Use of Anti-Craving Agents in Soldiers with Alcohol Dependence Syndrome

Relationship between Craving and Early Relapse in Alcohol Dependence: A Short-Term Follow-up Study

BACKGROUND

The role of craving in alcohol dependence and its relationship with relapse has been studied widely in the past decade. The present study was undertaken to assess the role of craving in short-term relapse of patients seeking treatment for alcohol dependence and changes in craving score at the end of detoxification and at follow-up.

MATERIALS AND METHODS

A total of 34 male individuals with alcohol dependence (excluding comorbid drug dependence, organic or psychiatric disorder), after detoxification and discharge, consented. No anticraving medicine, aversive or psychotherapy, was advised. They were diagnosed on the International Statistical Classification of Diseases-10 using Diagnostic Interview for Genetic Studies. Severity of Alcohol Dependence Questionnaire (SADQ) and Clinical Institute Withdrawal Assessment Scale-Alcohol-Revised (CIWA-AR) were administered at the time of admission. Penn Alcohol Craving Scale (PACS) was applied at the time of discharge and follow-up to measure craving for alcohol.

RESULTS

Out of a total of thirty patients analyzed after dropout, 21 relapsed at the end of 1 month. On comparing PACS scores between relapsed and nonrelapsed patients, the difference was significant at both time points, i.e., at discharge and follow-up (t = 4.15, P < 0.0001 and t = 4.01, P < 0.001, respectively). In the total sample, SADQ and CIWA-AR scores were positively correlated (r = 0.47, P = 0.009). PACS at discharge was compared with PACS at follow-up, of which the correlation was high (r = 0.832, P < 0.0001).

CONCLUSION

Craving seems to be a main factor related to relapse. Its measurement with PACS can be a useful tool to predict subsequent drinking and to identify individual risk for relapse during treatment.

Pharmacotherapy for relapse prevention of alcohol use disorder in the Indian setting: A systematic review

Alcohol use disorders (AUDs) is an important public health concern as estimates of the prevalence of AUD range at 4%-6% in the Indian population. Currently, there is limited literature on the pharmacotherapeutic interventions for AUD in the Indian setting. It is imperative to identify the possible variations in their effects from Western studies, and hence the current review was attempted to perform a comprehensive evaluation and critical appraisal of the methodology of the evidence on pharmacological strategies of relapse prevention of AUD in the Indian setting. A total of 18 studies were included in the review. Disulfiram was the most common pharmacological agent to be studied. The initial literature before 2000 focused primarily on disulfiram, whereas the studies in the next decade compared it to acamprosate and naltrexone and emerging interest in anticraving agents such as baclofen and topiramate had been noted over the past few years. No studies were available on newer agents such as ondansetron, selective serotonin reuptake inhibitors or formulations such as depot and implants. Deterrent agents were found to be better when compared to anticraving agents in terms of abstinence and relapse, whereas the latter were more effective for control of craving. Among the pharmacological agents studied, the greatest evidence exists for disulfiram for relapse prevention which could be due to affordability of disulfiram and social support in the Indian context. The chief methodological limitations include the lack of randomized trials and objective measures for assessing abstinence.

Critical needs in drug discovery for cessation of alcohol and nicotine polysubstance abuse

Polysubstance abuse of alcohol and nicotine has been overlooked in our understanding of the neurobiology of addiction and especially in the development of novel therapeutics for its treatment. Estimates show that as many as 92% of people with alcohol use disorders also smoke tobacco. The health risks associated with both excessive alcohol consumption and tobacco smoking create an urgent biomedical need for the discovery of effective cessation treatments, as opposed to current approaches that attempt to independently treat each abused agent. The lack of treatment approaches for alcohol and nicotine abuse/dependence mirrors a similar lack of research in the neurobiology of polysubstance abuse. This review discusses three critical needs in medications development for alcohol and nicotine co-abuse: (1) the need for a better understanding of the clinical condition (i.e. alcohol and nicotine polysubstance abuse), (2) the need to better understand how these drugs interact in order to identify new targets for therapeutic development and (3) the need for animal models that better mimic this human condition. Current and emerging treatments available for the cessation of each drug and their mechanisms of action are discussed within this context followed by what is known about the pharmacological interactions of alcohol and nicotine. Much has been and will continue to be gained from studying comorbid alcohol and nicotine exposure.

Anticonvulsants for alcohol dependence

BACKGROUND

Alcohol dependence is a major public health problem that is characterised by recidivism and a host of medical and psychosocial complications. Besides psychosocial interventions, different pharmacological interventions have been or currently are under investigation through Cochrane systematic reviews.

OBJECTIVES

The primary aim of the review is to assess the benefits/risks of anticonvulsants for the treatment of alcohol dependence.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group Trials Register (October 2013), PubMed (1966 to October 2013), EMBASE (1974 to October 2013) and CINAHL (1982 to October 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing anticonvulsants alone or in association with other drugs and/or psychosocial interventions versus placebo, no treatment and other pharmacological or psychosocial interventions.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by The Cochrane Collaboration.

MAIN RESULTS

A total of 25 studies were included in the review (2641 participants). Most participants were male, with an average age of 44 years. Anticonvulsants were compared with placebo (17 studies), other medications (seven studies) and no medication (two studies). The mean duration of the trials was 17 weeks (range four to 52 weeks). The studies took place in the USA, Europe, South America, India and Thailand. Variation was reported in the characteristics of the studies, including their design and the rating instruments used. For many key outcomes, the risk of bias associated with unclear or unconcealed allocation and lack of blinding affected the quality of the evidence.Anticonvulsants versus placebo: For dropouts (16 studies, 1675 participants, risk ratio (RR) 0.94, 95% confidence interval (Cl) 0.74 to 1.19, moderate-quality evidence) and continuous abstinence (eight studies, 634 participants, RR 1.21, 95% Cl 95% 0.97 to 1.52, moderate-quality evidence), results showed no evidence of differences. Moderate-quality evidence suggested that anticonvulsants reduced drinks/drinking days (11 studies, 1126 participants, mean difference (MD) -1.49, 95% Cl -2.32 to -0.65) and heavy drinking (12 studies, 1129 participants, standardised mean difference (SMD) -0.35, 95% Cl -0.51 to -0.19). Moreover, withdrawal for medical reasons (12 studies, 1410 participants, RR 1.22, 95% Cl 0.58 to 2.56, moderate-quality evidence) showed no evidence of difference, but for specific adverse effects (nine studies, 1164 participants), two of 18 adverse event outcomes favoured placebo. The direction of results was confirmed by subgroup analyses for topiramate and partially for gabapentin and valproate.Anticonvulsants versus naltrexone: No evidence of difference was shown in dropout rates (five studies, 528 participants, RR 0.74, 95% CI 0.52 to 1.06), severe relapse rates (four studies, 427 participants, RR 0.69, 95% Cl 0.44 to 1.07) and continuous abstinence rates (five studies, 528 participants, RR 1.21, 95% Cl 0.99 to 1.49); anticonvulsants were associated with fewer heavy drinking days (three studies, 308 participants, MD -5.21, 95% Cl -8.58 to -1.83), more days to severe relapse (three studies, 244 participants, MD 11.88, 95% Cl 3.29 to 20.46) and lower withdrawal for medical reasons (three studies, 245 participants, RR 0.13, 95% Cl 0.03 to 0.58).

AUTHORS' CONCLUSIONS

At the current stage of research, randomised evidence supporting the clinical use of anticonvulsants to treat alcohol dependence is insufficient. Results are conditioned by heterogeneity and by the low number and quality of studies comparing anticonvulsants with other medications. The uncertainty associated with these results leaves to clinicians the need to balance possible benefits/risks of treatment with anticonvulsants versus other medications as supported by evidence of efficacy.

Medical treatment of alcohol dependence: a systematic review

OBJECTIVE

To summarize published data on pharmacologic treatments for alcohol dependence alone and in combination with brief psychosocial therapies that may be feasible for primary care and specialty medical settings.

METHODS

We conducted electronic searches of published original research articles and reviews in MEDLINE, SCOPUS, CINAHL, Embase, and PsychINFO. In addition, hand searches of reference lists of review articles, supplemental searches of internet references and contacts with experts in the field were conducted. Randomized controlled studies published between January 1960 and August 2010 that met our inclusion/exclusion criteria were included.

RESULTS

A total of 85 studies, representing 18,937 subjects, met our criteria for inclusion. The evidence base for oral naltrexone (6% more days abstinent than placebo in the largest study) and topiramate (prescribed off-label) (e.g., 26.2% more days abstinent than placebo in a recent study) is positive but modest. Acamprosate shows modest efficacy with recently abstinent patients, with European studies showing better results than U.S. ones. The evidence-base for disulfiram is equivocal. Depot naltrexone shows efficacy (25% greater reduction in rate of heavy drinking vs. placebo, in one of the largest studies) in a limited number of studies. Some studies suggest that patients do better with extensive psychosocial treatments added to medications while others show that brief support can be equally effective.

CONCLUSIONS

Although treatment effects are modest, medications for alcohol dependence, in conjunction with either brief support or more extensive psychosocial therapy, can be effective in primary and specialty care medical settings.