1
|
Paino M, Aletraris L, Roman PM. The use of off-label medications in substance abuse treatment programs. Subst Abus 2019; 41:340-346. [PMID: 31361567 DOI: 10.1080/08897077.2019.1635962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background: Substance use disorder (SUD) treatment centers serve a population of clients who have diverse needs, and may desire or require access to varied treatments while seeking care for their SUDs. While pharmacotherapies have increased in popularity for the treatment of SUDs, adoption rates do remain quite low. But a wider array of pharmacotherapies has become available in recent years which may shift the trend. This article helps shed light on how variations in SUD treatment centers develop and persist with regard to the adoption and delivery of off-label medications. Methods: We use a nationally representative and longitudinal sample of SUD treatment centers in the US (N = 196). We use a logistic regression to analyze the relationship between organizational characteristics and offering any medications, off-label. We also use a negative binomial regression to analyze the relationship between organizational characteristics and the number of medications that were used off-label. Results: Our findings reveal that older centers, accredited centers, and centers that offer mental health screenings are all positively associated with the provision of off-label medication in SUD treatment. We also find a positive relationship between private funding and offering a greater number of off-label medications. Conclusions: Our results suggest that SUD clients who seek treatment from centers that offer medications off-label, may have access to a greater number of medication-assisted treatment options.
Collapse
Affiliation(s)
- Maria Paino
- Department of Sociology, Anthropology, Social Work, and Criminal Justice, Oakland University, Rochester, Michigan, USA
| | - Lydia Aletraris
- Owens Institute for Behavioral Research, University of Georgia, Athens, Georgia, USA
| | - Paul M Roman
- Owens Institute for Behavioral Research, University of Georgia, Athens, Georgia, USA
| |
Collapse
|
2
|
Pierce RC, Fant B, Swinford-Jackson SE, Heller EA, Berrettini WH, Wimmer ME. Environmental, genetic and epigenetic contributions to cocaine addiction. Neuropsychopharmacology 2018; 43:1471-1480. [PMID: 29453446 PMCID: PMC5983541 DOI: 10.1038/s41386-018-0008-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 12/21/2017] [Accepted: 12/30/2017] [Indexed: 12/13/2022]
Abstract
Decades of research on cocaine has produced volumes of data that have answered many important questions about the nature of this highly addictive drug. Sadly, none of this information has translated into the development of effective therapies for the treatment of cocaine addiction. This review endeavors to assess the current state of cocaine research in an attempt to identify novel pathways for therapeutic development. For example, risk of cocaine addiction is highly heritable but genome-wide analyses comparing cocaine-dependent individuals to controls have not resulted in promising targets for drug development. Is this because the genetics of addiction is too complex or because the existing research methodologies are inadequate? Likewise, animal studies have revealed dozens of enduring changes in gene expression following prolonged exposure to cocaine, none of which have translated into therapeutics either because the resulting compounds were ineffective or produced intolerable side-effects. Recently, attention has focused on epigenetic modifications resulting from repeated cocaine intake, some of which appear to be heritable through changes in the germline. While epigenetic changes represent new vistas for therapeutic development, selective manipulation of epigenetic marks is currently challenging even in animals such that translational potential is a distant prospect. This review will reveal that despite the enormous progress made in understanding the molecular and physiological bases of cocaine addiction, there is much that remains a mystery. Continued advances in genetics and molecular biology hold potential for revealing multiple pathways toward the development of treatments for the continuing scourge of cocaine addiction.
Collapse
Affiliation(s)
- R. Christopher Pierce
- 0000 0004 1936 8972grid.25879.31Department of Psychiatry, Center for Neurobiology and Behavior, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Bruno Fant
- 0000 0004 1936 8972grid.25879.31Department of Psychiatry, Center for Neurobiology and Behavior, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Sarah E. Swinford-Jackson
- 0000 0004 1936 8972grid.25879.31Department of Psychiatry, Center for Neurobiology and Behavior, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Elizabeth A. Heller
- 0000 0004 1936 8972grid.25879.31Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Wade H. Berrettini
- 0000 0004 1936 8972grid.25879.31Department of Psychiatry, Center for Neurobiology and Behavior, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Mathieu E. Wimmer
- 0000 0001 2248 3398grid.264727.2Department of Psychology, Temple University, Philadelphia, PA 19122 USA
| |
Collapse
|
3
|
Sheng Y, Filichia E, Shick E, Preston KL, Phillips KA, Cooperman L, Lin Z, Tesar P, Hoffer B, Luo Y. Using iPSC-derived human DA neurons from opioid-dependent subjects to study dopamine dynamics. Brain Behav 2016; 6:e00491. [PMID: 27547496 PMCID: PMC4884574 DOI: 10.1002/brb3.491] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/09/2016] [Accepted: 04/13/2016] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION The dopaminergic (DA) system plays important roles in addiction. However, human DA neurons from drug-dependent subjects were not available for study until recent development in inducible pluripotent stem cells (iPSCs) technology. METHODS In this study, we produced DA neurons differentiated using iPSCs derived from opioid-dependent and control subjects carrying different 3' VNTR (variable number tandem repeat) polymorphism in the human dopamine transporter (DAT or SLC6A3). In addition, the effects of valproic acid (VPA) exposures on iPSC-derived human DA neurons are also examined. RESULTS We present the first evidence suggesting that the 3' VNTR polymorphism in the hDAT gene affects DAT expression level in iPSC-derived human DA neurons. In human DA neurons, which provide an appropriate cellular milieu, VPA treatment alters the expression of several genes important for dopaminergic neuron function including DAT, Nurr1, and TH; this might partly explain its action in regulating addictive behaviors. VPA treatment also significantly increased DA D2 receptor (Drd2) expression, especially in the opioid-dependent iPSC cell lines. CONCLUSIONS Our data suggest that human iPSC-derived DA neurons may be useful in in vitro experimental model to examine the effects of genetic variation in gene regulation, to examine the underlying mechanisms in neurological disorders including drug addiction, and to serve as a platform for therapeutic development.
Collapse
Affiliation(s)
- Yang Sheng
- Department of Neurological Surgery Case Western Reserve University Cleveland Ohio 44106
| | - Emily Filichia
- Department of Neurological Surgery Case Western Reserve University Cleveland Ohio 44106
| | - Elizabeth Shick
- Department of Genetics Case Western Reserve University Cleveland Ohio 44106
| | - Kenzie L Preston
- National Institute on Drug Abuse Intramural Research Program Baltimore Maryland 21224
| | - Karran A Phillips
- National Institute on Drug Abuse Intramural Research Program Baltimore Maryland 21224
| | - Leslie Cooperman
- Department of Genetics Case Western Reserve University Cleveland Ohio 44106
| | - Zhicheng Lin
- Department of Psychiatry Mclean Hospital Harvard University Belmont Massachusetts 02478
| | - Paul Tesar
- Department of Genetics Case Western Reserve University Cleveland Ohio 44106
| | - Barry Hoffer
- Department of Neurological Surgery Case Western Reserve University Cleveland Ohio 44106
| | - Yu Luo
- Department of Neurological Surgery Case Western Reserve University Cleveland Ohio 44106
| |
Collapse
|
4
|
Abstract
Individuals suffering from drug addiction may also manifest features of bipolar spectrum disorders. Hyperthymic and cyclothymic temperaments may render individuals vulnerable to later development of substance abuse. Bipolar disorders themselves may be altered or precipitated by substance use, most notably by stimulants (amphetamines), alcohol, and cannabinoids. The clinical usefulness of mood stabilizers, particularly antiepileptics, has been established as safe and effective in substance abusers with and without comorbid mood disorders. Most studies on this issue have been of short duration and focused on the resolution of a currently manifest period of illness. Few studies have been conducted on the usefulness of these drugs on the long-term longitudinal course of these diseases, such as frequently encountered recurrent relapses into states of agitation, impulsivity, and/or dissatisfaction. As opposed to the clinical experience with traditional antidepressants and neuroleptics, antiepileptics do not induce counter-polar states (depressed patients abruptly turning manic or hypomanic; nor patients currently hypomanic or manic turning abruptly depressed). Many clinicians consider antiepileptic mood stabilizers to be the preferred category of medications for the treatment of such patients. Valproate appears to be a potentially fruitful medication to study in these dual diagnosis patients due to preliminary evidence demonstrating its anticraving efficacy.
Collapse
|
5
|
Edens E, Massa A, Petrakis I. Novel pharmacological approaches to drug abuse treatment. Curr Top Behav Neurosci 2010; 3:343-86. [PMID: 21161760 DOI: 10.1007/7854_2009_29] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The field of pharmacologic addiction treatment is expanding rapidly. While there are currently several FDA-approved medications for nicotine, alcohol, and opiate dependence, research into novel pharmacological approaches for these and additional substances is legion. Each drug of abuse, while sharing a common final neural pathway of increasing dopaminergic tone, has unique and individual characteristics that are important in developing improved and varied treatments. In this chapter, we discuss such research and present the neurobiological underpinnings of these explorations. In general, addiction treatment is focused on four areas: (1) reducing withdrawal discomfort, (2) diminishing cravings, (3) blocking rewarding effects of the drug, and (4) treating comorbidities, such as depression or ADHD. We present current ideas in pharmacologic research for nicotine, alcohol, cannabis, stimulants, and opiates.
Collapse
Affiliation(s)
- Ellen Edens
- West Haven Veterans Administration Medical Center, West Haven, CT 06516, USA
| | | | | |
Collapse
|
6
|
Valproate treatment and cocaine cue reactivity in cocaine dependent individuals. Drug Alcohol Depend 2009; 102:144-50. [PMID: 19375250 PMCID: PMC2712872 DOI: 10.1016/j.drugalcdep.2009.02.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Revised: 02/17/2009] [Accepted: 02/21/2009] [Indexed: 11/20/2022]
Abstract
Based on prior clinical trials indicating that gamma-aminobutyric acid (GABA)-based anticonvulsant medications reduce drug craving in cocaine dependent study participants, we tested the effects of valproate treatment on cue-induced cocaine craving. Crack cocaine dependent individuals (N=20) were tested in a randomized, placebo-controlled, within-subjects, crossover study design. Valproate treatment was titrated up to 1500 mg/day by Day 6 of treatment, cue testing was completed on Day 8 of treatment, and all study participants underwent a washout period of 5 days between active and placebo medication treatment periods. Testing included both cocaine and neutral cue exposure sessions, presented in a random and counterbalanced order. Main effects of cue exposure were found for subjective ratings of "desire to use cocaine now", the cocaine craving index, cocaine-like high, and cocaine withdrawal. Treatment interaction effects were found with "desire to use cocaine now", which underwent a greater increase following cocaine cue exposure in the valproate condition. Main effects of medication treatment were found, in which lower blood pressure and heart rate, and higher plasma cortisol levels, were associated with valproate treatment. Valproate treatment was also associated, at a trend level, with higher pre-test cocaine craving levels. The results demonstrate that cocaine cue reactivity is a robust phenomena across two assessment sessions, but fail to support the use of valproate as a means of reducing spontaneous and cue-induced cocaine craving. The use of valproate as a treatment for cocaine dependence is not supported.
Collapse
|
7
|
Mu P, Yu LC. Valproic acid sodium inhibits the morphine-induced conditioned place preference in the central nervous system of rats. Neurosci Lett 2007; 426:135-8. [PMID: 17904288 DOI: 10.1016/j.neulet.2007.04.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Revised: 04/08/2007] [Accepted: 04/09/2007] [Indexed: 11/23/2022]
Abstract
The present study was performed to investigate the effects of valproic acid sodium (VPA), a widely utilized antiepileptic drug, on the establishment of chronic morphine-induced conditioned place preference (CPP). The rat model of morphine-induced CPP was conditioned with alternating intracerebroventricular (i.c.v.) injections of morphine (60 microg/6 microl) and saline for 5 days. To investigate the influence of VPA on morphine-induced CPP, rats received chronic pretreatment of i.c.v. VPA (500 microg/rat) 10 min previous to the daily morphine injection. The results demonstrated that the morphine-induced CPP was significantly attenuated by VPA pretreatment, while the VPA itself could not induce any CPP or conditioned place aversion (CPA) effects. The results of the present study not only confirmed the reliability of establishing morphine-induced CPP model by i.c.v. injection, but also suggest that the antiepileptic drug VPA may be utilized as potential therapeutic medications for drug abuse in the future.
Collapse
Affiliation(s)
- Ping Mu
- Neurobiology Laboratory and National Laboratory of Biomembrane and Membrane Biotechnology, College of Life Sciences, Peking University, Beijing 100871, PR China
| | | |
Collapse
|
8
|
Wang J, Michelhaugh SK, Bannon MJ. Valproate robustly increases Sp transcription factor-mediated expression of the dopamine transporter gene within dopamine cells. Eur J Neurosci 2007; 25:1982-6. [PMID: 17439486 DOI: 10.1111/j.1460-9568.2007.05460.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Several lines of evidence suggest that valproate, a drug used in the treatment of mania and bipolar disorders, epilepsies, and addictions, may modulate dopamine transporter (DAT) function, yet the effects of valproate on DAT gene expression have not been directly assessed. Utilizing a human dopaminergic cell line and rat midbrain dopamine (DA) neurons in organotypic culture, we found that valproate increased endogenous DAT gene expression in a concentration- and time-dependent manner. Given previous data demonstrating that members of the specificity protein (Sp) family of transcription factors are strong trans-activators of DAT gene transcription, we investigated the Sp-dependence of valproate effects. Valproate-induced transcription of a DAT reporter construct was significantly attenuated by coexpression of a dominant negative form of Sp, mutation of a Sp-responsive cis-element, or expression in a Sp-null cellular background (SL-2 cells). Valproate significantly altered Sp protein abundance in both dopaminergic model systems employed. In summary, valproate treatment significantly increased DAT gene expression in a Sp transcription factor-dependent manner. Some of valproate's therapeutic effects may involve activation of DAT gene expression.
Collapse
Affiliation(s)
- Jun Wang
- Department of Pharmacology, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | | | | |
Collapse
|
9
|
Abstract
Despite huge advances in the neuroscience of substance abuse and dependence in the past 20 years, no approved pharmacological treatment exists for cocaine abuse. The available drugs for the treatment of cocaine abuse are poorly effective, hence the need for new compounds to be screened and tested for efficacy: targeting symptoms might improve the effectiveness of the treatment of cocaine abuse and dependence. On the basis of the known neurochemistry of cocaine, some target compounds have been studied: among others, BP-897, a D3 partial agonist; vanoxerine, a highly selective inhibitor of dopamine uptake; aripiprazole, a partial mixed-action agonist approved for the treatment of schizophrenia. Recently modafinil, approved for the treatment of narcolepsy, proved effective in favouring cocaine abstinence in cocaine-abusing people. Some placebo-controlled studies also reported the effectiveness of topiramate, a licensed antiepileptic drug, and of tiagabine, a gamma-aminobutyric acid (GABA) re-uptake inhibitor also approved as an anticonvulsant; both compounds increased cocaine abstinence with no serious adverse events. Promising results came from two more compounds acting on the GABA circuits, baclofen and valproic acid. Finally disulfiram, prescribed with active psychosocial therapy, was found to favour higher retention rates and longer abstinence periods from both alcohol and cocaine in polydrug-abusing patients. An alternative approach rests on the use of vaccines, to date in the experimental stage still. Psychosocial treatments are a useful companion in the pharmacotherapy of cocaine abuse, with group therapy and contingency management therapies improving motivation and social functioning, particularly in patients abusing alcohol as well.
Collapse
Affiliation(s)
- Antonio Preti
- Department of Psychology, University of Cagliari, Italy and Genneruxi Medical Center, Italy.
| |
Collapse
|
10
|
Abstract
The US FDA has approved a limited number of treatments for alcohol, nicotine and opioid dependence; however, no treatments for other abused drugs such as marijuana, cocaine or methamphetamine are approved. This review focuses on research into drug pharmacotherapies, particularly single-drug therapies, for substance abuse and dependence contributing to the most important dual substance use disorders (SUDs). Given the implications of poly-substance abuse, it is essential that clinicians and researchers be aware of potential pharmacotherapies for the treatment of dual SUDs.A substantial number of patients abuse more than one drug concurrently, complicating the treatment of SUD and leaving clinicians with few FDA-approved drug options for their patients. In this era of evidence-based medicine, such patients are typically treated with therapeutically proven medications, but in ways that are outside the scope of a drug's original indication by the FDA. Such 'off-label' prescribing has become an important therapeutic strategy for practitioners seeking treatments for other diseases in subpopulations such as paediatrics and gerontology or for medical conditions such as oncology or mental illness. Similarly, the information that most clinicians use to make their decisions for treating patients abusing multiple drugs stems from trials treating a single SUD, anecdotal experiences from their own practice or that of their colleagues, or single-case studies reported in the literature. The existing evidence suggests there are few treatments for SUDs that confer significant reductions in substance use across a broad patient population. Moreover, even fewer clinical efficacy trials have been conducted that provide evidence of therapeutic benefit for these drugs. Recognising the difficulty in making the proper drug choice for facilitating maximum treatment success, this review highlights the single drugs or drug combinations that show some potential for treating dual SUDs. This review finds strongest support for the use of disulfiram for treatment of alcohol and cocaine dependence (with or without concomitant methadone maintenance), baclofen for alcohol and cocaine dependence (but not opioid-dependent cocaine users), tiagabine for cocaine dependence in methadone-maintained patients, and topiramate for alcohol, nicotine and cocaine dependence. While ondansetron and olanzapine show some efficacy in treating alcohol and cocaine dependence, more research is needed to better delineate the subpopulation in which these drugs may provide their maximum effect.
Collapse
Affiliation(s)
- George A Kenna
- Department of Community Health, Center for Alcohol and Addiction Studies, Brown University, Providence, Rhode Island, USA.
| | | | | | | | | |
Collapse
|
11
|
Maremmani I, Perugi G, Pacini M, Akiskal HS. Toward a unitary perspective on the bipolar spectrum and substance abuse: opiate addiction as a paradigm. J Affect Disord 2006; 93:1-12. [PMID: 16675028 DOI: 10.1016/j.jad.2006.02.022] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2005] [Accepted: 02/13/2006] [Indexed: 11/20/2022]
Abstract
Bipolar spectrum disorders and addiction often co-occur and constitute reciprocal risk factors that the authors believe are best considered under a unitary perspective. In particular, we submit that patients whose disorders fall under the bipolar spectrum - and its hyperthymic and cyclothymic temperamental substrates are at increased risk for substance use, possibly moving towards addiction through exposure to intrinsically dependence-producing substances. In our experience, the contribution of bipolar spectrum disorders to the addictive process is often clinically missed, because attenuated and subclinical expressions of such mood disorders as bipolar II and cyclothymia are not adequately appreciated by our current formal diagnostic system (e.g. DSM-IV, as well as research and clinical practice based on it). The use of agonist treatment in dual diagnosis heroin addicts has allowed us to gather valuable knowledge about the intrinsic, and historically and clinically documented mood-regulating effects of opiates. From the therapeutic point of view, the challenge of double diagnosis requires double competence from clinicians. The combination of opiate agonists and mood stabilizers often produces results difficult to obtain with the use of the two types of drugs separately. We therefore submit that the present conceptualization of the link between bipolar spectrum and addictive disorders has not only heuristic and scientific values, but also an important message for the clinician.
Collapse
Affiliation(s)
- Icro Maremmani
- Santa Chiara University Hospital, Psychiatric Unit 1, University of Pisa, Italy, EU.
| | | | | | | |
Collapse
|
12
|
Abstract
Cocaine addiction continues to be an important public health problem with over 1.7 million users in the US alone. Although there are no approved pharmacotherapies for cocaine addiction, a number of medications have been tested with some promising results. In this review, we summarise some of the emerging targets for cocaine pharmacotherapy including dopaminergic and GABA medications, adrenoceptor antagonists, vasodilators and immunotherapies. The brain dopamine system plays a significant role in mediating the rewarding effects of cocaine. Among dopaminergic agents tested for cocaine pharmacotherapy, disulfiram has decreased cocaine use in a number of studies. Amantadine, another medication with dopaminergic effects, may also be effective in cocaine users with high withdrawal severity. GABA is the main inhibitory neurotransmitter in the brain, and accumulating evidence suggests that the GABA system modulates the dopaminergic system and cocaine effects. Two anticonvulsant medications with GABAergic effects, tiagabine and topiramate, have yielded positive findings in clinical trials. Baclofen, a GABA(B) receptor agonist, is also promising, especially in those with more severe cocaine use. Some of the physiological and behavioural effects of cocaine are mediated by activation of the adrenergic system. In cocaine users, propranolol, a beta-adrenoceptor antagonist, had promising effects in individuals with more severe cocaine withdrawal symptoms. Cerebral vasodilators are another potential target for cocaine pharmacotherapy. Cocaine users have reduced cerebral blood flow and cortical perfusion deficits. Treatment with the vasodilators amiloride or isradipine has reduced perfusion abnormalities found in cocaine users. The functional significance of these improvements needs to be further investigated. All these proposed pharmacotherapies for cocaine addiction act on neural pathways. In contrast, immunotherapies for cocaine addiction are based on the blockade of cocaine effects peripherally, and as a result, prevent or at least slow the entry of cocaine into the brain. A cocaine vaccine is another promising treatment for cocaine addiction. The efficacy of this vaccine for relapse prevention is under investigation. Many initial promising findings need to be replicated in larger, controlled clinical trials.
Collapse
Affiliation(s)
- Mehmet Sofuoglu
- School of Medicine, Department of Psychiatry and VA Connecticut Healthcare System, Yale University, 950 Campbell Ave., Bldg 36/116A4, West Haven, CT 06516, USA.
| | | |
Collapse
|
13
|
Reid MS, Casadonte P, Baker S, Sanfilipo M, Braunstein D, Hitzemann R, Montgomery A, Majewska D, Robinson J, Rotrosen J. A placebo-controlled screening trial of olanzapine, valproate, and coenzyme Q10/L-carnitine for the treatment of cocaine dependence. Addiction 2005; 100 Suppl 1:43-57. [PMID: 15730349 DOI: 10.1111/j.1360-0443.2005.00990.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIMS To conduct a medication screening trial on the efficacy of olanzapine, valproate or coenzyme Q10/L-carnitine combination versus placebo for the treatment of cocaine dependence. DESIGN A four-arm, modified blinded, parallel group study in an out-patient setting using the Cocaine Rapid Efficacy and Safety Trials (CREST) study design. SETTING The study was performed at the New York Medications Development Research Unit (MDRU). PARTICIPANTS All participants met Diagnostic and Statistical Manual version IV (DSM-IV) criteria for cocaine dependence and provided at least two urine samples positive for benzoylecgonine (BE) during the 2-week screening period. Sixty-eight participants were enrolled with 39 completing the study. INTERVENTION After a 2-week screening period, 68 subjects were assigned randomly to receive either olanzapine (10 mg/day), valproate (1500 mg/day), coenzyme Q10 (200 mg/day) and L-carnitine (500 mg/day) combination or placebo for an 8-week treatment period. All subjects also received individual cognitive behavioral counseling during treatment. MEASUREMENTS Primary outcome measures included quantitative urine benzoylecgonine (BE) levels, self-report of drug use, and global impression scores. Secondary outcomes included cocaine craving, study retention and related psychosocial measures. Safety measures included adverse event monitoring, vital signs, and extrapyramidal side-effects tests. RESULTS Study retention was similar across all treatment groups, and all groups showed improvement across most measures of treatment efficacy over the duration of the study. None of the study medications, however, were superior to placebo on any of the primary or secondary outcome measures. Cocaine use, as measured by urine BE levels and self-report, was not significantly lower than placebo in any of the drug treatment groups. All study medications were equally well tolerated, and few medication side effects were observed. CONCLUSION This pilot study does not support the effectiveness of olanzapine, valproate or coenzyme Q10/L-carnitine combination for the treatment of cocaine dependence.
Collapse
Affiliation(s)
- Malcolm S Reid
- Department of Psychiatry, New York University School of Medicine, VA New York Harbor Healthcare System, New York, NY 10010, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Kosten TR, Kosten TA. New medication strategies for comorbid substance use and bipolar affective disorders. Biol Psychiatry 2004; 56:771-7. [PMID: 15556122 DOI: 10.1016/j.biopsych.2004.07.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2003] [Revised: 06/07/2004] [Accepted: 07/26/2004] [Indexed: 10/26/2022]
Abstract
Comorbidity of substance abuse disorders (SUD) with bipolar disorders (BPD) is a serious treatment problem. Childhood BPD can be further complicated by comorbidity with attention-deficit/hyperactivity disorder (ADHD) and later SUD during adolescence. The aim of this article is to review the literature on pharmacotherapies for these patients. Developing the ideal pharmacotherapy for BPD and SUD can be informed by the role of gamma-aminobutyric acid (GABA) in the neurobiology of SUD. This ideal pharmacotherapy would have several key characteristics. These characteristics include treating the BPD, relieving withdrawal symptoms, and preventing relapse to SUD. The ideal medication should have low abuse liability, require infrequent dosing, be well tolerated, and have few side effects. A medication approaching this ideal is the GABA enhancer valproate. Adding atypical antipsychotic agents might not improve valproate's efficacy, but combining GABA medications with selective serotonin reuptake inhibitors holds promise for SUD with depression. Pemoline might be the best option for minimizing the risk of SUD complicating comorbid ADHD with BPD.
Collapse
Affiliation(s)
- Thomas R Kosten
- Department of Psychiatry, Yale University School of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut 06516, USA.
| | | |
Collapse
|
15
|
Abstract
Cocaine abuse is a serious health problem in many areas of the world, yet there are no proven effective medications for the treatment of cocaine dependence. Preclinical studies suggest that the reinforcing effect of cocaine that promotes its abuse is mediated by blockade of the presynaptic dopamine transporter. This results in increased dopamine activity in the mesolimbic or meso-accumbens dopamine reward system of brain. Development of new medications to treat cocaine dependence has focused on manipulation of this dopamine system, either by direct action on dopamine binding sites (transporter or receptors) or indirectly by affecting other neurotransmitter systems that modulate the dopamine system. In principle, a medication could act via one of three mechanisms: (i) as a substitute for cocaine by producing similar dopamine effects; (ii) as a cocaine antagonist by blocking the binding of cocaine to the dopamine transporter; or (iii) as a modulator of cocaine effects by acting at other than the cocaine binding site. The US National Institute on Drug Abuse has a Clinical Research Efficacy Screening Trial (CREST) programme to rapidly screen existing medications. CREST identified four medications warranting phase II controlled clinical trials: cabergoline, reserpine, sertraline and tiagabine. In addition, disulfiram and selegiline (deprenyl) have been effective and well tolerated in phase II trials. However, selegiline was found ineffective in a recent phase III trial. Promising existing medications probably act via the first or third aforementioned mechanisms. Sustained-release formulations of stimulants such as methylphenidate and amfetamine (amphetamine) have shown promise in a stimulant substitution approach. Disulfiram and selegiline increase brain dopamine concentrations by inhibition of dopamine-catabolising enzymes (dopamine-beta-hydroxylase and monoamine oxidase B, respectively). Cabergoline is a direct dopamine receptor agonist, while reserpine depletes presynaptic stores of dopamine (as well as norepinephrine and serotonin). Sertraline, baclofen and vigabatrin indirectly reduce dopamine activity by increasing activity of neurotransmitters (serotonin and GABA) that inhibit dopamine activity. Promising new medications act via the second or third aforementioned mechanisms. Vanoxerine is a long-acting inhibitor of the dopamine transporter which blocks cocaine binding and reduces cocaine self-administration in animals. Two dopamine receptor ligands that reduce cocaine self-administration in animals are also undergoing phase I human safety trials. Adrogolide is a selective dopamine D(1) receptor agonist; BP 897 is a D(3) receptor partial agonist.A pharmacokinetic approach to treatment would block the entry of cocaine into the brain or enhance its catabolism so that less cocaine reached its site of action. This is being explored in animals using the natural cocaine-metabolising enzyme butyrylcholinesterase (or recombinant versions with enhanced capabilities), catalytic antibodies, and passive or active immunisation to produce anti-cocaine binding antibodies. A recent phase I trial of a "cocaine vaccine" found it to be well tolerated and producing detectable levels of anti-cocaine antibodies for up to 9 months after immunisation.
Collapse
Affiliation(s)
- David A Gorelick
- Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Department of Health and Human Services, 5500 Nathan Shock Drive, Baltimore, MD 21224, USA.
| | | | | |
Collapse
|