 38498995 DOI: 10.1159/000536328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/21/2023] [Indexed: 03/20/2024]
Abstract
INTRODUCTION Sleep disturbance is common during methamphetamine (MA) use and withdrawal; however, the feasibility of combined subjective-objective measurement of sleep-wake has not been shown in this population. Actigraphy is a well-established, non-invasive measure of sleep-wake cycles with good concordance with polysomnography. This study aimed to investigate the feasibility and utility of using actigraphy and sleep diaries to investigate sleep during MA withdrawal. METHODS We conducted a feasibility and utility study of actigraphy and sleep diaries during a clinical trial of lisdexamfetamine for MA withdrawal. Participants were inpatients for 7 days, wore an actigraph (Philips Actiwatch 2) and completed a modified Consensus Sleep Diary each morning. Participants were interviewed between days 3-5. RESULTS Ten participants (mean age 37 years, 90% male) were enrolled. No participant removed the device prematurely. Participants interviewed (n = 8) reported that the actigraph was not difficult or distracting to wear or completion of daily sleep diary onerous. Actigraphic average daily sleep duration over 7 days was 568 min, sleep onset latency 22.4 min, wake after sleep onset (WASO) 75.2 min, and sleep efficiency 83.6%. Sleep diaries underreported daily sleep compared with actigraphy (sleep duration was 56 min (p = 0.008) and WASO 47 min (p < 0.001) less). Overall sleep quality was 4.4 on a nine-point Likert scale within the diary. CONCLUSIONS Continuous actigraphy is feasible to measure sleep-wake in people withdrawing from MA, with low participant burden. We found important differences in self-reported and actigraphic sleep, which need to be explored in more detail.
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Affiliation(s)
- Liam S Acheson
- The National Drug and Alcohol Research Centre (NDARC), The University of New South Wales, Sydney, New South Wales, Australia
- Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
- The National Centre for Clinical Research on Emerging Drugs (NCCRED), c/o the University of New South Wales, Sydney, New South Wales, Australia
| | - Christopher Gordon
- Susan Wakil School of Nursing and Midwifery, The University of Sydney, Sydney, New South Wales, Australia
- CIRUS Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Rebecca McKetin
- The National Drug and Alcohol Research Centre (NDARC), The University of New South Wales, Sydney, New South Wales, Australia
| | - Jonathan Brett
- Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
- St. Vincent's Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Michael Christmass
- Next Step Drug and Alcohol Services, Perth, Washington, Australia
- National Drug Research Institute, Curtin University, Perth, Washington, Australia
| | - Craig Rodgers
- Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
| | - Nicholas Lintzeris
- New South Wales Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Sydney, New South Wales, Australia
- Drug and Alcohol Services, Sydney, New South Wales, Australia
- Specialty of Addiction Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Adrian Dunlop
- New South Wales Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Sydney, New South Wales, Australia
- Drug and Alcohol Clinical Services, Newcastle, New South Wales, Australia
- School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Michael Farrell
- The National Drug and Alcohol Research Centre (NDARC), The University of New South Wales, Sydney, New South Wales, Australia
| | - Steven Shoptaw
- Department of Family Medicine, The University of California Los Angeles, Los Angeles, California, USA
| | - Nadine Ezard
- Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
- The National Centre for Clinical Research on Emerging Drugs (NCCRED), c/o the University of New South Wales, Sydney, New South Wales, Australia
- New South Wales Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Sydney, New South Wales, Australia
| | - Krista J Siefried
- The National Drug and Alcohol Research Centre (NDARC), The University of New South Wales, Sydney, New South Wales, Australia
- Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
- The National Centre for Clinical Research on Emerging Drugs (NCCRED), c/o the University of New South Wales, Sydney, New South Wales, Australia
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Guiraud J, Spanagel R, van den Brink W. Substitution therapy for patients with alcohol dependence: Mechanisms of action and efficacy. Int Rev Neurobiol 2024; 175:187-239. [PMID: 38555116 DOI: 10.1016/bs.irn.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
New approaches for the treatment of alcohol dependence (AD) may improve patient outcomes. Substitution maintenance therapy is one of the most effective treatment options for opioid and nicotine use disorders. So far, there has been little attention to substitution therapy for the treatment of AD. Here, we explain the mechanistic foundations of alcohol substitution maintenance therapy. Alcohol has many primary targets in the brain (and other organs) and the physical interaction of ethanol molecules with these specific ethanol-sensitive sites on a variety of ionotropic receptors (e.g. GABA-A, NMDA, and nicotinic acetylcholine (nACh) receptors) and ion channels provides the rationale for substitution. As such, a variety of compounds can interact with those ethanol-sensitive sites and can thus substitute for some of the effects of alcohol. For some of these compounds, alcohol discrimination studies have shown their substitution potential. Accordingly, potential substitution treatments include agonists acting at GABA receptors such as sodium oxybate, baclofen and benzodiazepines, NMDA receptor antagonists such as ketamine and memantine, or nAChRs agonists such as varenicline. All these compounds are already approved for other indications and we present clinical evidence for these drugs in the treatment of alcohol withdrawal syndrome (AWS) and in the long-term treatment of AD, and outline future steps for their acceptance as substitution treatment in AD. Finally, we discuss the substitution approach of managed alcohol programs for the most severely affected homeless populations. Results showed that sodium oxybate is probably the closest to a substitution therapy for AD and is already approved for the treatment of AWS and in the long-term treatment of AD in some countries. In conclusion, we argue that better AD treatment can be provided if substitution maintenance treatments for alcohol are implemented at a similar scale as for opioid and nicotine use disorder.
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Affiliation(s)
- Julien Guiraud
- Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Amsterdam, The Netherlands; Vergio, Clichy, France.
| | - Rainer Spanagel
- Institute of Psychopharmacology, Central Institute of Mental Health, Heidelberg University, Mannheim, Germany
| | - Wim van den Brink
- Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Amsterdam, The Netherlands
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Cheeks SN, Buzzi B, Valdez A, Mogul AS, Damaj MI, Fowler CD. Cannabidiol as a potential cessation therapeutic: Effects on intravenous nicotine self-administration and withdrawal symptoms in mice. Neuropharmacology 2024; 246:109833. [PMID: 38176534 PMCID: PMC10958588 DOI: 10.1016/j.neuropharm.2023.109833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/21/2023] [Accepted: 12/28/2023] [Indexed: 01/06/2024]
Abstract
Cigarette smoking remains a leading cause of preventable disease and death worldwide. Due to the devastating negative health effects of smoking, many users attempt to quit, but few are successful in the long-term. Thus, there is a critical need for novel therapeutic approaches. In these investigations, we sought to examine whether cannabidiol (CBD) has the potential to be repurposed as a nicotine cessation therapeutic. In the first study, male and female mice were trained to respond for intravenous nicotine infusions at either a low or moderate nicotine dose and then were pretreated with CBD prior to their drug-taking session. We found that CBD produced a significant decrease in the number of nicotine rewards earned, and this effect was evidenced across CBD doses and with both the low and moderate levels of nicotine intake. These effects on drug intake were not due to general motor-related effects, since mice self-administering food pellets did not alter their behavior with CBD administration. The potential effects of CBD in mitigating nicotine withdrawal symptoms were then investigated. We found that CBD attenuated the somatic signs of nicotine withdrawal and prevented nicotine's hyperalgesia-inducing effects. Taken together, these results demonstrate that modulation of cannabinoid signaling may be a viable therapeutic option as a smoking cessation aid.
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Affiliation(s)
- Samantha N Cheeks
- Department of Neurobiology and Behavior, University of California Irvine, Irvine, CA, 92697, USA
| | - Belle Buzzi
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - Ashley Valdez
- Department of Neurobiology and Behavior, University of California Irvine, Irvine, CA, 92697, USA
| | - Allison S Mogul
- Department of Neurobiology and Behavior, University of California Irvine, Irvine, CA, 92697, USA
| | - M Imad Damaj
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - Christie D Fowler
- Department of Neurobiology and Behavior, University of California Irvine, Irvine, CA, 92697, USA.
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Aubin HJ. Repurposing drugs for treatment of alcohol use disorder. Int Rev Neurobiol 2024; 175:153-185. [PMID: 38555115 DOI: 10.1016/bs.irn.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Repurposing drugs for the treatment of alcohol dependence involves the use of drugs that were initially developed for other conditions, but have shown promise in reducing alcohol use or preventing relapse. This approach can offer a more cost-effective and time-efficient alternative to developing new drugs from scratch. Currently approved medications for alcohol use disorder (AUD) include acamprosate, disulfiram, naltrexone, nalmefene, baclofen, and sodium oxybate. Acamprosate was developed specifically for AUD, while disulfiram's alcohol-deterrent effects were discovered incidentally. Naltrexone and nalmefene were originally approved for opioids but found secondary applications in AUD. Baclofen and sodium oxybate were repurposed from neurological conditions. Other drugs show promise. Topiramate and zonisamide, anticonvulsants, demonstrate efficacy in reducing alcohol consumption. Another anticonvulsant, gabapentin has been disappointing overall, except in cases involving alcohol withdrawal symptoms. Varenicline, a nicotinic receptor agonist, benefits individuals with less severe AUD or concurrent nicotine use. Ondansetron, a 5-HT3 antagonist, has potential for early-onset AUD, especially when combined with naltrexone. Antipsychotic drugs like aripiprazole and quetiapine have limited efficacy. Further investigation is needed for potential repurposing of α1 adrenergic receptor antagonists prazosin and doxazosin, glucocorticoid receptor antagonist mifepristone, the phosphodiesterase inhibitor Ibudilast, the cysteine prodrug N-acetylcysteine, and the OX1R and OX2R blocker Suvorexant. This review supports repurposing drugs as an effective strategy for expanding treatment options for AUD.
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Affiliation(s)
- Henri-Jean Aubin
- Université Paris-Saclay, Inserm, CESP, Villejuif, France; AP-HP, Université Paris Saclay, Villejuif, France.
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Flores-Ramirez FJ, Illenberger JM, Pascasio G, Terenius L, Martin-Fardon R. LY2444296, a κ-opioid receptor antagonist, selectively reduces alcohol drinking in male and female Wistar rats with a history of alcohol dependence. Sci Rep 2024; 14:5804. [PMID: 38461355 PMCID: PMC10925033 DOI: 10.1038/s41598-024-56500-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 03/07/2024] [Indexed: 03/11/2024] Open
Abstract
Alcohol use disorder (AUD) remains a major public health concern. The dynorphin (DYN)/κ-opioid receptor (KOP) system is involved in actions of alcohol, particularly its withdrawal-associated negative affective states. This study tested the ability of LY2444296, a selective, short-acting, KOP antagonist, to decrease alcohol self-administration in dependent male and female Wistar rats at 8 h abstinence. Animals were trained to orally self-administer 10% alcohol (30 min/day for 21 sessions) and were made dependent via chronic intermittent alcohol vapor exposure for 6 weeks or exposed to air (nondependent). After 6 weeks, the effect of LY2444296 (0, 3, and 10 mg/kg, p.o.) was tested on alcohol self-administration at 8 h of abstinence. A separate cohort of rats was prepared in parallel, and their somatic withdrawal signs and alcohol self-administration were measured after LY2444296 administration at 8 h, 2 weeks, and 4 weeks abstinence. LY2444296 at 3 and 10 mg/kg significantly reduced physical signs of withdrawal in dependent rats at 8 h abstinence, only. Furthermore, 3 and 10 mg/kg selectively decreased alcohol self-administration in dependent rats at only 8 h abstinence. These results highlight the DYN/KOP system in actions of alcohol during acute abstinence, suggesting KOP antagonism could be beneficial for mitigating acute withdrawal signs and, in turn, significantly reduce excessive alcohol consumption associated with AUD.
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Affiliation(s)
- Francisco J Flores-Ramirez
- Department of Molecular Medicine, The Scripps Research Institute, 10550 North Torrey Pines Road, SR-107, La Jolla, CA, 92037, USA.
| | - Jessica M Illenberger
- Department of Molecular Medicine, The Scripps Research Institute, 10550 North Torrey Pines Road, SR-107, La Jolla, CA, 92037, USA
| | - Glenn Pascasio
- Department of Molecular Medicine, The Scripps Research Institute, 10550 North Torrey Pines Road, SR-107, La Jolla, CA, 92037, USA
| | - Lars Terenius
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Rémi Martin-Fardon
- Department of Molecular Medicine, The Scripps Research Institute, 10550 North Torrey Pines Road, SR-107, La Jolla, CA, 92037, USA
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Ghasemian-Yadegari J, Adineh A, Mohammadi H, Davari S, Veisani Y, Ghaneialvar H, Aidy A, Abbasi N, Karimi E. Attenuation of cannabis withdrawal symptoms by Prosopis farcta extract, its luteolin and melatonin in mice: Involvement of brain-derived neurotrophic factor and dopamine. Cell Biochem Funct 2024; 42:e3980. [PMID: 38491827 DOI: 10.1002/cbf.3980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/20/2024] [Accepted: 03/03/2024] [Indexed: 03/18/2024]
Abstract
The aim of this study was the identification of luteolin in Prosopis farcta extract (PFE) and melatonin to evaluate its effect on THC withdrawal syndrome in mice. Luteolin was identified by high-performance liquid chromatography (HPCL). Signs of toxicity of mice in PFE and luteolin were monitored for LD50 calculation. The behavioral symptoms of THC withdrawal (stereotypies, ambulation, and inactivity time) induced by the rimonabant challenge were illustrated in THC-dependent mice receiving PFE, luteolin, and melatonin. The expression of mature BDNF (mBDNF) was evaluated by Western blot analysis. The dopamine concentrations were measured using HPLC. PFE and luteolin LD50 were 650 and 220 mg/kg, respectively. PFE (300 mg/kg), all doses of luteolin, and melatonin increased significantly the mBDNF expression and decreased the dopamine concentration. The findings suggest that PFE, luteolin, and melatonin are mighty in reducing the signs of THC withdrawal. It seems these effects were due to a decrease in dopamine concentration level and an increase in mBDNF protein expression in mice brains.
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Affiliation(s)
- Javad Ghasemian-Yadegari
- Department of Pharmacognosy, School of Pharmacy, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Ahmad Adineh
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Hamidreza Mohammadi
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Shima Davari
- Department of Pharmacognosy, School of Pharmacy, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Yousef Veisani
- Research Center for Psychosocial Injuries, Ilam University of Medical Sciences, Ilam, Iran
| | - Hori Ghaneialvar
- Biotechnology and Medicinal Plants Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Ali Aidy
- Biotechnology and Medicinal Plants Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Naser Abbasi
- Biotechnology and Medicinal Plants Research Center, Ilam University of Medical Sciences, Ilam, Iran
- Department of Pharmacology, Medical School, Ilam University of Medical Sciences, Ilam, Iran
| | - Elahe Karimi
- Biotechnology and Medicinal Plants Research Center, Ilam University of Medical Sciences, Ilam, Iran
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Smith KE, Rogers JM, Sharma A, McCurdy CR, Weiss ST, Dunn KE, Feldman JD, Kuntz MA, Mukhopadhyay S, Raju KSR, Taylor RC, Epstein DH. Responses to a "Typical" Morning Dose of Kratom in People Who Use Kratom Regularly: A Direct-Observation Study. J Addict Med 2024; 18:144-152. [PMID: 38174871 PMCID: PMC10939942 DOI: 10.1097/adm.0000000000001259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
INTRODUCTION Use of kratom has outpaced systematic study of its effects, with most studies reliant on retrospective self-report. METHODS We aimed to assess acute effects following kratom use in adults who use regularly, and quantify alkaloids in the products, urine, and plasma. Between July and November 2022, 10 adults came to our clinic and orally self-administered their typical kratom dose; blinding procedures were not used. Physiological measures included blood pressure, respiratory rate, heart rate, pulse oximetry, temperature, and pupil diameter. Subjective outcomes included Subjective Opioid Withdrawal Scale, Addiction Research Center Inventory, and Drug Effects Questionnaire. Psychomotor performance was also assessed. RESULTS Participants were 6 men and 4 women, mean age 41.2 years. Nine were non-Hispanic White; 1 was biracial. They had used kratom for 6.6 years (SD, 3.8 years) on average (2.0-14.1). Sessions were 190.89 minutes on average (SD, 15.10 minutes). Mean session dose was 5.16 g (median, 4.38 g; range, 1.1-10.9 g) leaf powder. Relative to baseline, physiological changes were minor. However, pupil diameter decreased (right, b = -0.70, P < 0.01; left, b = -0.73, P < 0.01) 40-80 minutes postdose and remained below baseline >160 minutes. Subjective Opioid Withdrawal Scale pre-dosing was mild (5.5 ± 3.3) and decreased postdose (b = [-4.0, -2.9], P < 0.01). Drug Effects Questionnaire "feeling effects" increased to 40/100 (SD, 30.5) within 40 minutes and remained above baseline 80 to 120 minutes (b = 19.0, P = 0.04), peaking at 72.7/100; 6 participants rated euphoria as mild on the Addiction Research Center Inventory Morphine-Benzedrine-scale. Psychomotor performance did not reliably improve or deteriorate postdosing. CONCLUSIONS Among regular consumers, we found few clinically significant differences pre- and post-kratom dosing. Alkaloidal contents in products were within expected ranges.
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Affiliation(s)
- Kirsten E. Smith
- Real-World Assessment, Prediction, and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jeffrey M. Rogers
- San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, United States
| | - Abhisheak Sharma
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Christopher R. McCurdy
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Stephanie T. Weiss
- Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
| | - Kelly E. Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jeffrey D. Feldman
- Real-World Assessment, Prediction, and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
| | - Michelle A. Kuntz
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Sushobhan Mukhopadhyay
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Kanumuri Siva Rama Raju
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Richard C. Taylor
- Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
| | - David H. Epstein
- Real-World Assessment, Prediction, and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, United States
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Raghav JG, Kumar H, Ji L, Vemuri K, Makriyannis A, Suh J, Leonard MZ, Dang V, Ty C, Marandola S, Kane N, Witt AS, Shaqour S, Miczek KA. The neutral CB1 antagonist AM6527 reduces ethanol seeking, binge-like consumption, reinforcing, and withdrawal effects in male and female mice. Psychopharmacology (Berl) 2024; 241:427-443. [PMID: 38001264 DOI: 10.1007/s00213-023-06500-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023]
Abstract
RATIONALE Alcohol use disorder (AUD) is a debilitating physiological and psychiatric disorder which affects individuals globally. The current pharmacological interventions to treat AUD are limited, and hence there is an urgent need for a novel pharmacological therapy which can be effective and safe across the population. OBJECTIVE We aimed to investigate a novel neutral cannabinoid receptor-1 (CB1R) antagonist, AM6527, in several preclinical models of ethanol consumption using male and female C57BL6/J mice. METHODS Independent groups of male and female mice were subjected to repeated cycles of drinking in the dark (DID), or intermittent access to alcohol (IAA) procedures. Twenty minutes prior to ethanol access in each procedure, animals were treated with intraperitoneal injections of either 1, 3, and 10 mg/kg of AM6527 or its respective vehicle. Acamprosate (100, 200, 300, and 400 mg/kg) or its respective vehicle was used as a positive control. Separate groups of male mice were subjected to a chain schedule of ethanol reinforcement to gain access to ethanol wherein completion of a fixed interval (FI; 5 min) schedule (link 1: "Seeking") was reinforced with continuous access to ethanol (fixed ratio; FR1) for up to 1.8 g/kg (link 2: "consumption"). All the animals were treated with 1, 3, and 10 mg/kg of AM6527 or its respective vehicle 20 mins prior to the start of the FI chain of the procedure. Separately, AM6527 was also evaluated in male and female mice undergoing acute ethanol withdrawal following 8 weeks of intermittent or continuous access to 20% ethanol drinking. RESULTS In both DID and IAA procedures, AM6527 reduced ethanol consumption in a dose-related manner in both male and female mice. AM6527 produced no tolerance in the DID procedure; mice treated with 3 mg/kg of AM6527 for 3 weeks continuously drank significantly smaller amounts of ethanol as compared to vehicle-treated mice over a period of three DID cycles. Moreover, in the IAA procedure, AM6527 caused an increase in water intake over the 24-h period. Acamprosate transiently reduced ethanol intake in male mice in both the DID and the IAA procedures but failed to produce any significant effect in female mice. AM6527 also produced a decrease in the FI responding ("ethanol seeking") in animals trained to self-administer ethanol. Lastly, AM6527 mitigated neurological withdrawal signs, i.e., handling induced convulsions (HIC) in mice undergoing acute ethanol withdrawal. CONCLUSIONS Current findings support previous studies with CB1R neutral antagonist in reducing voluntary ethanol intake and seeking behavior. Based on results shown in this work, AM6527 can be developed as a first in class CB1R neutral antagonist to treat AUD in both males and females.
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Affiliation(s)
- Jimit Girish Raghav
- Center for Drug Discovery, Northeastern University, 360 Huntington Avenue, Boston, MA, 02115, USA
| | - Hritik Kumar
- Center for Drug Discovery, Northeastern University, 360 Huntington Avenue, Boston, MA, 02115, USA
| | - Lipin Ji
- Center for Drug Discovery, Northeastern University, 360 Huntington Avenue, Boston, MA, 02115, USA
| | - Kiran Vemuri
- Center for Drug Discovery, Northeastern University, 360 Huntington Avenue, Boston, MA, 02115, USA
| | - Alexandros Makriyannis
- Center for Drug Discovery, Northeastern University, 360 Huntington Avenue, Boston, MA, 02115, USA.
| | - Junghyup Suh
- Division of Depression and Anxiety Disorders, Department of Psychiatry, Harvard Medical School, Mclean Hospital, Belmont, MA, 02478, USA
| | - Michael Z Leonard
- Dept. of Psychology, Tufts University, 530 Boston Ave (Bacon Hall), Medford, MA, 02155, USA
| | - Vivi Dang
- Dept. of Psychology, Tufts University, 530 Boston Ave (Bacon Hall), Medford, MA, 02155, USA
| | - Chelsea Ty
- Dept. of Psychology, Tufts University, 530 Boston Ave (Bacon Hall), Medford, MA, 02155, USA
| | - Stephen Marandola
- Dept. of Psychology, Tufts University, 530 Boston Ave (Bacon Hall), Medford, MA, 02155, USA
| | - Natalie Kane
- Dept. of Psychology, Tufts University, 530 Boston Ave (Bacon Hall), Medford, MA, 02155, USA
| | - Annika S Witt
- Dept. of Psychology, Tufts University, 530 Boston Ave (Bacon Hall), Medford, MA, 02155, USA
| | - Samar Shaqour
- Dept. of Psychology, Tufts University, 530 Boston Ave (Bacon Hall), Medford, MA, 02155, USA
| | - Klaus A Miczek
- Center for Drug Discovery, Northeastern University, 360 Huntington Avenue, Boston, MA, 02115, USA.
- Dept. of Psychology, Tufts University, 530 Boston Ave (Bacon Hall), Medford, MA, 02155, USA.
- Dept. of Neuroscience, Tufts University, Boston, MA, 02111, USA.
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Chellian R, Behnood-Rod A, Bruijnzeel AW. Mifepristone decreases nicotine intake in dependent and non-dependent adult rats. J Psychopharmacol 2024; 38:280-296. [PMID: 38332661 PMCID: PMC11061865 DOI: 10.1177/02698811241230255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
BACKGROUND Addiction to tobacco and nicotine products has adverse health effects and afflicts more than a billion people worldwide. Therefore, there is an urgent need for new treatments to reduce tobacco and nicotine use. Glucocorticoid receptor blockade shows promise as a novel treatment for drug abuse and stress-related disorders. AIM These studies aim to investigate whether glucocorticoid receptor blockade with mifepristone diminishes the reinforcing properties of nicotine in rats with intermittent or daily long access to nicotine. METHODS The rats self-administered 0.06 mg/kg/inf of nicotine for 6 h per day, with either intermittent or daily access for 4 weeks before treatment with mifepristone. Daily nicotine self-administration models regular smoking, while intermittent nicotine self-administration models occasional smoking. To determine whether the rats were dependent, they were treated with the nicotinic acetylcholine receptor antagonist mecamylamine, and somatic signs were recorded. RESULTS The rats with intermittent access to nicotine had a higher level of nicotine intake per session than those with daily access but only the rats with daily access to nicotine showed signs of physical dependence. Furthermore, mecamylamine increased nicotine intake during the first hour of access in rats with daily access but not in those with intermittent access. Mifepristone decreased total nicotine intake in rats with intermittent and daily access to nicotine. Moreover, mifepristone decreased the distance traveled and rearing in the open field test and operant responding for food pellets. CONCLUSION These findings indicate that mifepristone decreases nicotine intake but this effect may be partially attributed to the sedative effects of mifepristone.
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Affiliation(s)
| | - Azin Behnood-Rod
- Department of Psychiatry, University of Florida, Gainesville, FL, USA
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Leyton M, Nikolic M. Learning from opioid withdrawal: Effects on striatal dopamine (Commentary on Ahn et al., 2023). Eur J Neurosci 2024; 59:1063-1066. [PMID: 38129315 DOI: 10.1111/ejn.16235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 12/03/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Marco Leyton
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada
- Department of Psychology, McGill University, Montreal, Quebec, Canada
- Department of Neurology & Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
- Integrated Program in Neuroscience, McGill University, Montreal, Quebec, Canada
- Center for Studies in Behavioral Neurobiology, Concordia University, Montreal, Quebec, Canada
- Research Unit on Children's Psychosocial Maladjustment, Université de Montréal, Montreal, Quebec, Canada
| | - Maja Nikolic
- Integrated Program in Neuroscience, McGill University, Montreal, Quebec, Canada
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McCullough MA, Miller PR, Martin T, Rebo KA, Stettler GR, Martin RS, Cantley M, Shilling EH, Hoth JJ, Nunn AM. Eliminating the benzos: A benzodiazepine-sparing approach to preventing and treating alcohol withdrawal syndrome. J Trauma Acute Care Surg 2024; 96:394-399. [PMID: 37934662 DOI: 10.1097/ta.0000000000004188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
BACKGROUND Alcohol withdrawal syndrome (AWS) represents significant cost to the hospitalized trauma population from a clinical and financial perspective. Historically, AWS has been managed with benzodiazepines. Despite their efficacy, benzodiazepines carry a heavy adverse effect profile. Recently, benzodiazepine-sparing protocols for the prophylaxis and treatment of AWS have been used in medical patient populations. Most existing benzodiazepine-sparing protocols use phenobarbital, while ours primarily uses gabapentin and clonidine, and no such protocol has been developed and examined for safety and efficacy specifically within a trauma population. METHODS In December of 2019, we implemented our benzodiazepine-sparing protocol for trauma patients identified at risk for alcohol withdrawal on admission. Trauma patients at risk for AWS admitted to an academic Level 1 trauma center before (conventional) and after (benzodiazepine-sparing [BS]) protocol implementation were compared. Outcomes examined include morphine milligram equivalent dosing rates and lorazepam equivalent dosing rates as well as the Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scores, hospital length of stay, intensive care unit length of stay, and ventilator days. RESULTS A total of 387 conventional and 134 benzodiazepine sparing patients were compared. Injury Severity Score (13 vs. 16, p = 0.10) and admission alcohol levels (99 vs. 149, p = 0.06) were similar. Patients in the BS pathway had a lower maximum daily CIWA-Ar (2.7 vs. 1.5, p = 0.04). While mean morphine milligram equivalent per day was not different between groups (31.5 vs. 33.6, p = 0.49), mean lorazepam equivalents per day was significantly lower in the BS group (1.1 vs. 0.2, p < 0.01). Length of stay and vent days were not different between the groups. CONCLUSION Implementation of a benzodiazepine-sparing pathway that uses primarily clonidine and gabapentin to prevent and treat alcohol withdrawal syndrome in trauma patients is safe, reduces the daily maximum CIWA-Ar, and significantly decreases the need for benzodiazepines. Future studies will focus on outcomes affected by avoiding AWS and benzodiazepines in the trauma population. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Mary Alyce McCullough
- From the Department of Surgery (M.A.M., P.R.M., T.M., G.R.S., R.S.M., E.H.S., J.J.H., A.M.N.), and Department of Acute Care Pharmacy (K.A.R.), Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC; and Department of Clinical Pharmacy (M.C.), Virginia Commonwealth University Health, Richmond, VA
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Fleenor LM, Beavers JR, Tidwell WP, Atchison L, Woo E, Medvecz AJ, Beyene RT, Kast K, Marcovitz D, Dennis BM, Guillamondegui OD, Smith MC. Comparison of phenobarbital monotherapy to a benzodiazepine-based regimen for management of alcohol withdrawal syndrome in trauma patients. J Trauma Acute Care Surg 2024; 96:493-498. [PMID: 37599414 DOI: 10.1097/ta.0000000000004116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
BACKGROUND Alcohol withdrawal syndrome (AWS) is associated with increased morbidity and mortality in the trauma population. Benzodiazepines (BZDs) are standard of care for AWS; however, given the risk of delirium with BZDs and reports of BZD-refractory withdrawal, phenobarbital (PHB) has emerged as an alternative therapy for AWS. Safety and efficacy studies of PHB for AWS in trauma patients are lacking. Our aim was to compare a BZD versus PHB protocol in the management of AWS in trauma patients. METHODS We performed a retrospective cohort study at a level 1 trauma center of patients at risk for AWS managed with either a BZD or a low-dose oral PHB regimen. Patients were excluded if they were taking BZDs or barbiturates before admission, received propofol or dexmedetomidine before initiation of the study drug, presented with delirium tremens or seizures, or died or discharged within 24 hours of presentation. The primary outcome was complicated AWS (seizures or alcohol withdrawal delirium/delirium tremens). Secondary outcomes included uncomplicated AWS; therapy escalation; oversedation; delirium-, intensive care unit-, and ventilator-free days; and length of stay. RESULTS A total of 411 patients were identified; 118 received BZD, and 293 received PHB. The odds of developing complicated AWS with PHB versus BZD-based therapy were not statistically significant (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.21-1.39); however, patients receiving PHB were less likely to develop uncomplicated AWS (OR, 0.08; 95% CI, 0.04-0.14) and less likely to require escalation of therapy (OR, 0.45; 95% CI, 0.24-0.84). The PHB group had a length of stay 3.1 days shorter than the BZD group ( p = 0.002). There was no difference in intensive care unit-, ventilator-, or delirium-free days. CONCLUSION A PHB-based protocol for the management of AWS is a safe and effective alternative to BZD-based regimens in trauma patients. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Lori Montana Fleenor
- From the Department of Pharmaceutical Sciences (L.M.F., W.P.T., L.A.), Department of Pharmaceutical Sciences (J.R.B.), Department of Pharmacy Portfolio in HealthIT (E.W.), Division of Acute Care Surgery (A.J.M., R.T.B., B.M.D., O.D.G., M.C.S.), and Department of Psychiatry and Behavioral Sciences (K.K., D.M.), Vanderbilt University Medical Center, Nashville, Tennessee
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Sadek SM, Khatri SN, Kipp Z, Dunn KE, Beckmann JS, Stoops WW, Hinds TD, Gipson CD. Impacts of xylazine on fentanyl demand, body weight, and acute withdrawal in rats: A comparison to lofexidine. Neuropharmacology 2024; 245:109816. [PMID: 38128606 PMCID: PMC10843705 DOI: 10.1016/j.neuropharm.2023.109816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/05/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023]
Abstract
The opioid use landscape has recently shifted to include xylazine, a veterinary anesthetic, as an adulterant in the fentanyl supply. The health impacts of xylazine as an emerging fentanyl adulterant has raised alarm regarding xylazine as a public health threat, warranting research on the impacts of xylazine on fentanyl's behavioral effects. No prior studies have evaluated the effects of xylazine on fentanyl consumption at various unit doses, fentanyl demand, or withdrawal as compared to the Food and Drug Administration-approved opioid withdrawal medication, lofexidine (Lucemyra®). This is important because lofexidine and xylazine are both adrenergic α2a (A2aR) agonists, however, lofexidine is not a noted fentanyl adulterant. Here we evaluated xylazine and lofexidine combined with self-administered fentanyl doses in male and female rats and evaluated fentanyl demand, body weight, and acute withdrawal. Consumption of fentanyl alone increased at various unit doses compared to saline. Xylazine but not lofexidine shifted fentanyl consumption downward at a number of unit doses, however, both lofexidine and xylazine suppressed fentanyl demand intensity as compared to a fentanyl alone control group. Further, both fentanyl + lofexidine and fentanyl + xylazine reduced behavioral signs of fentanyl withdrawal immediately following SA, but signs increased by 12 h only in the xylazine co-exposed group. Weight loss occurred throughout fentanyl SA and withdrawal regardless of group, although the xylazine group lost significantly more weight during the first 24 h of withdrawal than the other two groups. Severity of weight loss during the first 24 h of withdrawal was also correlated with severity of somatic signs of fentanyl withdrawal. Together, these results suggest that body weight loss may be an important indicator of withdrawal severity during acute withdrawal from the xylazine/fentanyl combination, warranting further translational evaluation.
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Affiliation(s)
- Safiyah M Sadek
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
| | - Shailesh N Khatri
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
| | - Zachary Kipp
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
| | - Kelly E Dunn
- Psychiatry and Behavioral Sciences Department, Johns Hopkins University, Baltimore, MD, USA
| | - Joshua S Beckmann
- Department of Psychology, University of Kentucky, Lexington, KY, USA
| | - William W Stoops
- Department of Behavioral Sciences, University of Kentucky, Lexington, KY, USA
| | - Terry D Hinds
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
| | - Cassandra D Gipson
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA.
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Kaufman MJ, Meloni EG, Qrareya AN, Paronis CA, Bogin V. Effects of inhaled low-concentration xenon gas on naltrexone-precipitated withdrawal symptoms in morphine-dependent mice. Drug Alcohol Depend 2024; 255:110967. [PMID: 38150894 PMCID: PMC10841182 DOI: 10.1016/j.drugalcdep.2023.110967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Opioid withdrawal symptoms (OWS) are highly aversive and prompt unprescribed opioid use, which increases morbidity, mortality, and, among individuals being treated for opioid use disorder (OUD), recurrence. OWS are driven by sympathetic nervous system (SNS) hyperactivity that occurs when blood opioid levels wane. We tested whether brief inhalation of xenon gas, which inhibits SNS activity and is used clinically for anesthesia and diagnostic imaging, attenuates naltrexone-precipitated withdrawal-like signs in morphine-dependent mice. METHODS Adult CD-1 mice were implanted with morphine sulfate-loaded (60 mg/ml) minipumps and maintained for 6 days to establish morphine dependence. On day 7, mice were given subcutaneous naltrexone (0.3 mg/kg) and placed in a sealed exposure chamber containing either 21% oxygen/balance nitrogen (controls) or 21% oxygen/added xenon peaking at 30%/balance nitrogen. After 10 minutes, mice were transferred to observation chambers and videorecorded for 45 minutes. Videos were scored in a blind manner for morphine withdrawal behaviors. Data were analyzed using 2-way ANOVAs testing for treatment and sex effects. RESULTS AND CONCLUSIONS Xenon-exposed mice exhibited fewer jumps (P = 0.010) and jumping suppression was detectible within the first 10-minute video segment, but no sex differences were detected. Brief inhalation of low concentration xenon rapidly and substantially attenuated naltrexone-precipitated jumping in morphine-dependent mice, suggesting that it can inhibit OWS. If xenon effects translate to humans with OUD, xenon inhalation may be effective for reducing OWS, unprescribed opioid use, and for easing OUD treatment initiation, which could help lower excess morbidity and mortality associated with OUD.
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Affiliation(s)
- Marc J Kaufman
- Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, MA 02478, USA.
| | - Edward G Meloni
- Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, MA 02478, USA
| | - Alaa N Qrareya
- University of Mississippi School of Pharmacy, Faser Hall Room 331, University, MS 38677, USA
| | - Carol A Paronis
- Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, MA 02478, USA
| | - Vlad Bogin
- Nobilis Therapeutics, Inc., US Bancorp Tower, 111 S.W. Fifth Avenue, Suite 3150, Portland, OR 97204, USA
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Treiber MC, Grünberger J, Vyssoki B, Szeles JC, Kaniusas E, Kampusch S, Stöhr H, Walter H, Lesch OM, König D, Kraus C. Pupillary response to percutaneous auricular vagus nerve stimulation in alcohol withdrawal syndrome: A pilot trial. Alcohol 2024; 114:61-68. [PMID: 37661002 DOI: 10.1016/j.alcohol.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 08/19/2023] [Accepted: 08/20/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Autonomic symptoms in alcohol withdrawal syndrome (AWS) are associated with a sympathetic-driven imbalance of the autonomic nervous system. To restore autonomic balance in AWS, novel neuromodulatory approaches could be beneficial. We conducted a pilot trial with percutaneous auricular vagus nerve stimulation (pVNS) in AWS and hypothesized that pVNS will enhance the parasympathetic tone represented by a reduction of pupillary dilation in a parasympatholytic pharmacological challenge. METHODS Thirty patients suffering from alcohol use disorder, undergoing AWS, and stable on medication, were recruited in this open-label, single-arm pilot trial with repeated-measure design. Peripheral VNS (monophasic volt impulses of 1 msec, alternating polarity, frequency 1 Hz, amplitude 4 mV) was administered at the left cymba conchae for 72 h, followed by pupillometry under a tropicamide challenge. We assessed craving with a visual analog scale. We used pupillary mean as the dependent variable in a repeated-measures ANOVA (rmANOVA). RESULTS A repeated-measures ANOVA resulted in a significant difference for pupillary diameter across time and condition (F(2,116) = 27.97, p < .001, ηp2 > .14). Tukey-adjusted post hoc analysis revealed a significant reduction of pupillary diameter after pVNS. Alcohol craving was significantly reduced after pVNS (p < .05, Cohen's d = 1.27). CONCLUSION Our study suggests that pVNS activates the parasympathetic nervous system in patients with acute AWS, and that this activation is measurable by pupillometry. To this end, pVNS could be beneficial as a supportive therapy for AWS. Potential confounding effects of anti-craving treatment should be kept in mind.
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Affiliation(s)
- M C Treiber
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Medical University of Vienna, Austria.
| | - J Grünberger
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Medical University of Vienna, Austria
| | - B Vyssoki
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Medical University of Vienna, Austria
| | - J C Szeles
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Austria
| | - E Kaniusas
- Institute of Biomedical Electronics, Vienna University of Technology, Austria
| | | | - H Stöhr
- Faculty of Computer Science, University of Vienna, Austria
| | - H Walter
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Medical University of Vienna, Austria
| | - O M Lesch
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Medical University of Vienna, Austria
| | - D König
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Medical University of Vienna, Austria
| | - C Kraus
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Medical University of Vienna, Austria
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Takamine L, Krein SL, Ratliff E, Strominger J, Virk A, Maust DT. Examining Adult Patients' Success with Discontinuing Long-term Benzodiazepine Use: a Qualitative Study. J Gen Intern Med 2024; 39:247-254. [PMID: 37653209 PMCID: PMC10853089 DOI: 10.1007/s11606-023-08385-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/18/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Little is known about patients' experiences with benzodiazepine (BZD) discontinuation, which is thought to be challenging given the physiological and psychological dependence and accompanying potential for significant withdrawal symptoms. The marked decline in BZD prescribing over the past decade in the US Department of Veterans Affairs healthcare system presents an important opportunity to examine the experience of BZD discontinuation among long-term users. OBJECTIVE Examine the experience of BZD discontinuation among individuals prescribed long-term BZD treatment to identify factors that contributed to successful discontinuation. DESIGN Descriptive qualitative analysis of semi-structured interviews conducted between April and December of 2020. PARTICIPANTS A total of 21 Veterans who had been prescribed long-term BZD pharmacotherapy (i.e., > 120 days of exposure in a 12-month period) and had their BZD discontinued. APPROACH We conducted semi-structured interviews with Veteran participants to learn about their BZD use and the process of discontinuation, with interviews recorded and transcribed verbatim. Data were deductively and inductively coded and coded text entered into a matrix to identify factors that contributed to successful BZD discontinuation. KEY RESULTS The mean age of interview participants was 63.0 years (standard deviation 3.9); 94.2% were male and 76.2% were white. Of 21 participants, only 1 had resumed BZD treatment (prescribed by a non-VA clinician). Three main factors influenced success with discontinuation: (1) participants' attitudes toward BZDs (e.g., risks of long-term use, perceived lack of efficacy, potential for dependence); (2) limited withdrawal symptoms; and (3) effective alternatives, either from their clinician (e.g., medication, psychotherapy) or identified by participants. CONCLUSIONS BZD discontinuation after long-term use is relatively well tolerated, and participants appreciated reducing their medication exposure, particularly to one associated with physical dependence. These findings may help reduce both patient and clinician anxiety related to BZD discontinuation.
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Affiliation(s)
- Linda Takamine
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI, USA.
| | - Sarah L Krein
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Erika Ratliff
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Julie Strominger
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI, USA
| | - Amarra Virk
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, FL, USA
| | - Donovan T Maust
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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Wani A, Prabhakar B, Shende P. Competitive inhibition of nicotine acetylcholine receptors using microneedles of nicotine and varenicline for smoking withdrawal therapy. Eur J Pharm Biopharm 2024; 195:114171. [PMID: 38159871 DOI: 10.1016/j.ejpb.2023.114171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 09/25/2023] [Accepted: 12/18/2023] [Indexed: 01/03/2024]
Abstract
Current strategies for smoking withdrawal conditions involve monotherapy of nicotine and combinational therapy of nicotine with varenicline or bupropion as per the CDC and FDA. The available dosage forms for nicotine are patches, gums, inhalers and nasal sprays, bupropion and varenicline are available in tablet form. This research work focused on developing a microneedle delivery system to deliver combination drug for overcoming the obstacles encountered by oral route of administration of varenicline such as severe side effects (mood swings, agitation, depressed behaviour, seizures, etc), and nicotine therapy challenges such as short half-life, repeated dosing, nausea, and vomiting. The nanoparticles of nicotine prepared by nanoprecipitation method showed particle size PTZ (356.6 ± 65.98), percentage entrapment efficiency (35.55 % ± 0.007), in-vitro drug release (47.89 % ± 0.7) for 72 h. Microneedles showed height (600 μm), width (350 μm), and tip diameter (10 μm). The nanoparticles encapsulated in microneedles showed in-vitro sustained delivery of nicotine (67.00 % ± 4.92) and varenicline (79.78 % ± 1.09) in 48 h. Nicotine released in a sustained manner attaches to the nicotine acetylcholine receptors (nAchR) to release dopamine for controlling the withdrawal challenges such as anxiety, irritability, cravings, disturbed sleep pattern, etc. The varenicline released from microneedles binds to the nAchR and inhibits dopamine release responsible for the euphoric effect induced by nicotine, and thus assists in curbing the nicotine withdrawal symptoms. This combination microneedle system offers prolonged treatment in a single application for smoking withdrawal conditions wherein patients are not in stage of oral dosing because of repeated dosing resulting in adverse effects like seizures, hypertension, sleep disturbances, insomnia, and nausea.
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Affiliation(s)
- Ashwini Wani
- Shobhaben Pratapbhai Patel School of Pharmacy and Technology Management, SVKM'S NMIMS, V. L. Mehta Road, Vile Parle (W), Mumbai, India
| | - Bala Prabhakar
- Shobhaben Pratapbhai Patel School of Pharmacy and Technology Management, SVKM'S NMIMS, V. L. Mehta Road, Vile Parle (W), Mumbai, India
| | - Pravin Shende
- Shobhaben Pratapbhai Patel School of Pharmacy and Technology Management, SVKM'S NMIMS, V. L. Mehta Road, Vile Parle (W), Mumbai, India.
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Hastings LE, Frye EV, Carlson ER, Chuong V, Matthews AN, Koob GF, Vendruscolo LF, Marchette RCN. Cold nociception as a measure of hyperalgesia during spontaneous heroin withdrawal in mice. Pharmacol Biochem Behav 2024; 235:173694. [PMID: 38128767 PMCID: PMC10842911 DOI: 10.1016/j.pbb.2023.173694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023]
Abstract
Opioids are powerful analgesic drugs that are used clinically to treat pain. However, chronic opioid use causes compensatory neuroadaptations that result in greater pain sensitivity during withdrawal, known as opioid withdrawal-induced hyperalgesia (OWIH). Cold nociception tests are commonly used in humans, but preclinical studies often use mechanical and heat stimuli to measure OWIH. Thus, further characterization of cold nociception stimuli is needed in preclinical models. We assessed three cold nociception tests-thermal gradient ring (5-30 °C, 5-50 °C, 15-40 °C, and 25-50 °C), dynamic cold plate (4 °C to -1 °C at -1 °C/min, -1 °C to 4 °C at +1 °C/min), and stable cold plate (10 °C, 6 °C, and 2 °C)-to measure hyperalgesia in a mouse protocol of heroin dependence. On the thermal gradient ring, mice in the heroin withdrawal group preferred warmer temperatures, and the results depended on the ring's temperature range. On the dynamic cold plate, heroin withdrawal increased the number of nociceptive responses, with a temperature ramp from 4 °C to -1 °C yielding the largest response. On the stable cold plate, heroin withdrawal increased the number of nociceptive responses, and a plate temperature of 2 °C yielded the most significant increase in responses. Among the three tests, the stable cold plate elicited the most robust change in behavior between heroin-dependent and nondependent mice and had the highest throughput. To pharmacologically characterize the stable cold plate test, we used μ-opioid and non-opioid receptor-targeting drugs that have been previously shown to reverse OWIH in mechanical and heat nociception assays. The full μ-opioid receptor agonist methadone and μ-opioid receptor partial agonist buprenorphine decreased OWIH, whereas the preferential μ-opioid receptor antagonist naltrexone increased OWIH. Two N-methyl-d-aspartate receptor antagonists (ketamine, MK-801), a corticotropin-releasing factor 1 receptor antagonist (R121919), a β2-adrenergic receptor antagonist (butoxamine), an α2-adrenergic receptor agonist (lofexidine), and a 5-hydroxytryptamine-3 receptor antagonist (ondansetron) had no effect on OWIH. These data demonstrate that the stable cold plate at 2 °C yields a robust, reliable, and concise measure of OWIH that is sensitive to opioid agonists.
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Affiliation(s)
- Lyndsay E Hastings
- Neurobiology of Addiction Section, Integrative Neuroscience Research Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, USA
| | - Emma V Frye
- Neurobiology of Addiction Section, Integrative Neuroscience Research Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, USA
| | - Erika R Carlson
- Neurobiology of Addiction Section, Integrative Neuroscience Research Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, USA
| | - Vicky Chuong
- Neurobiology of Addiction Section, Integrative Neuroscience Research Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, USA; Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, Translational Addiction Medicine Branch, National Intitute on Drug Abuse, Intramural Research Program, and National Institute on Alcohol Abuse and Alcoholism, Division of Intramural Clinical and Biological Research, Baltimore, MD, USA
| | - Aniah N Matthews
- Neurobiology of Addiction Section, Integrative Neuroscience Research Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, USA
| | - George F Koob
- Neurobiology of Addiction Section, Integrative Neuroscience Research Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, USA
| | - Leandro F Vendruscolo
- Stress and Addiction Neuroscience Unit, Integrative Neuroscience Research Branch, National Institute on Drug Abuse, Intramural Research Program, and National Institute on Alcohol Abuse and Alcoholism, Division of Intramural Clinical and Biological Research, Baltimore, MD, USA
| | - Renata C N Marchette
- Neurobiology of Addiction Section, Integrative Neuroscience Research Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, USA.
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Mezzadri L. Screening for Alcohol Use Disorder and Management of Alcohol Withdrawal Syndrome in Critical Care Patients. Crit Care Nurse 2024; 44:46-54. [PMID: 38295866 DOI: 10.4037/ccn2024423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2024]
Abstract
BACKGROUND Evidence-based research indicates that subjective questionnaires should be eliminated in screening for alcohol use disorder and management of alcohol withdrawal syndrome in critical care patients. However, transitioning clinicians away from these screening tools remains challenging. OBJECTIVE To improve screening for alcohol use disorder and management of alcohol withdrawal syndrome in the critical care setting by implementing an evidence-based alcohol use disorder screening tool and alcohol withdrawal syndrome protocol for critical care patients. METHODS The project site was a 17-bed adult medical intensive care unit in a large, southeastern US teaching hospital. Interventions consisted of the elimination of previously used tools such as the Clinical Institute Withdrawal Assessment for Alcohol-Revised and implementation of the Prediction of Alcohol Withdrawal Severity Scale for alcohol use disorder screening and the Richmond Agitation-Sedation Scale and symptom-triggered benzodiazepine administration for alcohol withdrawal syndrome management. RESULTS Alcohol use disorder screening among the critical care patient population increased by 49% from before to after the intervention. Of the patients at risk for withdrawal, 79% had an order for monitoring with the new intensive care unit alcohol withdrawal protocol in the postintervention group, compared with 35% who had an order for monitoring with the Clinical Institute Withdrawal Assessment for Alcohol-Revised in the preintervention group. CONCLUSION The elimination of previously used tools and the implementation of the Prediction of Alcohol Withdrawal Severity Scale and the new intensive care unit alcohol withdrawal protocol improved alcohol use disorder screening and alcohol withdrawal syndrome management among critical care patients.
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Affiliation(s)
- Lindsay Mezzadri
- Lindsay Mezzadri is a nurse practitioner at the Medical University of South Carolina, Charleston, South Carolina
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Ratner JA, Blaney H, Rastegar DA. Management of alcohol withdrawal syndrome in patients with alcohol-associated liver disease. Hepatol Commun 2024; 8:e0372. [PMID: 38251886 PMCID: PMC10805424 DOI: 10.1097/hc9.0000000000000372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/13/2023] [Indexed: 01/23/2024] Open
Abstract
Alcohol-associated liver disease is a common and severe sequela of excessive alcohol use; effective treatment requires attention to both liver disease and underlying alcohol use disorder (AUD). Alcohol withdrawal syndrome (AWS) can be dangerous, is a common barrier to AUD recovery, and may complicate inpatient admissions for liver-related complications. Hepatologists can address these comorbid conditions by learning to accurately stage alcohol-associated liver disease, identify AUD using standardized screening tools (eg, Alcohol Use Disorder Identification Test), and assess risk for and symptoms of AWS. Depending on the severity, alcohol withdrawal often merits admission to a monitored setting, where symptom-triggered administration of benzodiazepines based on standardized scoring protocols is often the most effective approach to management. For patients with severe liver disease, selection of benzodiazepines with less dependence on hepatic metabolism (eg, lorazepam) is advisable. Severe alcohol withdrawal often requires a "front-loaded" approach with higher dosing, as well as intensive monitoring. Distinguishing between alcohol withdrawal delirium and HE is important, though it can be difficult, and can be guided by differentiating clinical characteristics, including time to onset and activity level. There is little data on the use of adjuvant medications, including anticonvulsants, dexmedetomidine, or propofol, in this patient population. Beyond the treatment of AWS, inpatient admission and outpatient hepatology visits offer opportunities to engage in planning for ongoing management of AUD, including initiation of medications for AUD and referral to additional recovery supports. Hepatologists trained to identify AUD, alcohol-associated liver disease, and risk for AWS can proactively address these issues, ensuring that patients' AWS is managed safely and effectively and supporting planning for long-term recovery.
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Affiliation(s)
- Jessica A. Ratner
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Hanna Blaney
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Darius A. Rastegar
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Gauer RL, Abellada A, Stewart M, Kozloski R. Managing Selected Chronic Conditions in Hospitalized Patients. Am Fam Physician 2024; 109:134-142. [PMID: 38393797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
The management of chronic illnesses should continue during hospitalization. Some chronic conditions require immediate intervention, whereas intensification of therapy for other conditions may be delayed until after discharge. Factors such as pain, anxiety, poor sleep hygiene, and concurrent illness can result in a transient elevation of blood pressure. Acute lowering of blood pressure in hospitalized patients who do not have target-organ damage is not recommended and may lead to harm. If treatment is needed, intravenous antihypertensive agents should be avoided. Patients with diabetes mellitus require continued management of their blood glucose while hospitalized. Noninsulin agents are typically discontinued. Blood glucose levels should be managed using basal, prandial, and/or correction insulin. During hospitalization, conservative blood glucose targets (140 to 180 mg per dL) are preferred vs. lower targets to reduce length of stay, mortality, and the risk of hypoglycemic events in critically ill patients. Alcohol use disorder is common and hospitalization for other conditions necessitates identification and management of alcohol withdrawal syndrome. The mainstay of therapy for alcohol withdrawal syndrome is benzodiazepines; however, phenobarbital is an alternative treatment option. The risk of venous thromboembolic disease is significantly increased for hospitalized patients. Venous thromboprophylaxis is recommended for all but low-risk patients. Pharmacologic prophylaxis with subcutaneous low-molecular-weight heparin is preferred; mechanical prophylaxis is an alternative for patients who are at high risk of bleeding or have contraindications to anticoagulation.
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Affiliation(s)
- Robert L Gauer
- Womack Army Medical Center, Fort Liberty, North Carolina; Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Alain Abellada
- Womack Army Medical Center, Fort Liberty, North Carolina
| | | | - Ryan Kozloski
- Womack Army Medical Center, Fort Liberty, North Carolina
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Lee HJ, Ortiz DM, Sayson LV, Kim M, Cheong JH, Kim HJ. Ameliorating effects of Acanthopanax koreanum extract and components on nicotine dependence and withdrawal symptoms. Addict Biol 2024; 29:e13360. [PMID: 38380695 PMCID: PMC10898842 DOI: 10.1111/adb.13360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 09/22/2023] [Accepted: 11/17/2023] [Indexed: 02/22/2024]
Abstract
Tobacco smoking is a serious health problem in society. While smoking rates are declining, smoking remains a serious risk to national health. Currently, there are several medications available to aid in smoking cessation. However, these medications have the disadvantages of low success rates in smoking cessation and various side effects. Therefore, natural-based smoking cessation aids are being suggested as a good alternative due to their accessibility and minimal side effects. The roots and stems of Acanthopanax koreanum (AK) Nakai, a plant that is native to Jeju Island, South Korea, have traditionally been used as tonic and sedatives. Moreover, eleutheroside B and chlorogenic acid are the main components of AK stem extract. In the present study, we investigated the effect of 70% ethanol AK extract and its components on ameliorating nicotine dependence and withdrawal symptoms by using behavioural tests in mice. In addition, alterations in the dopaminergic and DRD1-EPAC-ERK-CREB pathways were observed using dopamine ELISA and western blotting using mouse brains. Our findings demonstrate that the AK extract and its components effectively mitigated the effects of nicotine treatment in behavioural tests. Furthermore, it normalized the dopamine concentration and the expression level of nicotine acetylcholine receptor α7. Additionally, it was observed that AK extract and its components led to the normalization of DRD1, ERK and CREB expression levels. These results indicate that AK extract exhibits effects in ameliorating nicotine dependence behaviour and alleviating withdrawal symptoms. Moreover, EB and CGA are considered potential marker components of AK extract.
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Affiliation(s)
- Hyun Jun Lee
- Uimyung Research Institute for Neuroscience, Department of PharmacySahmyook UniversitySeoulRepublic of Korea
| | - Darlene Mae Ortiz
- Uimyung Research Institute for Neuroscience, Department of PharmacySahmyook UniversitySeoulRepublic of Korea
| | - Leandro Val Sayson
- Uimyung Research Institute for Neuroscience, Department of PharmacySahmyook UniversitySeoulRepublic of Korea
| | - Mikyung Kim
- Uimyung Research Institute for Neuroscience, Department of PharmacySahmyook UniversitySeoulRepublic of Korea
- Department of Chemistry & Life ScienceSahmyook UniversitySeoulRepublic of Korea
| | - Jae Hoon Cheong
- School of PharmacyJeonbuk National UniversityJeonjuRepublic of Korea
| | - Hee Jin Kim
- Uimyung Research Institute for Neuroscience, Department of PharmacySahmyook UniversitySeoulRepublic of Korea
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