Neurobiochemical and clinical aspects of craving in alcohol addiction: a review

Baseline gut microbiome and metabolites are correlated with changes in alcohol consumption in participants in a randomized Zonisamide clinical trial

Development and severity of alcohol use disorder (AUD) has been linked to variations in gut microbiota and their associated metabolites in both animal and human studies. However, the involvement of the gut microbiome in alcohol consumption of individuals with AUD undergoing treatment remains unclear. To address this, stool samples (n = 32) were collected at screening (baseline) and trial completion from a double-blind, placebo-controlled trial of zonisamide in individuals with AUD. Alcohol consumption was measured both at baseline and endpoint of 16-week trial period. Fecal microbiome was analyzed via 16 S rRNA sequencing and metabolome via untargeted LC-MS. Both sex (p = 0.003) and psychotropic medication usage (p = 0.025) are associated with baseline microbiome composition. The relative abundance of 11 genera at baseline was correlated with percent drinking reduction (p.adj < 0.1). Overall microbiome community structure at baseline differed between high and low reducers of alcohol drinking (67-100% and 0-33% drinking reduction, respectively; p = 0.034). A positive relationship between baseline fecal GABA levels and percent drinking reduction (R = 0.43, p.adj < 0.07) was identified by microbiome function prediction and confirmed by ELISA and metabolomics. Metabolomics analysis also found 3-hydroxykynurenine, a neurotoxic intermediate metabolite of tryptophan, was negatively correlated with drinking reduction (p.adj = 0.047), and was over-represented in low reducers. These findings highlight importance of baseline microbiome and amino acid metabolites in drinking reduction in AUD participants undergoing zonisamide treatment. It may hold significant value as a predictive tool in clinical settings to better personalize intervention and improve reduction in alcohol consumption in future.

Interoceptive sensibility and alcohol craving in Polish prisoners: the role of alexithymia and emotional dysregulation

Introduction

Alcohol craving, characterized by a strong desire or compulsion to consume alcohol, is a prominent symptom of substance dependence syndrome. Research indicates that alcohol craving is a significant factor leading to the termination of abstinence. The mechanisms underlying the activation of alcohol craving remain not fully understood. The urge to reach for alcohol may be stimulated by emotions, memories, thoughts, or bodily sensations, as well as external factors. It has been postulated that individuals with high levels of interoceptive sensibility tend to exhibit a high degree of alexithymia and emotion dysregulation in the context of alcohol craving. Deficits in identifying and verbalizing emotions, along with an operational thinking style, facilitate alcohol consumption by impeding accurate insight into one's mental state, thereby hindering the comprehension of bodily states, emotions, and the regulation of self.

Method

This study involved 160 inmates incarcerated in a prison in Poland, awaiting participation in therapy for individuals with substance dependence following psychiatric diagnosis. Four questionnaires were used in the study: multidimensional Assessment of Interoceptive Sensibility (MAIA) for interoceptive sensibility, Toronto Alexithymia Scale (TAS-20) for alexithymia, Difficulties in Emotion Regulation Scale (DERS) for emotional dysregulation, and the Penn Alcohol Craving Scale (PACS) for alcohol craving assessment.

Results

The results of the study are as follows: the study findings indicated that alexithymia and emotional dysregulation significantly mediates the relationship between interoceptive sensibility and alcohol craving. The indirect effect for both factors was found to be significant, similar to the indirect effect observed for alexithymia as an mediator. However, in the case of emotional dysregulation, no significant indirect effect was observed.

Conclusion

Our study provides insights into the potential contribution of interoceptive sensibility to the heightened risk of alcohol dependence. Specifically, impaired interoceptive sensibility may be associated with the development of alexithymia and emotional dysregulation, potentially rendering individuals more susceptible to alcohol craving. Interoceptive sensibility could serve as a prerequisite for the cultivation of positive emotional processing skills.

Baseline gut microbiome and metabolites are correlated with alcohol consumption in a zonisamide clinical trial of heavy drinking alcoholic civilians

Development and severity of alcohol use disorder (AUD) has been linked to variations in gut microbiota and their associated metabolites in both animal and human studies. However, the involvement of the gut microbiome in alcohol consumption of individuals with AUD undergoing treatment remains unclear. To address this, stool samples (n=48) were collected at screening (baseline) and trial completion from a single site of a multi-site double-blind, placebo-controlled trial of Zonisamide in individuals with AUD. Alcohol consumption, gamma-glutamyl transferase (GGT), and phosphatidylethanol (PEth)levels were measured both at baseline and endpoint of 16-week trial period. Fecal microbiome was analyzed via 16S rRNA sequencing and metabolome via untargeted LC-MS. Both sex (p = 0.003) and psychotropic medication usage (p = 0.025) are associated with baseline microbiome composition. The relative abundance of 12 genera at baseline was correlated with percent drinking reduction, baseline and endpoint alcohol consumption, and changes in GGT and PeTH over the course of treatment (p.adj < 0.05). Overall microbiome community structure at baseline differed between high and low responders (67-100% and 0-33% drinking reduction, respectively; p = 0.03). A positive relationship between baseline fecal GABA levels and percent drinking reduction (R=0.43, p < 0.05) was identified by microbiome function prediction and confirmed by ELISA and metabolomics. Predicted microbiome function and metabolomics analysis have found that tryptophan metabolic pathways are over-represented in low responders. These findings highlight importance of baseline microbiome and metabolites in alcohol consumption in AUD patients undergoing zonisamide treatment.

Impact of a pre-test measurement of alcohol craving in cue-exposure studies: Relationship with social desirability and demand effects

Craving is one of the most studied concepts in the field of addiction. It is often investigated with repeated-measure experimental designs using self-reported scales. However, the explicit nature of self-reported craving scales may make them vulnerable to social desirability and demand effects. The aim of the present study was to test whether a pre-experimental measurement of craving affects its post-experimental assessment after an alcohol video exposure and whether these changes relate to social desirability, demand effects, and alcohol consumption. Seventy-five healthy volunteers aged 18-30 years were randomly assigned to two experimental groups: a pre-post and a post-only craving assessment group. They were invited to watch an alcohol-related video. Social desirability, demand effects, engagement toward the video, and severity of alcohol consumption were assessed in all participants. The results showed a significant effect of alcohol consumption (p < .001, η2p = .09) on post-experimental craving. The main effect of the repeated measure of craving was also significant (p = .04, η2p = .001), together with the interaction between these two variables (p = .03, η2p = .06). The pre-experimental craving measurement increased its post-experimental levels, but only in heavy drinkers. However, no evidence was found that these changes were related to social desirability or demand effects. Additional exploratory analyses indicated that craving increase in high alcohol drinkers was mediated by a stronger engagement toward the alcohol-related video. In summary, the repeated measurement of craving with explicit scales has a significant impact on the results of alcohol craving studies and may not always be desirable, especially when the true purpose of the study needs to be hidden from the participants. However, the present results also suggest that the pre-post experimental design is advisable when the experimenters seek to maximize the relationship between the individual levels of alcohol consumption and alcohol cue-exposure craving changes.

Targeting cravings in substance addiction with transcranial direct current stimulation: insights from a meta-analysis of sham-controlled trials

Addiction is a substantial health concern; craving-the core symptom of addiction-is strongly associated with relapse. Transcranial direct current stimulation (tDCS) is a noninvasive brain stimulation technique that reduces cravings by altering cortical excitability and connectivity in brain regions. This systematic review and meta-analysis was conducted (following the PRISMA guidelines) to evaluate the efficacy of tDCS in reducing cravings for substances. Our analysis included 43 randomized, sham-controlled trials involving 1,095 and 913 participants receiving tDCS and sham stimulation, respectively. We analyzed the changes in craving scores and found that tDCS led to a moderate reduction in cravings compared with the sham effects. This effect was particularly pronounced when bilateral stimulation was used, the anodal electrode was placed on the right dorsolateral prefrontal cortex, current intensities ranged from 1.5 to 2 mA, stimulation sessions lasted 20 minutes, and the electrodes size was ≥35 cm². Notably, tDCS effectively reduced cravings for opioids, methamphetamine, cocaine, and tobacco but not for alcohol or cannabis. Our findings indicate tDCS as a promising, noninvasive, and low-risk intervention for reducing cravings for opioids, methamphetamine, cocaine, and tobacco. Additional studies are warranted to refine stimulation parameters and evaluate the long-term efficacy of tDCS in managing substance cravings.

Distress tolerance, coping motives, and alcohol craving and consumption: Two experiments testing momentary responses to a mood induction

BACKGROUND

The current studies examined the relationship between state and trait distress tolerance (DT), drinking-related variables (alcohol craving and consumption), and the moderating role of drinking to cope with negative affect (i.e., coping motives).

METHODS

Study 1 was a laboratory-based experiment. Participants (n=71) completed measures of trait DT, craving, coping motives, and affect valence prior to a negative mood induction task. Post-mood induction, participants completed measures of affect valence, alcohol craving, and state DT. Next, participants completed an alcohol taste task, measuring alcohol consumption. Study 2 was completed online. Participants (n=592) completed the same pre- and post-mood induction measures as study 1, but were randomized to a mood condition (neutral, negative, or positive). Study 2 did not include alcohol consumption.

RESULTS

Negative mood induction lowered reported affect in both studies. In study 1, higher coping motives predicted increased craving in response to negative mood induction but state and trait DT did not predict craving change alone. Contrary to our hypothesis, individuals with higher coping motives showed a positive relationship between trait DT and craving. Analyses predicting alcohol consumption were not significant. In study 2, lower trait DT predicted post-mood induction craving prior to inclusion of interactions in the model. Higher coping motives were the strongest and most consistent predictor of craving. Other predictors (state DT, mood condition) and interaction terms were not significant.

CONCLUSIONS

Findings broadly align with previous research suggesting that coping motives are predictive of craving and indicate that trait DT may also impact craving.

Effects of 10 add-on HF-rTMS treatment sessions on alcohol use and craving among detoxified inpatients with alcohol use disorder: a randomized sham-controlled clinical trial

BACKGROUND AND AIMS

Alcohol use disorder (AUD) is a chronic disorder with high relapse rates. There are currently few clinical trials of high frequency repetitive transcranial magnetic stimulation (HF-rTMS) to reduce alcohol use among AUD patients, and results are mixed. The current study tested the effect of 10 add-on sessions of HF-rTMS over the right dorsolateral pre-frontal cortex (DLPFC) on alcohol use and craving.

DESIGN

Single-center, single blind sham-controlled parallel-group RCT (n = 80), with 3 and 6 months follow-up.

SETTING

Clinical treatment center in Amsterdam, the Netherlands.

PARTICIPANTS

Eighty detoxified and abstinent AUD inpatients in clinical treatment (20 females, average age = 44.35 years).

INTERVENTION

Ten sessions of active or sham HF-rTMS (60 10 Hz trains of 5 sec at 110% motor threshold) over the right DLPFC on 10 consecutive work-days.

MEASUREMENTS

The primary outcome measure is the number of abstinent days over 6-month follow-up (FU). Secondary outcome measures are craving over 6-month FU (alcohol urge questionnaire and obsessive-compulsive drinking scale), time to first relapse over 6-month FU and grams of alcohol consumed over 6-month FU. Additional outcome measures: full abstinence over 6-month FU and treatment success over 12-month FU.

FINDINGS

HF-rTMS did not affect the number of abstinent days over 6 months FU [sham = 124 ± 65.9 days, active = 115 ± 69.8 days, difference: 9 days, 95% confidence interval (CI) = Poisson model: 0.578-3.547]. Moreover, HF-rTMS did not affect craving (AUQ/OCDS) (sham = 15.38/5.28, active = 17.48/4.75, differences = 2.1/-0.53, 95% CI mixed-effects model = -9.14 to 2.07/-1.44 to 2.40).

CONCLUSIONS

There was no clear evidence that high-frequency repetitive transcranial magnetic stimulation over the right dorsolateral pre-frontal cortex treatment has a long-term positive effect on alcohol use or craving as add-on treatment for alcohol use disorder. High treatment response at 6-month follow-up could have limited the possibility to find an effect.

Spironolactone as a potential new pharmacotherapy for alcohol use disorder: convergent evidence from rodent and human studies

Evidence suggests that spironolactone, a nonselective mineralocorticoid receptor (MR) antagonist, modulates alcohol seeking and consumption. Therefore, spironolactone may represent a novel pharmacotherapy for alcohol use disorder (AUD). In this study, we tested the effects of spironolactone in a mouse model of alcohol drinking (drinking-in-the-dark) and in a rat model of alcohol dependence (vapor exposure). We also investigated the association between spironolactone receipt for at least 60 continuous days and change in self-reported alcohol consumption, using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), in a pharmacoepidemiologic cohort study in the largest integrated healthcare system in the US. Spironolactone dose-dependently reduced the intake of sweetened or unsweetened alcohol solutions in male and female mice. No effects of spironolactone were observed on drinking of a sweet solution without alcohol, food or water intake, motor coordination, alcohol-induced ataxia, or blood alcohol levels. Spironolactone dose-dependently reduced operant alcohol self-administration in dependent and nondependent male and female rats. In humans, a greater reduction in alcohol consumption was observed among those who received spironolactone, compared to propensity score-matched individuals who did not receive spironolactone. The largest effects were among those who reported hazardous/heavy episodic alcohol consumption at baseline (AUDIT-C ≥ 8) and those exposed to ≥ 50 mg/day of spironolactone. These convergent findings across rodent and human studies demonstrate that spironolactone reduces alcohol use and support the hypothesis that this medication may be further studied as a novel pharmacotherapy for AUD.

Cyclic Nucleotide Phosphodiesterases in Alcohol Use Disorders: Involving Gut Microbiota

Alcohol abuse is 1 of the most significant public health problems in the world. Chronic, excessive alcohol consumption not only causes alcohol use disorder (AUD) but also changes the gut and lung microbiota, including bacterial and nonbacterial types. Both types of microbiota can release toxins, further damaging the gastrointestinal and respiratory tracts; causing inflammation; and impairing the functions of the liver, lung, and brain, which in turn deteriorate AUD. Phosphodiesterases (PDEs) are critical in the control of intracellular cyclic nucleotides, including cyclic adenosine monophosphate and cyclic guanosine monophosphate. Inhibition of certain host PDEs reduces alcohol consumption and attenuates alcohol-related impairment. These PDEs are also expressed in the microbiota and may play a role in controlling microbiota-associated inflammation. Here, we summarize the influences of alcohol on gut/lung bacterial and nonbacterial microbiota as well as on the gut-liver/brain/lung axis. We then discuss the relationship between gut and lung microbiota-mediated PDE signaling and AUD consequences in addition to highlighting PDEs as potential targets for treatment of AUD.

Restoring an adequate dietary fiber intake by inulin supplementation: a pilot study showing an impact on gut microbiota and sociability in alcohol use disorder patients

Alcohol use disorder (AUD) is a chronic relapsing disease associated with malnutrition, metabolic disturbances, and gut microbiota alterations that are correlated with the severity of psychological symptoms. This study aims at supplementing AUD patients with prebiotic fiber during alcohol withdrawal, in order to modulate the gut microbiota composition and to evaluate its effect on gastrointestinal tolerance, metabolism, and patient's behavior. A randomized, double-blind, placebo-controlled study included 50 AUD patients assigned to inulin versus maltodextrin daily supplementation for 17 days. Biological measurements (fecal microbial 16S rDNA sequencing, serum biology), dietary intake, validated psychological questionnaires, and gastrointestinal tolerance assessment were performed before and after the intervention. Inulin significantly decreased the richness and evenness and induced changes of 8 genera (q < 0.1) including Bifidobacterium and Bacteroides. Prebiotic had minor effects on gastrointestinal symptoms and nutritional intakes compared to placebo. All patients showed an improvement in depression, anxiety, and craving scores during alcohol withdrawal regardless of the intervention group. Interestingly, only patients treated with inulin significantly improved the sociability score and had an increased serum level of brain-derived neurotrophic factor. This pilot study shows that inulin is well tolerated and modulates the gut microbiota and the social behavior in AUD patients, without further improving other psychological and biological parameters as compared to placebo. Gut2Brain study, clinicaltrial.gov: NCT03803709, https://clinicaltrials.gov/ct2/show/NCT03803709.

Preventive Effects of Baclofen but Not Diazepam on Hippocampal Memory and Glucocorticoid Alterations After Prolonged Alcohol Withdrawal in Mice

Our study aims at comparing in C57/Bl male mice, the impact of repeated injections of baclofen (an agonist of GABAB receptor) or diazepam (a benzodiazepine acting through a positive allosteric modulation of GABAA receptor) administered during the alcohol-withdrawal period on hippocampus-dependent memory impairments and brain regional glucocorticoid dysfunction after a short (1-week) or a long (4-week) abstinence. Hence, mice were submitted to a 6-month alcohol consumption (12%v/v) and were progressively withdrawn to water. Then, after a 1- or 4-weeks abstinence, they were submitted to a contextual memory task followed by measurements of corticosterone concentrations in the dorsal hippocampus (dHPC), the ventral hippocampus (vHPC) and the prefrontal cortex (PFC). Results showed that 1- and 4-week withdrawn mice exhibited a severe memory deficit and a significant abnormal rise of the test-induced increase of corticosterone (TICC) in the dHPC, as compared to water-controls or to mice still under alcohol consumption. Repeated daily systemic administrations of decreasing doses of diazepam (ranged from 0.5 to 0.12 mg/kg) or baclofen (ranged from 1.5 to 0.37 mg/kg) during the last 15 days of the withdrawal period, normalized both memory and TICC scores in the dHPC in 1-week withdrawn animals; in contrast, only baclofen-withdrawn mice showed both normal memory performance and TICC scores in the dHPC after a 4-week withdrawal period. In conclusion, the memory improvement observed in 4-week withdrawn mice administered with baclofen stem from the protracted normalization of glucocorticoid activity in the dHPC, a phenomenon encountered only transitorily in diazepam-treated withdrawn mice.

Orexin receptor blockers: A tool for lowering alcohol intake and alcohol addictive behavior in the light of preclinical studies

Alcohol use disorder (AUD) is a severe and globally widespread neurological and psychiatric problem. The treatment with currently used drugs often does not bring the expected effect. New optimization methods or directions in pharmacotherapy are still being sought. The group of bioactive ligands, targeted at neuropeptides called orexins (OXs) and their receptors (OXRs), affects a number of functions including ingestion, sleep-wake regulation, as well as the brain reward system which is the basis of addiction.

The purpose of this paper is to systematize the knowledge in the field of preclinical behavioral studies on rodents (rats and mice) in several models of alcohol consumption using the OXRs antagonists.

The results of the experiments indicated a potential efficacy of particular OXRs antagonists in the AUD treatment, especially those selectively blocking the OX1R. Among them, SB-334867 in the lowest effective dose of 3 mg/kg i.p. was most studied, as shown in the model of two-bottle choice using C57BL/6 mice. Moreover, this compound did not affect the reduction of cognitive functions. GSK1059865 was also involved in the selective reduction of ethanol intake, and simultaneously did not alter the consumption of sugar solution. The other group of selective OX2R antagonists, such as TCS-OX2-29 and LSN2424100, was less efficient.

In summary, the OX1R antagonists proved to have the potential in AUD therapy, not only through the reduction of ethanol consumption but also in the treatment of coexisting behavioral and physiological disorders, such as insomnia and anxiety.

Interoception and alcohol: Mechanisms, networks, and implications

Interoception refers to the perception of the internal state of the body and is increasingly being recognized as an important factor in mental health disorders. Drugs of abuse produce powerful interoceptive states that are upstream of behaviors that drive and influence drug intake, and addiction pathology is impacted by interoceptive processes. The goal of the present review is to discuss interoceptive processes related to alcohol. We will cover physiological responses to alcohol, how interoceptive states can impact drinking, and the recruitment of brain networks as informed by clinical research. We also review the molecular and brain circuitry mechanisms of alcohol interoceptive effects as informed by preclinical studies. Finally, we will discuss emerging treatments with consideration of interoception processes. As our understanding of the role of interoception in drug and alcohol use grows, we suggest that the convergence of information provided by clinical and preclinical studies will be increasingly important. Given the complexity of interoceptive processing and the multitude of brain regions involved, an overarching network-based framework can provide context for how focused manipulations modulate interoceptive processing as a whole. In turn, preclinical studies can systematically determine the roles of individual nodes and their molecular underpinnings in a given network, potentially suggesting new therapeutic targets and directions. As interoceptive processing drives and influences motivation, emotion, and subsequent behavior, consideration of interoception is important for our understanding of processes that drive ongoing drinking and relapse.

Influence of dopamine-related genes on craving, impulsivity, and aggressiveness in Korean males with alcohol use disorder

Dopamine is a major neuromodulator that is acutely involved in various cognitive processes, reward-motivated behaviors, and impulsivity. Abnormality in dopaminergic neurotransmission is implicated in the pathophysiology of alcohol use disorder (AUD). The present study examined the genetic influence of dopamine system on problematic drinking, impulsivity, and aggressiveness in a Korean male population with AUD. Five single nucleotide polymorphisms (SNPs) (rs4532 in DRD1, rs2283265 in DRD2, rs6280 in DRD3, rs1800497 in ANKK1, and rs4680 in COMT) and a variable number of tandem repeats (VNTRs) in DAT1 in 295 male patients with AUD were genotyped. For AUD-related clinical characteristics, the Alcohol Use Disorders Identification Test and the Obsessive-Compulsive Drinking Scale (OCDS) were used to assess the severity of hazardous drinking and craving symptoms, respectively. Participants also completed the UPPS-P Impulsive Behavior Scale (UPPS-P) and Buss-Perry Aggression Questionnaire (BPAQ). Analyses were performed using R package SNPassoc; statistical significance was set as p < 0.0083 after Bonferroni correction. A significant association was detected between DRD3 SNP rs6280 and OCDS scores. In regard to impulsivity and aggressiveness, rs4532 of DRD1 was significantly associated with UPPS-P score. Also, rs4532 demonstrated a nominally significant association with BPAQ score, although it did not reach statistical significance after correction for multiple comparisons. Results of this study support the idea that genetic variations in the dopamine system may contribute to alcohol cravings and impulsivity in patients with AUD.

Portuguese validation of the Alcohol Craving Questionnaire-Short Form-Revised

Alcohol craving has been described as a strong subjective desire to drink, being considered highly valuable in the clinical practice, as it is recognized as a strong predictor of alcohol relapse in alcohol-dependent individuals. However, to date, there is not a multifactorial questionnaire available for assessing short-term acute craving experience in Portugal. The aim of the present study was to validate a swift and efficient tool for the assessment of acute alcohol craving in a sample of Portuguese citizens. For that purpose, the Alcohol Craving Questionnaire–Short Form–Revised (ACQ-SF-R) was translated into European Portuguese and administered to a sample of 591 college participants with ages between 18 and 30 years. Results suggested that a three-factor model (i.e., Emotionality, Purposefulness, and Compulsivity) proved to be most suitable for the Portuguese sample. Overall, the ACQ-SF-R exhibited good psychometric properties, having a good internal consistency both for the general craving index (Cronbach’s α = 0.85) and each subscale (Cronbach’s α = 0.66–0.83), as well as an appropriate convergent validity with the Penn Alcohol Craving Scale (r = 0.65, p<0.001), suggesting a good construct validity. In addition, the ACQ-SF-R also showed a good concurrent validity with the Alcohol Use Disorders Identification Test (r = 0.57, p<0.001), indicating that risky alcohol use patterns are associated with increased craving scores in the ACQ-SF-R. Collectively, these findings suggest that the Portuguese version of the ACQ-SF-R can accurately measure alcohol craving at a multifactorial level, being a valid and reliable tool to use in Portuguese samples in research settings.

Effects of cortisol administration on craving during in vivo exposure in patients with alcohol use disorder

Alcohol-associated memories and craving play a crucial role in the development and maintenance of alcohol use disorder (AUD). As treatment options are limited in AUD, novel treatment strategies focus on the manipulation of alcohol-associated memories. The stress hormone cortisol affects various memory processes, and first clinical studies have shown that it inhibits the retrieval of disorder-specific memories and enhances extinction memory. This study aimed to investigate the effects of a single oral administration of cortisol on craving in patients with AUD during repeated in vivo exposure to alcohol pictures and the preferred alcoholic drink. In a double-blind, block-randomized, placebo-controlled cross-over design, 46 patients with AUD were treated with two sessions of in vivo exposure to alcohol. Cortisol (20 mg) or placebo was orally administered 1 h before each test day. Craving, stress, and cortisol were repeatedly measured during exposure sessions. Results show, that cortisol administration had distinct effects on craving depending on the severity of AUD and test day. While cortisol administration significantly enhanced craving during exposure on the first test day in patients with less severe AUD, it reduced craving in patients with more severe AUD. Independent of the cortisol administration, repeated in vivo exposure reduced craving from test day 1 to test day 2. In conclusion, adding cortisol to in vivo exposure might be a promising approach for reducing the strength of alcohol-associated memories and might promote the consolidation of extinction memory in patients with severe AUD. However, the differential effect of cortisol on craving depending on AUD severity cannot be conclusively explained and highlights the need for future studies elucidating the underlying mechanism.

No control and overwhelming cravings: Australian adults' perspectives on the experience of food addiction

Research in the area of food addiction is continuing to increase with recent reviews suggesting that food addiction is a distinctive condition that has many symptoms similar to substance use disorders. The current study explored the perspectives and experiences of Australian adults seeking treatment for addictive eating. Quantitative data for this study was collected via self-report questionnaires completed online, including demographics, the Yale Food Addiction Scale 2.0, and the Depression, Anxiety, and Stress Scale-21. Qualitative data was collected via semi-structured interviews using open-ended questions about the individual experience of food addiction and perspectives regarding intervention and recovery. Interview data was available for 34 participants, with the majority (n = 33) being females who were overweight, (mean ± SD age = 42.9 ± 13.2 years, BMI=36.5 ± 6.8 kg/m²). Stress (19.9 ± 11.4 out of 21) and depression (16.8 ± 10.2 out of 21) were the most prominent negative emotional states. Thematic analysis identified two themes of compulsion and control. Compulsion distinguished the participants' experiences related to addictive eating behaviours, in particular the notion of craving. Control encompassed their perception of both the processes and outcomes of overcoming their addictive eating. The two themes identified were not mutually exclusive, and relationships between them and their influence on each other were observable. This study provides a unique contribution to understanding adults' experience of food addiction by highlighting the strong desire to be in control of eating behaviours, and the inability of participants to overcome their compulsions to eat specific food despite minimal anticipation of positive effect.

Phenobarbital Monotherapy for the Management of Alcohol Withdrawal Syndrome in Surgical-Trauma Patients

BACKGROUND

Benzodiazepine is first-line therapy for alcohol withdrawal syndrome (AWS), and phenobarbital is an alternative therapy. However, its use has not been well validated in the surgical-trauma patient population.

OBJECTIVE

To describe the use of fixed-dose phenobarbital monotherapy for the management of patients at risk for AWS in the surgical-trauma intensive care unit.

METHODS

Surgical-trauma critically ill patients who received phenobarbital monotherapy, loading dose followed by a taper regimen, for the management of AWS were included in this evaluation. The effectiveness of phenobarbital monotherapy to treat AWS and prevent development of AWS-related complications were evaluated. Safety end points assessed included significant hypotension, bradycardia, respiratory depression, and need for invasive mechanical ventilation.

RESULTS

A total of 31 patients received phenobarbital monotherapy; the majority of patients were at moderate risk for developing AWS (n = 20; 65%) versus high risk (n = 11; 35%). None of the patients developed AWS-related complications; all patients were successfully managed for their AWS. Nine patients (29%) received nonbenzodiazepine adjunct therapy for agitation post-phenobarbital initiation. Three patients (10%) experienced hypotension, and 3 (10%) were intubated. None of the patients had clinically significant bradycardia or respiratory depression.

CONCLUSION AND RELEVANCE

Fixed-dose phenobarbital monotherapy appears to be well tolerated and effective in the management of AWS. Further evaluation is needed to determine the extent of benefit with the use of phenobarbital monotherapy for management of AWS.

The Influence of Alexithymia on Alcohol Craving, Health-Related Quality of Life and Gender in Alcohol-Dependent Outpatients

Alexithymia is a vulnerability factor for physical and mental illness that can significantly influence the daily function of alcohol-dependent patients. The aim of this study was to examine the indirect effect of obsessive thoughts and compulsive behaviors involving alcohol craving on the relationship between alexithymia, quality of life (QoL) of psychological well-being and health status. Three hundred and eighty-one outpatients (263 males and 118 females) in treatment for alcohol dependence completed self-report measures of alexithymia, alcohol craving, GHQ-28 (QoL-psychological well-being) and SF-36 (QoL-health status). Males scored significantly higher than females on aspects of alexithymia, and females reported significantly higher levels of alcohol craving. Path analysis showed an indirect effect of alcohol craving on the relationship between alexithymia, QoL-psychological well-being and self-reported QoL-health status for males only. The current study provides important new information about impaired self-reported health status and well-being among male alcohol-dependent treatment seekers with alexithymia.

Gut microbiota compositional and functional fingerprint in patients with alcohol use disorder and alcohol-associated liver disease

BACKGROUND & AIMS

Alcohol use disorder (AUD) represents the most common cause of liver disease. The gut microbiota plays a critical role in the progression of alcohol-related liver damage. Aim of this study was to characterize the gut microbial composition and function in AUD patients with alcohol-associated liver disease (AALD).

METHODS

This study included 36 AUD patients (14 with cirrhosis) who were active drinkers and an equal number of matched controls. Stool microbial composition, serum levels of lipopolysaccharide, cytokines/chemokines and gut microbiota functional profile were assessed.

RESULTS

AUD patients had a decreased microbial alpha diversity as compared to controls (0.092 vs 0.130, P = .047) and a specific gut microbial signature. The reduction of Akkermansia and the increase in Bacteroides were able to identify AUD patients with an accuracy of 93.4%. Serum levels of lipopolysaccharide (4.91 vs 2.43, P = .009) and pro-inflammatory mediators (tumour necrosis factor alpha 60.85 vs 15.08, P = .001; interleukin [IL] 1beta 4.43 vs 1.72, P = .0001; monocyte chemoattractant protein 1 225.22 vs 16.43, P = .006; IL6 1.87 vs 1.23, P = .008) were significantly increased in AUD patients compared to controls and in cirrhotic patients compared to non-cirrhotic ones (IL6 3.74 vs 1.39, P = .019; IL8 57.60 vs 6.53, P = .004). The AUD-associated gut microbiota showed an increased expression of gamma-aminobutyric acid (GABA) metabolic pathways and energy metabolism.

CONCLUSIONS

AUD patients present a specific gut microbial fingerprint, associated with increased endotoxaemia, systemic inflammatory status and functional alterations that may be involved in the progression of the AALD and in the pathogenesis of AUD.

Altered brain activities associated with cue reactivity during forced break in subjects with Internet gaming disorder

BACKGROUND

Studies have proven that forced break can elicit strong psychological cravings for addictive behaviors. This phenomenon could create an excellent situation to study the neural underpinnings of addiction. The current study explores brain features during a cue-reactivity task in Internet gaming disorder (IGD) when participants were forced to stop their gaming behaviors.

METHODS

Forty-nine IGD subjects and forty-nine matched recreational Internet game users (RGU) were asked to complete a cue-reactivity task when their ongoing gaming behaviors were forced to break. We compared their brain responses to gaming cues and tried to find specific features associated with IGD.

RESULTS

Compared with RGU, the IGD subjects showed decreased activation in the anterior cingulate cortex (ACC), parahippocampal gyrus, and dorsolateral prefrontal cortex (DLPFC). Significant negative correlations were observed between self-reported gaming cravings and the baseline activation level (bate value) of the ACC, DLPFC, and parahippocampal gyrus.

CONCLUSIONS

IGD subjects were unable to suppress their gaming cravings after unexpectedly forced break. This result could also explain why RGU subjects are able to play online games without developing dependence.

Randomized trial to assess safety/feasibility of memantine administration during residential treatment for alcohol use disorder: a pilot study

The N-methyl-D-aspartate receptor (NMDAr) system is critically involved in the pathogenesis and neurobehavioral sequelae of alcohol use disorder (AUD), and constitutes a potential pharmacotherapeutic target. Memantine (Namenda) is an FDA-approved NMDAr antagonist with suggested utility in AUD, however its safety and tolerability during long-term administration among recently-detoxified patients remains uncharacterized. This pilot study assessed safety, feasibility, and several secondary measures of interest, during a 4-week period of residential AUD treatment. Participants (N = 18) met diagnostic criteria for AUD. A double-blind, placebo-controlled, escalating-dose design was utilized. Assessments of medication side-effects were conducted weekly. At intake, week 2, and study completion, participants completed a battery assessing affective symptomatology, craving, and neurocognitive function. Medication groups reported equivalent side effects and severity. Medication compliance was high, and did not differ by group. No memantine effects were observed in secondary outcome measures. Memantine maintains a profile of high tolerability and low side-effects during post-detoxification AUD treatment. These data suggest a more aggressive dosing/escalation schedule may be used safely in future trials designed to ascertain improvements in neurocognitive function, affect, and/or craving as primary measures.

Ethnopharmacological Applications Targeting Alcohol Abuse: Overview and Outlook

Excessive alcohol consumption is the cause of several diseases and thus is of a major concern for society. Worldwide alcohol consumption has increased by many folds over the past decades. This urgently calls for intervention and relapse counteract measures. Modern pharmacological solutions induce complete alcohol self-restraint and prevent relapse, but they have many side effects. Natural products are most promising as they cause fewer adverse effects. Here we discuss in detail the medicinal plants used in various traditional/folklore medicine systems for targeting alcohol abuse. We also comprehensively describe preclinical and clinical studies done on some of these plants along with the possible mechanisms of action.

Attachment Style, Early Childhood Trauma, Alexithymia, and Dissociation Among Persons Addicted to Alcohol: Structural Equation Model of Dependencies

AIM

Attachment theory is a broadly used paradigm for understanding human affective development. It is recognized that alexithymia is a key factor responsible for the non-adaptive strategies of regulating emotions in people addicted to alcohol. In addition, an important role is attributed to early childhood trauma and dissociation. The theoretical model was examined, in which connections between attachment styles, trauma, and alexithymia and dissociation were investigated in persons addicted to alcohol.

METHODS

The total number of study participants amounted to 268 persons, including 116 women (43% of all subjects) and 152 men (57% of all subjects) at the age of 18-73 (M = 39.19; SD = 13.45). In order to measure the analyzed variables, the following questionnaires were applied: Michigan alcoholism screening test (MAST), attachment styles questionnaire (ASQ), 20-item Toronto Alexithymia Scale (TAS-20), traumatic experiences checklist (TEC), and curious experiences survey (CES).

RESULTS

A comparative analysis between the group of alcohol addicts and non-addicts showed statistically significant differences related to attachment style, intensity of trauma, alexithymia, and dissociation. With structural equation models (i.e., AMOS and GLS), the adjustment of theoretical model to data was examined, which allowed the description of dependency paths. As a result of the conducted analysis of paths, it was found out that the model was accurately fitted to data, but only when an impact path related to a direct connection between an attachment style and an addiction was deleted. This impact is indirect, and from one side, it results from affective and cognitive deficits, i.e., alexithymia, and on the other side, from the intensity of traumatic experiences. No direct impact of dissociation on the development of an inclination to addiction was found, if contextual variables, i.e., alexithymia and trauma, are taken into account. The strongest direct relation was proven in the case of the anxious-ambivalent attachment style and alexithymia (β = 0.389; p < 0.01) and avoidant attachment style and alexithymia (β = 0.497; p < 0.01), which turned out a strong predictor fostering the development of alexithymia and the occurrence of traumas related to emotional negligence and mental violence and finally addiction.

CONCLUSION

Our studies revealed how important it is to investigate the role of individual variables in the context of developmental models. An extremely important element of the scientific achievement presented here is showing pillars of trauma, alexithymia, and dissociation in their cumulative impact on the development of emotional disorders resulting in addiction.

Prevalence and Correlates of Past-Year Recovery From DSM-5 Alcohol Use Disorder: Results From National Epidemiologic Survey on Alcohol and Related Conditions-III

BACKGROUND

Little is known about remission, recovery, and other outcomes of alcohol use disorder (AUD) as defined by the DSM-5.

METHODS

Data from a large representative sample of the United States was used to examine correlates of past-year AUD status among individuals with prior-to-past-year AUD: persistent AUD, symptomatic high-risk drinking, asymptomatic high-risk drinking, symptomatic low-risk drinking, asymptomatic low-risk drinking (nonabstinent recovery, NAR), and abstainer (abstinent recovery, AR). Multiple logistic regression analyses were conducted to compare: (i) AR and NAR with persistent AUD, (ii) AR with NAR, and (iii) asymptomatic and symptomatic high-risk drinking with AR and NAR.

RESULTS

Among individuals with AUD prior to past year (n = 7,785), 34.2% were classified with persistent AUD, 8.8 and 1.6% were symptomatic high-risk and symptomatic low-risk drinkers, respectively, 21.5% were asymptomatic high-risk drinkers, 17.9% were asymptomatic low-risk drinkers, and 16.0% were abstainers. One-quarter of individuals with AUD prior to past year achieved AR or NAR without the benefit of treatment, while a much greater percentage of individuals achieving AR (43.2%) reported receiving treatment relative to those with NAR (12.3%). The number of lifetime AUD symptoms was greater among those achieving AR (among the treated) and lower among those achieving NAR relative to persistent AUD. The number of AUD symptoms was also greater among those achieving AR than NAR and lower among asymptomatic and symptomatic risk drinkers relative to those achieving AR and NAR. Consumption was greater among those achieving AR relative to those achieving NAR and greater among asymptomatic and symptomatic risk drinkers relative to AR and NAR. Odds of achieving AR or NAR relative to persistent AUD were generally lower among non-Hispanic Blacks and those with higher education, greater among women and married individuals, and lower among illicit drug users and individuals with histories of a personality disorder or mood/anxiety disorder.

CONCLUSIONS

There appears to be a substantial level of recovery from AUD. Information on specific factors associated with AUD outcomes can be useful in targeting appropriate treatment efforts.

Substance craving changes in university students receiving heart rate variability biofeedback: A longitudinal multilevel modeling approach

BACKGROUND

Previously published findings from a study of university students living in substance use disorder (SUD) recovery housing showed an eight-session heart rate variability biofeedback (HRVB) intervention significantly reduced craving. That study, however, uncovered pronounced inter-participant variability in craving change patterns through the course of HRVB that warranted further exploration. The purpose of the current investigation was to examine how within- and between-person factors may have differentially influenced craving changes.

METHODS

A longitudinal multilevel modeling approach was used with time at level-1 nested within persons at level-2. Multilevel models of change were estimated to model craving trajectories and predictor relationships over time as a function of age, sex, length of abstinence, daily HRVB practice, anxiety, depression, and stress.

RESULTS

A quadratic pattern of craving reductions was found, indicating that craving reductions accelerated over time for some participants. Daily HRVB practice of >12 min and older age significantly enhanced craving reductions over time. Increases in depressive symptoms attenuated the effects of HRVB on craving. The other predictors were not significantly associated with craving in this study. The true R² for the final model indicated that 20.5% of the variance in craving was explained by older age, daily HRVB >12 min, and within-person changes in depression.

CONCLUSIONS

HRVB shows promise as an accessible, scalable, and cost-effective complementary anti-craving intervention. Healthcare providers may help persons recovering from SUD to better manage substance craving by the routine and strategic use of HRVB practice.

Craving Mediates the Relation Between Impulsivity and Alcohol Consumption Among University Students

BACKGROUND AND OBJECTIVES

The relationship between impulsivity and craving in severe alcohol use disorders is well established, but the presence and characteristics of this link in University students are still to be established. The present study aims to better understand the relationship between impulsivity and craving in university students and to determine the influence of these variables on alcohol consumption characteristics.

METHODS

A large sample of university students (N = 1055, mean age: 20.9 years; 713 women) completed an online questionnaire to evaluate alcohol use, impulsivity, and craving.

RESULTS

Linear regression analysis demonstrated that the compulsive dimensions of craving (P < .001), sensation seeking (P < .001), and lack of premeditation (P < .001) constitute strong predictors of current consumption. A receiver operating characteristic (ROC) curve analysis determined the threshold level above which craving intensity can identify specific high-risk populations. A mediation analysis showed that craving has a partial mediator effect on the impact of impulsivity on alcohol consumption for this population (37,8%, P < .001).

DISCUSSION AND CONCLUSIONS

The sensation seeking and lack of premeditation dimensions of impulsivity, coupled with compulsive craving, are efficient predictors of excessive alcohol consumption for university students. The partial mediator effect of craving is important in terms of characterizing the relationship between impulsivity and alcohol consumption.

SCIENTIFIC SIGNIFICANCE

Our study centrally shows that the interaction between elevated levels of impulsivity and craving constitute a crucial risk factor for alcohol consumption in university students, and should thus constitute a target for primary prevention programs (Am J Addict 2019;00:00-00).

Posterior Cingulate Cortical Response to Active Avoidance Mediates the Relationship between Punishment Sensitivity and Problem Drinking

Many people drink to alleviate negative affect, reflecting an avoidance strategy which can lead to alcohol misuse. Individuals with heightened sensitivity to punishment (SP) are especially susceptible to problem drinking via this maladaptive coping mechanism. As imaging studies have largely focused on sensation-seeking traits and approach behavior, the neural substrates underlying behavioral avoidance as well as their relationship with punishment sensitivity and alcohol use remain unclear. Here, we examined in humans the cerebral correlates of response inhibition to avoid a penalty in relation to both problem drinking and SP, as evaluated by the Alcohol Use Disorders Identification Test and the Sensitivity to Punishment and Sensitivity to Reward Questionnaire, respectively. Seventy nondependent female and male drinkers performed a reward go/no-go task with approximately two-thirds go and one-third no-go trials. Correct go and no-go responses were rewarded, and incorrect responses were punished. The results showed that SP and Alcohol Use Disorders Identification Test scores were both positively correlated with brain activations during response inhibition, and these activations overlapped in the posterior cingulate cortex (PCC). Thus, the PCC may represent a shared neural substrate for avoidance, punishment sensitivity, and problem drinking. Mediation analyses further suggested that PCC response to avoidance completely and bidirectionally mediated the relationship between SP and hazardous alcohol use. These findings substantiated the role of the PCC in behavioral avoidance and its link to problem drinking in punishment-sensitive nondependent drinkers.SIGNIFICANCE STATEMENT Many people drink to alleviate negative affect, reflecting an avoidance strategy that can lead to alcohol misuse. Individuals with heightened punishment sensitivity (SP) trait are particularly vulnerable to this maladaptive coping mechanism. The current study examined the neural substrates underlying behavioral avoidance and their relationship with SP and problem drinking. Using a reward go/no-go task, we showed both SP and drinking severity were positively correlated with the posterior cingulate cortex (PCC) activation during action inhibition. Thus, the PCC may represent a shared neural substrate for avoidance behavior, punishment sensitivity, and problem drinking. Further, PCC response to avoidance mediated the relationship between SP and alcohol use. These findings substantiated the neural processes linking avoidance tendency to alcohol misuse in punishment-sensitive drinkers.

Baclofen but Not Diazepam Alleviates Alcohol-Seeking Behavior and Hypothalamic-Pituitary-Adrenal Axis Dysfunction in Stressed Withdrawn Mice

This study compares the impact of repeated injections of baclofen (an agonist of GABA_B receptors) or diazepam (a benzodiazepine having an agonist action on GABA_A receptors) given during the alcohol-withdrawal period on the stress-induced restoration of alcohol-seeking behavior and hypothalamic-pituitary-adrenal (HPA) axis dysfunction after a long (4 weeks) abstinence. Thus, C57BL/6 mice were submitted to a 6-month alcohol consumption [12% volume/volume (v/v)] and were progressively withdrawn to water before testing. Diazepam (Valium^®, Roche) and baclofen (Baclofen^®, Mylan) were administered intraperitoneally for 15 consecutive days (1 injection/day) during the withdrawal period at decreasing doses ranging from 1.0 mg/kg (Day 15) to 0.25 mg/kg (Day 1) for diazepam and from 1.5 mg/kg (Day 15) to 0.37 mg/kg (Day 1) for baclofen. Alcohol-seeking behavior was evaluated by alcohol-place preference in an odor recognition task. In the stress condition, mice received three electric footshocks 45 min before behavioral testing. Blood was sampled immediately after behavioral testing, and plasma corticosterone concentrations were measured by commercial enzyme immunoassay kits. Results showed that non-stressed withdrawn mice did not exhibit alcohol-place preference or alteration of plasma corticosterone concentrations relative to water controls. After stress, however, withdrawn mice exhibited a significant alcohol-place preference and higher circulating corticosterone concentrations as compared to stressed water controls. Interestingly, repeated administration during the withdrawal phase of baclofen but not diazepam suppressed both the alcohol-place preference and normalized corticosterone levels in stressed withdrawn animals. In conclusion, this study evidences that a pre-treatment with baclofen but not with diazepam during the withdrawal phase normalized, even after a long period of abstinence, the HPA axis response to stress, which contributes to the long-term preventing effects of this compound on alcohol-seeking behavior.

Risk-Taking Propensity, Affect, and Alcohol Craving in Adolescents' Daily Lives

Background: Alcohol craving is common among adolescents, stronger among those with more alcohol-related problems, and predicts drinking levels in their daily lives. Yet, the conditions that predict momentary changes in craving in real time among adolescents remain unclear. Objectives: This study examined the interactive effects of momentary risk-taking propensity and affect on adolescents' alcohol craving by leveraging ecological momentary assessment (EMA) methods. Methods: Participants were 29 adolescents ages 15-19 years (55% female; 69% White; 10% Black; 17% Hispanic); 45% met criteria for alcohol dependence. Following a laboratory session that captured self-report and behavioral assessments, including the well-established Balloon Analog Risk Task (BART), participants completed multiple daily assessments of alcohol craving, positive and negative affect, and risk propensity for approximately one week. Momentary risk propensity was captured in real-world settings via an EMA behavioral task ("Balloon Game"). Results: Mixed-effects models with EMA reports (Level 1) nested within participants (Level 2) revealed the majority (74%) of variability in "Balloon Game" performance was due to within-person, momentary, fluctuations. Greater momentary positive affect predicted increased alcohol craving, but only when participants exhibited heightened risk-taking propensity. Negative affect did not influence the relation between momentary risk-taking and craving. Conclusions/Importance: Momentary fluctuations in positive affect predicted acute increases in craving but only in moments when adolescents demonstrated higher levels of risk-taking propensity, as captured with an EMA-delivered behavioral task. Momentary risk-taking assessments offer new avenues to substantiate dominant theories on the driving mechanisms of craving and alcohol use among adolescents.

Relationship Between Attachment Style in Adulthood, Alexithymia, and Dissociation in Alcohol Use Disorder Inpatients. Mediational Model

Background: Attachment theory is a widely used framework for understanding emotion regulation as well as alexithymia, and dissociation and this perspective has also been applied to understand alcohol use disorders. Apart from these theoretical suggestions, there has been scarce empirical research on this subject-matter. Therefore, the objective of the present study was to investigate potential associations between attachment style in adulthood, alexithymia, and dissociation in alcohol use disorder inpatients. Methods: The Revised Adult Attachment Scale (RAAS), the Toronto Alexithymia Scale-20 (TAS-20), the Michigan Alcoholism Screening Test (MAST), and the Curious Experiences Survey (CES) were administered to a sample of 97 alcohol use disorder inpatients recruited from drug and alcohol treatment centers in Warsaw, and 104 persons in control groups, Poland. Results: A comparative analysis between the group of alcohol addicts and non-addicts showed statistically significant differences related to: alexithymia, dissociation, and attachment styles. The analysis of models related to the impact of attachment styles on the level of alcohol addiction with regard to a mediatory role of alexithymia and dissociation showed that all models are well fitted to data and statistically significant: intimacy F(3.197) = 34.41; p < 0.001 and explains 34% (R ² = 0.3438); depend F(3.197) = 36.55; p < 0.001, and explains 36% (R ² = 0.3576); anxiety F(3.197) = 34.71; p < 0.001, and explains 35% (R ² = 0.3458) of the variability of alcohol addiction scores. Mediation analysis found that alexithymia and dissociation enhance the fear of intimacy and rejection in a romantic relationship. Conclusion: These findings support the broad attachment theory suggesting that attachment is associated with and predicts alexithymia and dissociation in the sample of substance use disorder inpatients. Alexithymia and dissociation, by inhibiting the processes of emotions' identification and verbalization, cause that language does not serve for the purpose of changing self or others, as the communication is distorted. Absent are common meanings and accurate mutual understanding in a relationship.

Baclofen: its effectiveness in reducing harmful drinking, craving, and negative mood. A meta-analysis

BACKGROUND AND AIMS

There are a limited number of pharmacotherapies licensed for alcohol use disorders (AUDs). Baclofen is a γ-aminobutyric acid B (GABA-B) agonist which is used increasingly as an off-label treatment. A meta-analysis of randomized controlled trials (RCTs) was conducted to determine the efficacy of baclofen in reducing drinking behaviour, craving, depression and anxiety compared with placebo.

METHODS

Random-effects meta-analyses were computed on outcome data from 12 RCTs comparing baclofen with placebo. Included RCTs provided data on at least one of the primary outcome measures (drinking-related: heavy drinking days, abstinent days, abstinence rates) or secondary outcome measures (craving, anxiety, depression).

RESULTS

Baclofen had a significant effect on abstinence rates when using intention-to-treat analysis [total n baclofen = 307, total n control = 283: odds ratio (OR) = 2.67, 95% confidence interval (CI) = 1.03, 6.93; Z = 2.01, P = 0.04, I²  = 76%, number needed to treat = 8]. No other significant effects of treatment efficacy [e.g. heavy drinking days: standardized mean differences (SMD) = -0.26, 95% CI = -0.68, 0.15; Z = 1.24, P = 0.21, I²  = 95%] or mechanism of action (e.g. craving: SMD = -0.13, 95% CI = -0.36, 0.09; Z = 1.18, P = 0.24, I²  = 87%) were observed. There was substantial heterogeneity in effect sizes across each analysis.

CONCLUSIONS

As a treatment for alcohol use disorders, baclofen is associated with higher rates of abstinence than placebo. However, there is no superior effect of baclofen on increasing number of abstinent days, or decreasing heavy drinking, craving, anxiety or depression. These results suggest that the current increasing use of baclofen as a treatment for alcohol use disorders is premature.

Applications of virtual reality in individuals with alcohol misuse: A systematic review

BACKGROUND

Alcohol use and misuse have been intensively studied, due to their negative consequences in the general population. Evidence-based literature emphasizes that alcohol craving plays a crucial role in the development and maintenance of alcohol-drinking patterns. Many individuals develop Alcohol Use Disorders (AUD); significantly, after treatment many also experience relapses, in which alcohol craving has been repeatedly implicated. Cue-exposure therapy (CET) has been widely used in the treatment of alcohol misuse, but the results are inconsistent. Virtual reality (VR) can add effectiveness to cue-exposure techniques by providing multiple variables and inputs that enable personalized alcohol use assessment and treatment. The aim of this review was to examine the applications of virtual reality in individuals who misuse alcohol.

METHOD

We conducted an exhaustive literature search of the Web of Science, Scopus, Embase, Google Scholar, and PsycInfo databases, using as search items terms such as "alcohol" and its derivates, and virtual reality.

RESULTS

We identified 13 studies on alcohol craving that implemented virtual reality as an assessment or treatment tool.

CONCLUSIONS

The studies that incorporate VR present clear limitations. First, no clinical trials were conducted to explore the efficacy of the VR as a treatment tool; nor were there any studies of the generalization of craving responses in the real world, or of the long-term effects of VR treatment. Despite these limitations, the studies included showed consistent results as regards eliciting and reducing alcohol craving. We suggest that VR shows promise as a tool for the assessment and treatment of craving among individuals with alcohol misuse. Further studies implementing VR in the field of alcohol consumption are now required.

Current Evidence on Heart Rate Variability Biofeedback as a Complementary Anticraving Intervention

BACKGROUND

The limited success of conventional anticraving interventions encourages research into new treatment strategies. Heart rate variability biofeedback (HRVB), which is based on slowed breathing, was shown to improve symptom severity in various disorders. HRVB, and certain rates of controlled breathing (CB), may offer therapeutic potential as a complementary drug-free treatment option to help control substance craving.

METHODS

This review evaluated current evidence on the effectiveness of HRVB and CB training as a complementary anticraving intervention, based on guidelines from the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Studies that assessed a cardiorespiratory feedback or CB intervention with substance craving as an outcome were selected. Effect sizes were calculated for each study. The Scale for Assessing Scientific Quality of Investigations in Complementary and Alternative Medicine was used to evaluate the quality of each study reviewed.

RESULTS

A total of eight articles remained for final review, including controlled studies with or without randomization, as well as noncontrolled trials. Most studies showed positive results with a variety of methodological quality levels and effect size. Current HRVB studies rated moderately on methodological rigor and showed inconsistent magnitudes of calculated effect size (0.074-0.727) across populations. The largest effect size was found in a nonclinical college population of high food cravers utilizing the most intensive HRVB training time of 240 min.

CONCLUSIONS

Despite the limitations of this review, there is beginning evidence that HRVB and CB training can be of significant therapeutic potential. Larger clinical trials are needed with methodological improvements such as longer treatment duration, adequate control conditions, measures of adherence and compliance, longitudinal examination of craving changes, and more comprehensive methods of craving measurement.

Accesses for alcohol intoxication to the emergency department and the risk of re-hospitalization: An observational retrospective study

BACKGROUND

Alcohol use disorders (AUD) are a frequent cause of admission to emergency departments (EDs) for acute alcohol intoxication (AAI). Patients with AUD present a higher risk of readmission to EDs for AAI than the general population, however, the distinction between sporadic AAI and AAI in the context of AUD in the ED setting is difficult.

AIMS

To analyze the epidemiological characteristics of patients admitted to EDs because of AAI and to identify factors associated with repeated admissions in order to develop a risk stratification system for patients with AUD based on objective data that can be easily applied in an ED setting.

METHODS

An observational retrospective study was performed. All patients with diagnosis of AAI at admission in 2014 were enrolled.

RESULTS

Five hundred and sixty-five patients were enrolled, of which 92 (16%) were admitted more than once to the ED. At multivariate analysis, factors associated with readmission were past episodes of alcohol abuse, social discomfort, previous traumas and psychiatric disorders. Basing on this parameter, a risk-score for re-hospitalization was developed. This score has a high predictive power for the risk of readmission to the ED (AROC 0.837, 95%CI 0.808-0.866), moreover, the cumulative probability of readmission within one year, increased in parallel with score value, being highest in patients presenting 3 or more risk factors.

CONCLUSION

The present study demonstrates that several risk factors stratify the risk of re-hospitalization in patients admitted to EDs for AAI, allowing the identification of those presenting more severe conditions and who would likely benefit from multidisciplinary intervention.

The Association between the Level of Plasma Oxytocin and Craving among Former Heroin Users

BACKGROUND

Animal studies have demonstrated that oxytocin can influence addiction behaviors and might interact with the dopaminergic system, which is a key component of addiction behaviors. However, related evidence from clinical studies is scarce. The aim of our study was to explore the relationship between plasma oxytocin level and heroin craving among patients receiving methadone maintenance treatment, and to ascertain whether this relationship is moderated by novelty-seeking.

METHODS

The study was conducted in a methadone maintenance therapy clinic of a medical center in Taiwan. Seventy-seven patients with heroin addiction were enrolled. Plasma oxytocin was measured using an ELISA kit. Craving was assessed using an established instrument, the Chinese Craving Scale.

RESULTS

A significant negative association was found between the plasma oxytocin level and craving score, which remained robust after controlling the effects of social support and low-density lipoprotein cholesterol. An interaction between oxytocin and novelty-seeking indicated that this relationship was stronger among patients with a lower level of novelty-seeking.

CONCLUSION

This finding may be taken into account in future studies and may provide a basis for the development of potential treatment for addiction. The effect of oxytocin for the treatment of opioid dependence might be modulated by some psychological factors.

Alcohol addiction - the safety of available approved treatment options

INTRODUCTION

Alcohol Use Disorders (AUD) is a leading cause of mortality and morbidity worldwide. At present disulfiram, naltrexone and acamprosate are approved for the treatment of AUD in U.S. and Europe. Nalmefene is approved in Europe and sodium oxybate is approved in Italy and Austria only. Baclofen received a 'temporary recommendation for use' in France.

AREAS COVERED

The safety of the above mentioned medications on liver, digestive system, kidney function, nervous system, pregnancy and lactation and their possible side effects are described and discussed.

EXPERT OPINION

Mechanism of action and metabolism of these drugs as well as patients' clinical characteristics can affect the safety of treatment. All approved medications are valid tools for the treatment of AUD in patients without advanced liver disease. For some drugs, attention should be paid to patients with renal failure and medications may be used with caution, adjusting the dosage according to kidney function. In patients with AUD and advanced liver disease, at present only baclofen has been formally tested in randomized controlled trials showing its safety in this population.

Desire thinking as a confounder in the relationship between mindfulness and craving: Evidence from a cross-cultural validation of the Desire Thinking Questionnaire

Desire thinking and mindfulness have been associated with craving. The aim of the present study was to validate the French version of the Desire Thinking Questionnaire (DTQ) and to investigate the relationship between mindfulness, desire thinking and craving among a sample of university students. Four hundred and ninety six university students completed the DTQ and measures of mindfulness, craving and alcohol use. Results from confirmatory factor analyses showed that the two-factor structure proposed in the original DTQ exhibited suitable goodness-of-fit statistics. The DTQ also demonstrated good internal reliability, temporal stability and predictive validity. A set of linear regressions revealed that desire thinking had a confounding effect in the relationship between mindfulness and craving. The confounding role of desire thinking in the relationship between mindfulness and craving suggests that interrupting desire thinking may be a viable clinical option aimed at reducing craving.

Difficulties in emotion regulation mediate negative and positive affects and craving in alcoholic patients

The aim of this study was to assess the mediating effects of difficulties in emotion regulation (DER) on the relations of negative and positive affects to craving in alcoholic patients. 205 treatment-seeking alcoholic outpatients were included. DER, positive and negative affects as well as craving were evaluated by the Difficulties in Emotion Regulation Scale (DERS), the Positive/Negative Affect Scales, and the Obsessive Compulsive Drinking Scale (OCDS) respectively. Clinical factors including depression and severity of alcohol dependence were investigated by the Alcohol Use Disorders Identification Test (AUDIT) and the Beck Depression Inventory-II (BDI-II) respectively. Results revealed that both increased negative affect and decreased positive affect indirectly influenced craving through limited access to emotion regulation strategies. It was concluded that limited access to emotion regulation strategies may be important in predicting craving for alcoholics who experience both increased negative affect and decreased positive affect. This suggests that treatment and prevention efforts focused on increasing positive affect, decreasing negative affect and teaching effective regulation strategies may be critical in reducing craving in alcoholic patients.

Alcohol use disorder and GABAB receptor gene polymorphisms in an Italian sample: haplotype frequencies, linkage disequilibrium and association studies

BACKGROUND

Alcohol use disorder (AUD) is a complex trait with genetic and environmental influences. Several gene variants have been associated with the risk for AUD, including genes encoding the sub-units of the γ-aminobutyric acid (GABA) receptors.

AIM

This study evaluated whether specific single nucleotide polymorphisms (SNPs) in genes encoding GABAB receptor sub-units can be considered as candidates for the risk of AUD.

SUBJECTS AND METHODS

Seventy-four AUD subjects and 128 Italian controls were genotyped for 10 SNPs in genes encoding GABA-B1 and GABA-B2 sub-units (GABBR1 and GABBR2). Allele, genotype, and haplotype frequencies were tested for the association with the AUD trait.

RESULTS

A significant difference between AUD individuals and controls was observed at genotype level for rs2900512 of GABBR2 gene. The homozygous T/T genotype was not found in the controls, whereas it was over-represented in the AUD individuals. Under the recessive model (T/T vs C/T + C/C) this result was statistically significant, as well as the Odds Ratio for the association with the AUD trait.

CONCLUSIONS

The results provide preliminary data on the association between GABAB receptor gene variation and risk of AUD. To confirm this finding, studies with larger samples and additional characterisation of the phenotypic AUD trait are required.

The Mini Alcohol Craving Experience Questionnaire: Development and Clinical Application

BACKGROUND

Standardized alcohol craving scales are rarely used outside of research environments despite recognized clinical utility. Scale length is a key barrier to more widespread application. A brief measure of alcohol craving is needed to improve research and treatment of alcohol use disorders (AUDs). Grounded in the Elaborated Intrusion Theory of Desire, the Alcohol Craving Experience (ACE) Questionnaire comprises two 11-item self-report scales that assess past-week frequency and maximum strength of alcohol craving. This study aimed to create a brief version of the ACE while maintaining psychometric integrity and clinical utility.

METHODS

Patients attending a university hospital alcohol and drug outpatient service for the treatment of AUD completed the ACE as part of a questionnaire battery. Three patient samples were utilized: 519 patients with pretreatment and outcome data, 228 patients with pretreatment data, and 66 patients who completed the ACE at treatment sessions 1 and 2.

RESULTS

The Frequency scale of the ACE possessed greater clinical utility and predictive validity than the Strength scale. Revision of the Frequency measure produced a 5-item "Mini Alcohol Craving Experience" (MACE) Questionnaire. Satisfactory validity (construct, predictive, concurrent, convergent, and incremental) and reliability (internal and test-retest) were maintained. A 1 standard deviation increase in pretreatment MACE score was associated with a 54 percentage increase in the odds of patient lapse or dropout.

CONCLUSIONS

The MACE provides a brief, theoretically, and psychometrically robust measure of alcohol craving suitable for use with AUD populations in time-limited clinical and research settings.

Comparative Evaluation of Partial α2 -Adrenoceptor Agonist and Pure α2 -Adrenoceptor Antagonist on the Behavioural Symptoms of Withdrawal after Chronic Alcohol Administration in Mice

As an addictive drug, alcohol produces withdrawal symptoms if discontinued abruptly after chronic use. Clonidine (CLN), a partial α2 -adrenergic agonist, and mirtazapine (MRT), an antagonist of α2 -adrenoceptor, both clinically aid alcohol withdrawal. Considering different mechanisms of action of the two drugs, this study was designed to see how far these two mechanistically different drugs differ in their ability to decrease the severity of ethanol withdrawal syndrome. The effect of CLN and MRT on ethanol withdrawal-induced anxiety, depression and memory impairment was analysed using EPM, FST and PAR tests, respectively. Animals received distilled water, ethanol and/or either of the drugs (CLN and MRT) in different doses. Relapse to alcohol use was analysed by CPP test. Animals received ethanol as a conditioning drug and distilled water, CLN or MRT as test drug. CLN and MRT both alleviated anxiety in a dose-dependent manner. MRT (4 mg/kg) was more effective than CLN (0.1 mg/kg) in ameliorating the anxiogenic effect of alcohol withdrawal. However, CLN treatment increased depression. It significantly decreased swimming time and increased immobility time, whereas MRT treatment decreased immobility time and increased climbing and swimming time during abstinence. The effect was dose dependent for both drugs. The results of PAR test show that CLN treatment worsens working memory. Significant increase in SDE and TSZ and decrease in SDL were observed in CLN-treated animals. MRT treatment, on the other hand, improved working memory at both doses. Further, both CLN and MRT alleviated craving. A significant decrease in time spent in the ethanol-paired chamber was seen. MRT treatment at both doses showed better effect than CLN in preventing the development of preference in CPP test. These findings indicate a potential therapeutic use and better profile of mirtazapine over clonidine in improving memory, as well as in alleviating depression, anxiety and craving associated with alcohol withdrawal.

Elevated Glutamate Levels in the Left Dorsolateral Prefrontal Cortex Are Associated with Higher Cravings for Alcohol

BACKGROUND

Quantifying craving longitudinally during the course of withdrawal, early abstinence, and relapse is essential for optimal management of alcohol use disorder (AUD). In an effort to identify biological correlates of craving, we used proton magnetic resonance spectroscopy (1H-MRS) to investigate the correlation between craving and glutamate levels in the left dorsolateral prefrontal cortex (LDLPFC) of patients with AUD.

METHODS

Participants underwent 1H-MRS of the LDLPFC with 2-dimensional J-resolved (2DJ) averaged PRESS. MRS data were processed with LCModel and cerebrospinal fluid (CSF)-corrected to generate metabolite concentrations. The Penn Alcohol Craving Scale (PACS) and the 30-day time line follow-back (TLFB 30) were used to quantify craving for alcohol and drinking patterns, respectively.

RESULTS

There was a statistically significant positive correlation between CSF-corrected glutamate ([Glu]) levels and PACS scores (n = 14; p = 0.005). When PACS scores were dichotomized (< or ≥median = 16), [Glu] levels were significantly higher in the high- versus low-craving group (p = 0.007). In addition, there was a significant negative correlation between CSF-corrected N-acetyl aspartic acid ([NAA]) levels and mean number of drinks per drinking day in the past month (n = 13; TLFB 30; p = 0.012). When mean TLFB 30 was dichotomized (< or ≥median = 7.86), [NAA] levels were significantly lower in subjects that consumed more alcoholic beverages. There was no significant correlation between [Glu] and [NAA] levels with other measures of drinking behavior and or depression symptom severity.

CONCLUSIONS

While limited by small sample size, these data suggest that glutamate levels in LDLPFC are associated with alcohol craving intensity in patients with AUD. Further study with larger sample size is needed to replicate this finding and evaluate the merits of glutamate spectroscopy as a biological correlate of alcohol craving intensity and a guide to treatment interventions.

Serotonergic Neuroplasticity in Alcohol Addiction

Alcohol addiction is a debilitating disorder producing maladaptive changes in the brain, leading drinkers to become more sensitive to stress and anxiety. These changes are key factors contributing to alcohol craving and maintaining a persistent vulnerability to relapse.

Serotonin (5-Hydroxytryptamine, 5-HT) is a monoamine neurotransmitter widely expressed in the central nervous system where it plays an important role in the regulation of mood. The serotonin system has been extensively implicated in the regulation of stress and anxiety, as well as the reinforcing properties of all of the major classes of drugs of abuse, including alcohol. Dysregulation within the 5-HT system has been postulated to underlie the negative mood states associated with alcohol use disorders.

This review will describe the serotonergic (5-HTergic) neuroplastic changes observed in animal models throughout the alcohol addiction cycle, from prenatal to adulthood exposure. The first section will focus on alcohol-induced 5-HTergic neuroadaptations in offspring prenatally exposed to alcohol and the consequences on the regulation of stress/anxiety. The second section will compare alterations in 5-HT signalling induced by acute or chronic alcohol exposure during adulthood and following alcohol withdrawal, highlighting the impact on the regulation of stress/anxiety signalling pathways. The third section will outline 5-HTergic neuroadaptations observed in various genetically-selected ethanol preferring rat lines. Finally, we will discuss the pharmacological manipulation of the 5-HTergic system on ethanol- and anxiety/stress-related behaviours demonstrated by clinical trials, with an emphasis on current and potential treatments.