The role of alcohol in cocaine dependence

The Dangerous Pattern of Concurrent Use of Alcohol and Cocaine Among Drunk-Drivers of Northeast Italy

Aim

To estimate the prevalence of drug and polydrug use among drunk-drivers during the driving license regranting program, in order to assess the inclusion of toxicological tests on hair and urine samples in the systematic methodology in this category of subjects.

Short summary

A total of 2160 drunk-drivers were tested for alcohol and drugs during driving license regranting. Thirty-one subjects showed alcohol use, 212 illicit drug use and, among these, 131 were polydrug users. Nineteen different patterns of drug and polydrug use were found. Cocaine was detected in 165 subjects.

Methods

The study was performed on 2160 drunk-drivers examined at Legal Medicine and Toxicology Unit of the University of Padova, in a 3-year-period (2014-2017). The positivity for one or more illicit drugs in hair or urine samples was confirmed by LC/MS and GC/MS methods. Chi-square test, Fischer's exact test and Cochran-Armitage Trend test were used to study the correlation between general characteristics of the examined sample and the presence of drug/polydrug use.

Results

Thirty-one subjects showed alcohol use, 212 illicit drug use and, among these, 131 were polydrug users. Nineteen different patterns of drug and polydrug use were found. Cocaine was detected in 165 subjects in whom 122 showed a concurrent use of alcohol and cocaine, identified through the detection of cocaethylene in hair samples. No significant association and/or trends between drug/polydrug use and the general characteristics of the sample were detected.

Conclusions

The results show that drug and polydrug use among drunk-drivers should be subjected to toxicological as well as alcohological monitoring, especially in the regranting procedure. The implementation of this procedure could improve the knowledge of dimensions of the issue, providing a powerful means for the reduction of phenomenon of driving under the influence of alcohol and drugs.

Disulfiram efficacy in the treatment of alcohol dependence: a meta-analysis

Background

Despite its success with compliant or supervised patients, disulfiram has been a controversial medication in the treatment of alcoholism. Often, study designs did not recognize a pivotal factor in disulfiram research, the importance of an open-label design. Our objectives are: (1) to analyze the efficacy and safety of disulfiram in RCTs in supporting abstinence and (2) to compare blind versus open-label studies, hypothesizing that blinded studies would show no difference between disulfiram and control groups because the threat would be evenly spread across all groups.

Methods and Findings

We searched PubMed, EMBASE and the Cochrane Central Register for RCTs on disulfiram use with alcoholics in comparison to any alcoholic control group. The primary outcome was defined by the authors of each trial. Additional analyses included: blind vs. open-label, with or without supervision, cocaine study or not, and type of control.

Overall, the 22 included studies showed a higher success rate of disulfiram compared to controls Hedges'g = .58 (95%CI = .35–.82). When comparing blind and open-label RCTs, only open-label trials showed a significant superiority over controls g = .70 (95%CI = .46–.93). RCTs with blind designs showed no efficacy of disulfiram compared to controls. Disulfiram was also more effective than the control condition when compared to naltrexone g = .77, 95%CI = .52–1.02, to acamprosate g = .76, 95%CI = .04–1.48, and to the no disulfiram groups g = .43, 95%CI = .17–.69.

Limits include: (1) a population of 89% male subjects and (2) a high but unavoidable heterogeneity of the studies with a substantial I-square in most subgroups of studies.

Conclusions

Blinded studies were incapable of distinguishing a difference between treatment groups and thus are incompatible with disulfiram research. Based on results with open-label studies, disulfiram is a safe and efficacious treatment compared to other abstinence supportive pharmacological treatments or to no disulfiram in supervised studies for problems of alcohol abuse or dependence.

Disulfiram attenuates drug-primed reinstatement of cocaine seeking via inhibition of dopamine β-hydroxylase

The antialcoholism medication disulfiram (Antabuse) inhibits aldehyde dehydrogenase (ALDH), which results in the accumulation of acetaldehyde upon ethanol ingestion and produces the aversive 'Antabuse reaction' that deters alcohol consumption. Disulfiram has also been shown to deter cocaine use, even in the absence of an interaction with alcohol, indicating the existence of an ALDH-independent therapeutic mechanism. We hypothesized that disulfiram's inhibition of dopamine β-hydroxylase (DBH), the catecholamine biosynthetic enzyme that converts dopamine (DA) to norepinephrine (NE) in noradrenergic neurons, underlies the drug's ability to treat cocaine dependence. We tested the effects of disulfiram on cocaine and food self-administration behavior and drug-primed reinstatement of cocaine seeking in rats. We then compared the effects of disulfiram with those of the selective DBH inhibitor, nepicastat. Disulfiram, at a dose (100 mg/kg, i.p.) that reduced brain NE by ∼40%, did not alter the response for food or cocaine on a fixed ratio 1 schedule, whereas it completely blocked cocaine-primed (10 mg/kg, i.p.) reinstatement of drug seeking following extinction. A lower dose of disulfiram (10 mg/kg) that did not reduce NE had no effect on cocaine-primed reinstatement. Nepicastat recapitulated the behavioral effects of disulfiram (100 mg/kg) at a dose (50 mg/kg, i.p.) that produced a similar reduction in brain NE. Food-primed reinstatement of food seeking was not impaired by DBH inhibition. Our results suggest that disulfiram's efficacy in the treatment of cocaine addiction is associated with the inhibition of DBH and interference with the ability of environmental stimuli to trigger relapse.

mechanisms of disulfiram-induced cocaine abstinence: antabuse and cocaine relapse

The anti-alcoholism drug disulfiram (Antabuse), which is an inhibitor of aldehyde dehydrogenase, induces an aversive reaction to alcohol consumption and thereby helps patients reduce alcohol intake. Recent clinical trials, initiated to investigate whether disulfiram could be used to treat individuals who abuse both alcohol and cocaine, have indicated that disulfiram effectively decreases cocaine consumption. Yet the ability of disulfiram to curb cocaine intake cannot be explained by the disruption of ethanol metabolism. Here, we synthesize clinical and animal data that point to dopamine beta-hydroxylase inhibition as a mechanism underlying the efficacy of disulfiram in the treatment of cocaine dependence.

Treatment Outcome Predictors for Cocaine Dependence

Over the past decade, a large number of potential medications have been examined in clinical trials for cocaine dependence. Unfortunately, no effective pharmacotherapies for cocaine dependence have been found to date. Although effective treatments for cocaine dependence are still being investigated, a few variables have been found to significantly predict cocaine treatment response. These variables include cocaine use variables, such as days of cocaine use in the month before treatment, baseline urine cocaine results, and cocaine withdrawal symptoms. Comorbid depression and alcohol use have also been shown to be risk factors for relapse. Among personality variables, impulsivity and similar personality traits may predict treatment response. Initial promising findings with genetic polymorphism, brain activation, and stress response have also been found and need to be replicated in future studies.

CRACK COCAINE, ALCOHOL, AND OTHER DRUG USE PATTERNS AMONG HOMELESS PERSONS WITH OTHER MENTAL DISORDERS

This study examined the co-occurrence of cocaine, alcohol, marijuana, and other drug use among treatment seeking homeless persons to determine whether alcohol use predicted cocaine use differently than marijuana and other drugs predicted cocaine use. Participants were 141 homeless persons with substance use and other nonpsychotic mental disorders seeking drug treatment at a metropolitan health care agency for homeless persons. They were 72.3% male, 27.7% female, 82.7% African American, 17.3% Caucasian, with an average age of 37.7 (SD 7.1) years and had 13.1 (SD 2.4) average years of education. Results supported the assertion that cocaine use was strongly associated with extent of alcohol use and that the association between cocaine and alcohol was stronger than the association between cocaine and other drug use, including marijuana. Participants with cocaine plus alcohol disorders were retained longer in treatment than disorders of cocaine only with no differences in abstinence outcome. The findings should drive further research into the use of alcohol as a trigger or predictor of cocaine use, the deleterious effects of the combined use of cocaine and alcohol, and specialized treatments for polysubstance users.

A case-control study on alcohol and psychiatric disorders as risk factors for drug abuse pattern

We evaluated alcohol and psychiatric disorders as risk factors for the pattern of drug abuse/dependence in a matched case-control study (370 adults). Cases (drug abusers) and controls were selected in the community using the snowball technique and matched by sex, age, and friendship. Information was gathered using the "Composite International Diagnostic Interview" (CIDI). Three patterns of drug abuse/dependence were evaluated: any drug abuse/dependence, only cannabis, and cocaine and other drugs. Logistic conditional regression showed that alcohol dependence was strongly associated with pattern of drug abuse/dependence. Thus, compared to the "no drug abuse group", the odds ratio for association with diagnosis of abuse/dependence on cocaine and other drugs was 10.2 (95% CI: 4.9-21.2), whereas for abuse/dependence on cannabis only, the odds ratio was 1.0. For affective disorders, the odds ratio was 2.0 (95% CI: 1.10-3.64) for the group that received a diagnosis of abuse/dependence on cocaine and other drugs, whereas no association was found for those with abuse/dependence on cannabis only. In conclusion, there is not a homogeneous group of "drug users", and the role of risk factors depends on the drug use pattern.

[Mental disorders as risk factors for the development of cocaine abuse/dependence: case-control study]

OBJECTIVE

To evaluate the role of psychiatric disorders and alcohol dependence as possible risk factors for cocaine abuse/dependence.

METHODS

The case-control study used the "snowball" technique in order to select untreated cocaine users (cases) and to match sex, age and friendship. Information was gathered using the Composite International Diagnostic Interview (CIDI), and computer diagnosis were generated according to the DSM-III-R criteria. The analysis was performed through the logistic conditional regression.

RESULTS

The study included 208 subjects. The main results showed that having a history of alcohol dependence was independently associated with an increased risk of cocaine abuse/dependence (OR=15,1; 95% CI 3,8-60, 2); no other psychiatric disorder was significantly associated with an increase in this risk after the multivariate analysis. An increased risk of cocaine abuse/dependence was also found for those who related suicide thoughts (OR=3,1; 95% CI 0,91-10,8), suggesting an association between more severe manifestations of depression and cocaine abuse.

CONCLUSIONS

These findings suggest that programs directed towards the treatment and prevention of cocaine abuse must be prepared to address issues related to comorbidity of drug abuse with alcohol and other psychiatric disorders

Acute and chronic alcohol-cocaine interactions in rats

The widespread combined use of alcohol and cocaine across the United States underscores the importance of understanding how the actions of those two agents interact upon important physiological regulatory processes. In an experiment exploring acute ethanol-cocaine interactions, 16 rats were given 2.0 g/kg (IP) doses of ethanol at time zero. Two hours later, half of the rats were given cocaine (20 mg/kg, IP), while the other half were given injections of saline. The group given cocaine displayed a prolongation of the hypothermia condition induced by ethanol injection. In a chronic experiment, three groups of rats (n = 6-8) were exposed for an 11-day period to daily IP injections of 10 mg/kg cocaine, 20 mg/kg of cocaine, or saline. On day 12 these groups did not differ in their response to loss of the righting reflex induced by a 3.0 g/kg dose of ethanol. However, recovery from ethanol hypothermia was more rapid in the rats exposed to chronic cocaine. In summary, these initial studies provide evidence for exacerbation of the acute hypothermic effects of ethanol when a cocaine challenge is given 2 h after ethanol. In contrast, ethanol hypothermia was observed to be reduced when tested on day 12 after an 11-day chronic regimen of cocaine. Other dosage regimens and response measures need to be tested to understand the full scope of acute and chronic cocaine-ethanol interactions and the possible health consequences.