Pregabalin, tiapride and lorazepam in alcohol withdrawal syndrome: a multi-centre, randomized, single-blind comparison trial

[Antipsychotic Treatment of Alcohol Withdrawal Syndrome with Focus on Delirium Tremens: a Systematic Review]

BACKGROUND

Delirium tremens (DT) is a common complication of alcohol withdrawal. Pharmacological treatment of hospitalized patients with DT is important in addiction medicine but also in other medical disciplines where DT can occur as a complication of hospitalization. Patients suffering from DT require treatment with benzodiazepines (short-acting benzodiazepines for elderly patients to reduce accumulation), and in cases of psychotic symptoms, treatment with antipsychotics. Benzodiazepines are a first-line treatment for DT. A specific guideline for the use of antipsychotics has yet to be developed. This review discusses the current guidelines and literature on the antipsychotic treatment options in DT.

AIM

Systematic presentation of relevant antipsychotics for the treatment of DT.

METHODS

A systematic literature search was conducted using Scopus and PubMed. The last search was conducted on May 22nd 2022. Original articles and reviews on antipsychotic treatment in alcohol withdrawal and DT were included in this review. Further, international guidelines were also considered. The review was registered using the PROSPERO database (https://www.crd.york.ac.uk/prospero/); CRD42021264611.

RESULTS

Haloperidol is mainly recommended for use in the intensive care unit. There is little literature on the use of atypical antipsychotics to treat DT. Treatment with antipsychotics always should be combined with benzodiazepines, and physicians should watch out for complications like neuroleptic malignant syndrome, QTc interval prolongation, extrapyramidal symptoms and withdrawal seizures resulting from lowering the threshold for seizures.

CONCLUSION

Antipsychotic treatment should depend on the experience of the physician. Beside haloperidol, no other clear recommendations are available.

Comparative efficacy of various pharmacologic treatments for alcohol withdrawal syndrome: a systematic review and network meta-analysis

This study was to compare multiple classes of medications and medication combinations to find alternatives or additives for patients not applicable to benzodiazepines (BZDs). We performed a network meta-analysis to assess the comparative effect of 11 pharmacologic treatments in patients with alcohol withdrawal syndrome. Forty-one studies were included, comprising a total sample size of 4187 participants. The pooled results from the randomized controlled trials showed that there was no significant difference in the Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar) reduction with other medications or medication combinations compared to BZDs. Compared to BZDs, the mean difference in ICU length of stay of anticonvulsants + BZDs was -1.71 days (95% CI = -2.82, -0.59). Efficacy rankings from cohort studies showed that anticonvulsant + BZDs were superior to other treatments in reducing CIWA-Ar scores and reducing the length of stay in the ICU. Synthesis results from randomized controlled trials indicate that there are currently no data suggesting that other medications or medication combinations can fully replace BZDs. However, synthetic results from observational studies have shown that BZDs are effective in the context of adjuvant anticonvulsant therapy, particularly with early use of gabapentin in combination with BZDs in the treatment of alcohol withdrawal syndrome, which represents a promising treatment option.

Beyond benzodiazepines: a meta-analysis and narrative synthesis of the efficacy and safety of alternative options for alcohol withdrawal syndrome management

PURPOSE

To compare the efficacy and safety of non-benzodiazepines (non-BZDs) to benzodiazepines (BZDs) in the treatment of alcohol withdrawal syndrome (AWS).

METHODS

For relevant literature, Google Scholar, PubMed, Embase, OVID MEDLINE, EBSCO, Cochrane Central Registry of Controlled Trials, Web of Science, and Scopus were searched. Randomized control trials (RCTs) were included, omitted were nonblinded trials, blinded trials that were not randomized, and open-label studies. The Effective Public Health Practice Project Quality Assessment was used to assess the trial's quality. A meta-analysis and a narrative synthesis were carried out.

RESULTS

Twenty non-BZDs and five BZDs were investigated in thirty RCTs. Meta-analysis favored gabapentin over chlordiazepoxide and lorazepam (d = 0.563, p < 0.001) and carbamazepine over oxazepam and lorazepam (d = 0.376, p = 0.029), for reducing Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) scale scores. Eleven non-BZDs fared better than BZDs for reducing CIWA-Ar, Total Severity Assessment, Selective Severity Assessment, Borg and Weinholdt, and Gross Rating Scale for Alcohol Withdrawal scores. Eight non-BZDs outmatched BZDs regarding autonomic, motor, awareness, and psychiatric symptoms. Sedation and fatigue were prevalent in BZDs, while seizures were prevalent in non-BZDs.

CONCLUSION

For AWS treatments, non-BZDs are superior to or equally effective as BZDs. Non-BZD adverse events warrant further investigation. Agents that inhibit gated ion channels are promising candidates.

PROTOCOL REGISTRATION

PROSPERO CRD42022384875.

Evaluating Craving in Alcohol Use Disorder: Psychometric Characteristics of the Craving Typology Questionnaire-15 (CTQ-15)

AIMS

The Craving Typology Questionnaire (CTQ) is a psychometric instrument used to assess alcohol craving in normal controls and subjects with alcohol use disorder (AUD). It allows a dimensional self-rating assessment of craving according to a three-pathway psychobiological model of craving distinguishing craving into a reward, relief and obsessive component. The aim of the present study is to evaluate psychometric properties of the CTQ-15, a revised version of CTQ with 15 items.

METHODS

The CTQ-15 was firstly administered to two groups of control subjects, one (414 subjects) used for the exploratory factor analysis and the other one (415 subjects) for the confirmatory factor analysis. A three-factor model was assessed and compared to alternative models.

RESULTS

The resulting structure was in line with the original scale CTQ. Obsessive craving accounted for 15.20% of the total variance, relief craving for the 13.99% and reward craving for 13.13% of the total variance. The three-factor model (M1) reached good fit indices (CFI = 0.96, TLI = 0.95, RMSEA = 0.06 and SRMR = 0.05) and was significantly better than other alternative models. Reliability showed good internal consistency for each scale, i.e. obsessive craving (α = 0.92), relief craving (α = 0.82) and reward craving (α = 0.81).

CONCLUSIONS

The CTQ-15 proved to be reliable and practical for identifying the three dimensions of craving in clinical practice. Craving plays a crucial role in the mechanisms of dependence and relapse; thus, characterizing the craving can be fundamental to a targeted drug therapy.

Efficacy of tiapride in the treatment of psychiatric disorders: A systematic review

BACKGROUND

Tiapride is an atypical antipsychotic used to treat alcohol withdrawal, aggressiveness and agitation, headache, dyskinesias, tic and Tourette's disorder. More recently, it has been proposed for the treatment of delirium and agitation in hospitalised patients with COVID-19. Although its safety profile makes it suitable for use in vulnerable populations, the use of tiapride for psychiatric disorders is limited. This work aims to systematically review the available evidence on the efficacy and tolerability of tiapride in individuals with a psychiatric disorder.

METHODS

We searched PubMed, Embase, PsycINFO, GreyLit, OpenGrey, and ProQuest up to March 2020 for randomised controlled trials focussing on the use of tiapride in the treatment of individuals with a psychiatric disorder (e.g., mood disorder, schizophrenia spectrum, substance use disorder). The Risk of Bias 2 was performed for the quality assessment of the included studies.

RESULTS

We identified 579 records. Of them, six studies (published between 1982 and 2010) were included in the review. Four studies referred to alcohol withdrawal, and two to the management of agitation in elderly patients with dementia. None of the studies reported significant differences between tiapride and other active comparators in terms of efficacy and tolerability. The overall risk of bias was moderate to high.

CONCLUSION

Tiapride may be considered as a relatively safe treatment option for selected patients with alcohol withdrawal or agitation in dementia. However, solid evidence of its efficacy in the scientific literature is lacking. High-quality trials remain necessary to fully sustain its use in clinical practice.

The effectiveness and tolerability of anti-seizure medication in alcohol withdrawal syndrome: a systematic review, meta-analysis and GRADE of the evidence

BACKGROUND AND AIMS

Anti-seizure medications (ASMs) have been used historically as treatment options in alcohol withdrawal syndrome (AWS). In the past 10 years, there have been no large-scale meta-analyses comparing ASMs with placebo or the current AWS treatment standard, benzodiazepines. We aimed to evaluate the efficacy and tolerability of ASMs in AWS.

METHODS

Systematic review and meta-analysis of randomised controlled trials (RCTs) via searching Medline, Embase and PsychINFO from database inception to March 2020 involving adults age >18 years with AWS. We included 24 RCTs reporting on a total of 2223 participants. Efficacy outcomes included the number of participants experiencing AWS related seizures or delirium, Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) score reduction and rescue medication requirements. Tolerability outcomes included adverse event rate and dropout because of adverse events, alongside severe and life-threatening adverse event rates. Quality was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

There was no evidence of significant improvements in any efficacy outcomes when comparing ASMs with placebo or benzodiazepines. When compared with benzodiazepines, ASMs demonstrated significantly increased odds of requiring rescue medications (OR = 3.50, 95% CI = 1.32, 9.28; P = 0.012). When comparing ASMs with placebo, there were significantly more dropouts because of adverse events (OR = 1.86, 95% CI = 1.05, 3.28; P = 0.034). Most results were of very low quality with the majority of included studies conducted before 2000.

CONCLUSIONS

This systematic review and meta-analysis found no evidence to support general first line clinical use of anti-seizure medications in alcohol withdrawal syndrome treatment.

The Effectiveness of Non-Benzodiazepine, Non-Barbiturate Medications for Alcohol Withdrawal Syndrome: A Rapid Systematic Review

AIM

There are potential clinical, ethical and legal concerns with overdosing benzodiazepines (or barbiturates) for the treatment of moderate to severe alcohol withdrawal symptoms (AWS) through telemedicine or ambulatory outpatients. A rapid systematic review to (a) qualitatively summarize the non-benzodiazepine treatment alternatives, (b) evaluate the quality of evidence for the same to effectively manage moderate to severe AWS.

METHODS

We conducted searches on PubMed (January 1990 to 31 March 2020), Cochrane Central Register of Controlled Trials, and Google Scholar. We selected the English language randomized controlled trials (RCTs) assessing the efficacy and adverse effects of non-benzodiazepine and non-barbiturate medications among adults with a diagnosis of AWS. Data extraction was done in a predefined format. Risk of bias (RoB) assessment and qualitative synthesis of evidence was done with the RoB2 tool and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) proGDT.

RESULTS

Thirty-four RCTs were included. Gabapentin (n = 6), carbamazepine (n = 5), baclofen (n = 5), valproate (n = 3), clonidine/lofexidine (n = 3) and acamprosate (n = 2) had more than one trial with a particular comparison group. Four studies were found to have a low ROB. The GRADE evidence summary showed gabapentin had a 'moderate' level of evidence against standard benzodiazepine treatments for reducing the severity of AWS. The level of certainty was 'low' for carbamazepine, baclofen and valproate and 'very low' for acamprosate and clonidine/lofexidine. Reported adverse events between these alternative medications and benzodiazepines or placebo were generally unremarkable.

CONCLUSIONS

Although benzodiazepines remain the treatment of choice for AWS, during particular circumstances, gabapentin could be an alternative although like benzodiazepines is not without risk when used in the community. Future RCTs must aim to improve upon the quality of evidence.

An open-label pilot study of pregabalin pharmacotherapy for alcohol use disorder

Background: There is a need for alcohol use disorder (AUD) pharmacotherapy that can be administered to actively drinking outpatients. Pregabalin, a gabapentoid anticonvulsant, has preliminary evidence supporting effects on alcohol withdrawal and AUD.Objectives: To evaluate the safety, tolerability, and optimal dosing of pregabalin for treating AUD.Methods: In an open-label, 8-week, outpatient trial of eighteen adults (nine women) with AUD, participants were titrated to 600 mg/day (or the maximum tolerated dose) over 3 weeks and then maintained for 5 weeks.Results: The majority (11/14, 78.6%) of participants with at least one-week of medication exposure achieved a maximum dose of 600 mg/day. Mean retention was 6.8 weeks (SD = 2.6). Eighty percent (12/15) of participants with post-enrollment data reported any adverse effects during the trial; and for those reporting adverse effects the most common were drowsiness (33.3%, 4/12), and fogginess (25%, 3/12), dizziness (25%, 3/12), and insomnia (25%, 3/12). Two participants discontinued study medication due to adverse effects and one had a dose reduction. Mean Heavy Drinking Days (HDD)/week decreased significantly by 3.43 days (SD = 2.47; median (IQR) = 4.00 (1.00 to 5.50)); Wilcoxon signed rank test statistic ((S) = 49.5, p = .0006). Mean proportion of HDD significantly decreased on average by 48.7% (SD = 35.1%; median (IQR) = 57.1% (14.3% to 78.6%)). The proportion of abstinent days increased significantly on average by 36.1% (SD = 35.0%; median (IQR) = 17.9% (14.3% to 75.0%); S = 49.5, p = .0005).Conclusions: Pregabalin treatment of AUD appears to be safe and well tolerated in doses up to 600 mg per day.Trial Registration: clinicaltrials.gov identifier: NCT03256253.

[Pregabalin abuse and dependence in various European countries: Association with substitution policies]

INTRODUCTION

Pregabalin was first approved in 2004 for the treatment of peripheral neuropathic pain and focal epileptic seizures, with or without secondary generalization. Prescription frequency has increased significantly since approval. In the early days, little attention was paid to the problem of misuse and dependence on pregabalin; in recent years, there has been a significant increase in the number of publications focusing on this problem. This review deals with these risk factors and risk groups of pregabalin abuse and dependence in different European countries and their drug policies.

RESULTS

Pregabalin abuse and dependence has increased significantly since its introduction to the market. It was shown that solo abuse of pregabalin is rare. In most cases, pregabalin was combined with other substances, which is also a predictor of pregabalin abuse. There were different reasons for the non-prescription use of pregabalin; it was used to increase the psychotropic effect, on the one hand, and to alleviate withdrawal symptoms, on the other hand. Furthermore, in Sweden, pregabalin was found in 28% of fatal intoxications among drug addicts. Young people were particularly affected. Abuse of pregabalin was detected in countries with restrictive substitution programmes, while in countries with liberal drug policies, no abuse was detected. However, the data situation in Switzerland with a liberal substitution programme is based on only one study, which is why pregabalin use in liberal substitution programmes cannot be conclusively clarified.

CONCLUSIONS

There seems to be a connection between a country's drug policy and the illegal use of pregabalin among persons in a substitution programme in that country. There are also risk factors and risk groups for pregabalin dependence and abuse.

Gabapentinoids for treatment of alcohol use disorder: A systematic review and meta-analysis

OBJECTIVE

Gabapentin (GBP) and pregabalin (PGB) have been used to treat alcohol use disorder (AUD) and alcohol withdrawal, but with inconsistent results. In this meta-analysis, we explored the effects of GBP/PGB treatment on AUD and their effects on withdrawal, craving, depression, and sleep disturbance in AUD patients.

METHODS

We carried out a systematic review and meta-analysis of randomized controlled trials comparing the effects of GBP/PGB on AUD with those of a placebo or control treatment. Electronic databases were searched for relevant articles published before September 2019. The primary outcome was defined as the efficacy measure on achieving abstinence or reducing alcohol consumption in a hierarchical order. We included 16 studies in our meta-analysis.

RESULTS

Overall, GBP had no significant benefit comparing to placebo or control treatment (Hedges' g = 0.0725, p = 0.6743). For specific alcohol-related outcome, GBP had significant effect on percentage of heavy drink (Hedges' g = 0.5478, p = 0.0441) and alcohol withdrawal symptoms (Hedges' g = 0.2475, p = 0.0425). GBP/PGB did not have significant beneficial effect on craving, depressive symptoms, or sleep disturbance. Instability was shown in sensitivity analyses of some above results.

CONCLUSIONS

GBP may be helpful to reduce AUD patients' heavy drinking behavior and withdrawal, but more studies are needed for drawing conclusions.

Patterns of gabapentin and pregabalin use and misuse: Results of a population-based cohort study in France

AIMS

The aim of this study was to assess the use and factors associated with the misuse of gabapentin and pregabalin in the general French population, through a cohort study in the EGB (General Sample of Beneficiaries), a national representative sample of the French general population.

METHODS

New users of gabapentin and pregabalin were identified from June 2006 to December 2014, and new users of duloxetine served as control group. Misuse was defined as a use of higher daily doses than recommended. Cox proportional hazard regression models were performed to identify associated factors of misuse.

RESULTS

Misuse was more frequent in the 8692 new users of pregabalin (12.8%) than in the 1963 gabapentin (6.6%) or the 3214 duloxetine new users (9.7%) (P < 0.001). Factors associated with misuse were pregabalin (hazard ratio [HR] 1.48; 95% confidence interval [CI] [1.29-1.69]), age (HR_{[18-45] versus > 70 years} 1.98 [1.70-2.31] and HR_{[58-70] versus > 70 years} 1.25 [1.06-1.47]), multiple prescribers (HR_{2 or 3 versus 1 prescriber} 1.29 [1.15-1.45]; HR_{4 or more versus 1 prescriber} 1.54 [1.30-1.83]), cancer (1.28 [1.11-1.47]), multiple sclerosis (1.53 [1.07-2.18]), neuropathy (1.85 [1.19-2.89]), depression (1.26 [1.07-1.49]) and methadone (2.61 [1.16-5.84]). After this first episode of drug misuse, 11.6% of gabapentin and 10.7% of pregabalin misusers developed a primary addiction.

CONCLUSION

In a cohort of new users, misuse is more likely to occur in new users of pregabalin, with different associated factors of misuse compared to gabapentin and duloxetine. Health professionals and prescribers must be aware of this misuse potential, which could lead to abuse and dependence.

Diagnosis and treatment of acute alcohol intoxication and alcohol withdrawal syndrome: position paper of the Italian Society on Alcohol

The chronic use of alcohol can lead to the onset of an alcohol use disorder (AUD). About 50% of subjects with an AUD may develop alcohol withdrawal syndrome (AWS) when they reduce or discontinue their alcohol consumption and, in 3-5% of them, convulsions and delirium tremens (DTs), representing life-threatening complications, may occur. Unfortunately, few physicians are adequately trained in identifying and treating AWS. The Italian Society on Alcohol has, therefore, implemented a task force of specialists to draw up recommendations for the treatment of AWS with the following main results: (1) while mild AWS may not require treatment, moderate and severe AWS need to be pharmacologically treated; (2) out-patient treatment is appropriate in patients with mild or moderate AWS, while patients with severe AWS need to be treated as in-patients; (3) benzodiazepines, BDZs are the "gold standard" for the treatment of AWS and DTs; (4) alpha-2-agonists, beta-blockers, and neuroleptics may be used in association when BDZs do not completely resolve specific persisting symptoms of AWS; (5) in the case of a refractory form of DTs, the use of anaesthetic drugs (propofol and phenobarbital) in an intensive care unit is appropriate; (6) alternatively to BDZs, sodium oxybate, clomethiazole, and tiapride approved in some European Countries for the treatment of AWS may be employed for the treatment of moderate AWS; (7) anti-convulsants are not sufficient to suppress AWS, and they may be used only in association with BDZs for the treatment of refractory forms of convulsions in the course of AWS.

Investigational drug therapies in phase I and phase II clinical trials for alcohol use disorders

INTRODUCTION

Alcohol use disorder (AUD) is a complex psychiatric condition characterized by craving, compulsive seeking, loss of control of alcohol consumption as well as the emergence of negative emotional states during withdrawal. Despite the large socioeconomic burden of AUD, therapeutic treatment options lag behind.

AREAS COVERED

This review covers pharmacotherapies currently in phase I/II clinical trials for the treatment of AUDs listed on clinicaltrials.gov. We discuss drug therapies that modulate monoamine, GABA/Glutamate, neuropeptide and neuroimmune systems. We examine in depth preclinical and clinical evidence of a select range of these compounds and consider their utility in treating AUDs.

EXPERT OPINION

Current therapeutic options to treat AUD are inadequate at a population level. Currently there are 30 different compounds and one compound combination in phase I/II clinical trials for AUD. These compounds target various aspects of neurotransmitter signaling, neuroimmune modulation, and alcohol metabolism. Almost 75% of these compounds under trial are Food and Drug Administration (FDA) approved for other indications, which may save time and costs in treatment development. Further, development of therapeutics focused on genetic biomarkers and behavioral screening may improve how treatment decisions are made in the future on a case-by-case basis.

New steps for treating alcohol use disorder

Alcohol use disorder is a complex syndrome with multiple treatment points including drug-induced pathology, withdrawal management, behavioral/cognitive strategies, and relapse prevention. These different components may be complicated by genotype and phenotype. A huge milestone for the treatment of alcohol use disorder across several countries in the last 10 years was the introduction of practice guidelines integrating clinical expertise and research evidence. These provide a summary of interventions that have been shown to be effective following rigorous and replicated clinical trials. Inspection of these guidelines reveals good consistency, but little evidence of progress in treatment approaches for alcohol use disorder over the past decade. In this mini-review, we discuss emerging treatments for alcohol use disorder that may supplement or improve the evidence-based treatments that are currently recommended. New medications, the emergence of digital technology, and other novel approaches such as transcranial magnetic stimulation are all discussed with reference to treatments already in practice. We also consider how individual differences in genotype and phenotype may affect outcomes. Together with improvements in technology, this knowledge offers a powerful tool for designing personalized approaches to treatment, and hence improving prognosis for rehabilitation programs.

Medications for alcohol use disorders: An overview

Patients who suffer from alcohol use disorders (AUDs) usually go through various socio-behavioral and pathophysiological changes that take place in the brain and other organs. Recently, consumption of unhealthy food and excess alcohol along with a sedentary lifestyle has become a norm in both developed and developing countries. Despite the beneficial effects of moderate alcohol consumption, chronic and/or excessive alcohol intake is reported to negatively affect the brain, liver and other organs, resulting in cell death, organ damage/failure and death. The most effective therapy for alcoholism and alcohol related comorbidities is alcohol abstinence, however, chronic alcoholic patients cannot stop drinking alcohol. Therefore, targeted therapies are urgently needed to treat such populations. Patients who suffer from alcoholism and/or alcohol abuse experience harmful effects and changes that occur in the brain and other organs. Upon stopping alcohol consumption, alcoholic patients experience acute withdrawal symptoms followed by a protracted abstinence syndrome resulting in the risk of relapse to heavy drinking. For the past few decades, several drugs have been available for the treatment of AUDs. These drugs include medications to reduce or stop severe alcohol withdrawal symptoms during alcohol detoxification as well as recovery medications to reduce alcohol craving and support abstinence. However, there is no drug that completely antagonizes the adverse effects of excessive amounts of alcohol. This review summarizes the drugs which are available and approved by the FDA and their mechanisms of action as well as the medications that are under various phases of preclinical and clinical trials. In addition, the repurposing of the FDA approved drugs, such as anticonvulsants, antipsychotics, antidepressants and other medications, to prevent alcoholism and treat AUDs and their potential target mechanisms are summarized.

Gabapentin for the treatment of alcohol use disorder

INTRODUCTION

Alcohol misuse is the fifth leading risk factor for premature death and disability worldwide. Fewer than 10% of afflicted Americans receive pharmacological treatment for alcohol use disorder. Gabapentin is a calcium channel GABAergic modulator that is widely used for pain. Studies showing reduced drinking and decreased craving and alcohol-related disturbances in sleep and affect in the months following alcohol cessation suggest therapeutic potential for alcohol use disorder. Areas covered: Human laboratory and clinical studies assessing gabapentin for alcohol use disorder are reviewed. Data were obtained by searching for English peer-reviewed articles on PubMed, reference lists of identified articles, and trials registered on clinicaltrials.gov. Additionally, the mechanism of action of gabapentin specific to alcohol use disorder, and studies of gabapentin for alcohol withdrawal and non-alcohol substance use disorders are summarized. Expert opinion: Alcohol use disorder represents a challenge and large, unmet medical need. Evidence from single-site studies lend support to the safety and efficacy of gabapentin as a novel treatment for alcohol use disorder, with unique benefits for alcohol-related insomnia and negative affect, relative to available treatments. Proprietary gabapentin delivery systems may open a path to pivotal trials and registration of gabapentin as a novel treatment for alcohol use disorder.

Treatment of Comorbid Alcohol Dependence and Anxiety Disorder: Review of the Scientific Evidence and Recommendations for Treatment

Patients with alcohol-use disorders (AUDs) have a high prevalence of anxiety disorders (AnxDs). "Co-occurring disorders" refers to the coexistence of an AUD and/or drug related disorders with another non-addictive psychiatric disorder. The aim of this study was to assess the effectiveness of psychopharmacological treatments and psychotherapy in patients with AUD and AnxD and to propose recommendations for the treatment of patients with comorbid AnxDs and AUDs. Randomized clinical trials, meta-analyses, and clinical guidelines were retrieved from PubMed, Embase, and Cochrane databases. Paroxetine was found to be effective in social anxiety patients with alcohol dependence. Selective serotonin reuptake inhibitors (SSRIs), especially sertraline, showed effective results in posttraumatic stress disorder and in comorbid AnxD-AUD. However, SSRIs should be used with caution when patients are actively drinking because they may increase alcohol consumption. Buspirone, gabapentin, and pregabalin were found to be effective in comorbid AnxD-AUD. The treatment of dual AnxDs should start as early as possible. Since AUDs and AnxDs can reinforce each other, treatments targeting both pathologies can be effective. Women suffer from higher levels of stress and AnxDs than men, and they are also more vulnerable to maintaining alcohol consumption levels. Further research is needed in this comorbid patient population, including the study of different types of patients and gender perspectives.

Medications development for the treatment of alcohol use disorder: insights into the predictive value of animal and human laboratory models

Development of effective treatments for alcohol use disorder (AUD) represents an important public health goal. This review provides a summary of completed preclinical and clinical studies testing pharmacotherapies for the treatment of AUD. We discuss opportunities for improving the translation from preclinical findings to clinical trial outcomes, focusing on the validity and predictive value of animal and human laboratory models of AUD. Specifically, while preclinical studies of medications development have offered important insights into the neurobiology of the disorder and alcohol's molecular targets, limitations include the lack of standardized methods and streamlined processes whereby animal studies can readily inform human studies. Behavioral pharmacology studies provide a less expensive and valuable opportunity to assess the feasibility of a pharmacotherapy prior to initiating larger scale clinical trials by providing insights into the mechanism of the drug, which can then inform recruitment, analyses, and assessments. Summary tables are provided to illustrate the wide range of preclinical, human laboratory, and clinical studies of medications development for alcoholism. Taken together, this review highlights the challenges associated with animal paradigms, human laboratory studies, and clinical trials with the overarching goal of advancing treatment development and highlighting opportunities to bridge the gap between preclinical and clinical research.

Pregabalin for the Treatment of Drug and Alcohol Withdrawal Symptoms: A Comprehensive Review

Treatments for physical dependence and associated withdrawal symptoms following the abrupt discontinuation of prescription drugs (such as opioids and benzodiazepines), nicotine, alcohol, and cannabinoids are available, but there is still a need for new and more effective therapies. This review examines evidence supporting the potential use of pregabalin, an α2δ voltage-gated calcium channel subunit ligand, for the treatment of physical dependence and associated withdrawal symptoms. A literature search of the MEDLINE and Cochrane Library databases up to and including 11 December 2015 was conducted. The search term used was '(dependence OR withdrawal) AND pregabalin'. No other date limits were set and no language restrictions were applied. Works cited in identified articles were cross-referenced and personal archives of references also searched. Articles were included based on the expert opinions of the authors. There is limited evidence supporting the role of pregabalin for the treatment of physical dependence and accompanying withdrawal symptoms associated with opioids, benzodiazepines, nicotine, cannabinoids, and alcohol, although data from randomized controlled studies are sparse. However, the current evidence is promising and provides a platform for future studies, including appropriate randomized, placebo- and/or comparator-controlled studies, to further explore the efficacy and safety of pregabalin for the treatment of withdrawal symptoms. Given the potential for pregabalin misuse or abuse, particularly in individuals with a previous history of substance abuse, clinicians should exercise caution when using pregabalin in this patient population.

Dopamine receptor agonists modulate voluntary alcohol intake independently of individual levels of alcohol intake in rats

RATIONALE

Individual susceptibility to alcohol use disorder has been related to functional changes in dopaminergic neurotransmission.

OBJECTIVES

The aim of the current work was to assess the effects of selective dopamine D1 and D2 receptor agonists and antagonists on alcohol consumption in rats that differ in individual levels of alcohol intake.

METHODS

The effects of the dopamine D1 receptor agonist SKF 82958, the dopamine D1 receptor antagonist SCH 23390, the dopamine D2 receptor agonist sumanirole and the dopamine D2 receptor antagonist L741,626 on alcohol consumption and preference were assessed at different time points after treatment in subgroups of low and high alcohol drinking rats (LD and HD) using an intermittent alcohol access paradigm.

RESULTS

SKF 82958 decreased alcohol intake and alcohol preference throughout the 24-h session. Sumanirole decreased alcohol intake during the first 2 h, but increased alcohol intake during the remainder of the session. The effects of SKF 82958 and sumanirole on alcohol intake and alcohol preference were comparable in LD and HD. By contrast, the dopamine receptor antagonists SCH 23390 and L741,626 did not alter alcohol consumption in either group at any time point.

CONCLUSIONS

These data indicate that stimulation of dopamine D1 receptors reduces alcohol intake, but that endogenous dopamine does not play a primary role in alcohol consumption. Moreover, the difference in alcohol consumption between LD and HD does not involve altered dopamine signaling.

Anticonvulsants for the treatment of alcohol withdrawal syndrome and alcohol use disorders

Alcoholic patients suffer from harmful allostatic neuroplastic changes in the brain causing an acute withdrawal syndrome upon cessation of drinking followed by a protracted abstinence syndrome and an increased risk of relapse to heavy drinking. Benzodiazepines have long been the treatment of choice for detoxifying patients and managing alcohol withdrawal syndrome (AWS). Non-benzodiazepine anticonvulsants (NBACs) are increasingly being used both for alcohol withdrawal management and for ongoing outpatient treatment of alcohol dependence, with the goal of either abstinence or harm reduction. This expert narrative review summarizes the scientific basis and clinical evidence supporting the use of NBACs in treating AWS and for reducing harmful drinking patterns. There is less evidence in support of NBAC therapy for AWS, with few placebo-controlled trials. Carbamazepine and gabapentin appear to be the most promising adjunctive treatments for AWS, and they may be useful as monotherapy in select cases, especially in outpatient settings and for the treatment of mild-to-moderate low-risk patients with the AWS. The body of evidence supporting the use of the NBACs for reducing harmful drinking in the outpatient setting is stronger. Topiramate appears to have a robust effect on reducing harmful drinking in alcoholics. Gabapentin is a potentially efficacious treatment for reducing the risk of relapse to harmful drinking patterns in outpatient management of alcoholism. Gabapentin's ease of use, rapid titration, good tolerability, and efficacy in both the withdrawal and chronic phases of treatment make it particularly appealing. In summary, several NBACs appear to be beneficial in treating AWS and alcohol use disorders.

Craving Typology Questionnaire (CTQ): a scale for alcohol craving in normal controls and alcoholics

INTRODUCTION

Craving is commonly thought to play a crucial role both in the transition from controlled drinking to alcohol dependence and in the mechanism underlying relapse. However there is no consensus on its definition, and on its correct assessment. Another significant hindrance is that craving is almost certainly a multi-faceted construct. To this respect a three pathway psychobiological model able to differentiate craving into a reward, relief, and obsessive component has been suggested.

METHODS

CTQ was administered to 547 control subjects and to 100 alcohol dependent patients. The dimensional structure of the questionnaire, through the principal component analysis, the reliability and the threshold values were evaluated in both the control and clinical sample.

RESULTS

The results showed and confirmed that the CTQ is composed of three dimensions. Cronbach's alpha coefficients suggest that the questionnaire is reliable. Alcohol-dependent subjects had a significantly higher mean score as compared to the normative sample in both Reward, Relief, Obsessive craving. Younger age correlated with higher scores on Reward craving (r=0.38; p<0.001) and males reported significantly higher scores than women on Reward craving (t=4.36; p<0.001).

DISCUSSION

CTQ showed to be a reliable and valid questionnaire to distinguish a normative sample from pathological individuals. The average scores obtained represent the first normative data available for this questionnaire. Identifying a craving type may represent an important predicting or matching variable for anti-craving psychotropics. More research is needed with respect to CTQ's external validity, i.e. correlations with phenotypic, endophenotypic and genetic indicators of relief, reward and obsessive drinking.

Glucuronic acid and the ethanol metabolite ethyl-glucuronide cause toll-like receptor 4 activation and enhanced pain

We have previously observed that the non-opioid morphine metabolite, morphine-3-glucuronide, enhances pain via a toll-like receptor 4 (TLR4) dependent mechanism. The present studies were undertaken to determine whether TLR4-dependent pain enhancement generalizes to other classes of glucuronide metabolites. In silico modeling predicted that glucuronic acid alone and ethyl glucuronide, a minor but long-lasting ethanol metabolite, would dock to the same MD-2 portion of the TLR4 receptor complex previously characterized as the docking site for morphine-3-glucuronide. Glucuronic acid, ethyl glucuronide and ethanol all caused an increase in TLR4-dependent reporter protein expression in a cell line transfected with TLR4 and associated co-signaling molecules. Glucuronic acid-, ethyl glucuronide-, and ethanol-induced increases in TLR4 signaling were blocked by the TLR4 antagonists LPS-RS and (+)-naloxone. Glucuronic acid and ethyl glucuronide both caused allodynia following intrathecal injection in rats, which was blocked by intrathecal co-administration of the TLR4 antagonist LPS-RS. The finding that ethyl glucuronide can cause TLR4-dependent pain could have implications for human conditions such as hangover headache and alcohol withdrawal hyperalgesia, as well as suggesting that other classes of glucuronide metabolites could have similar effects.

Correlates of benzodiazepine dependence in the Netherlands Study of Depression and Anxiety

AIMS

Benzodiazepines (BZDs) are effective in the short term against anxiety and insomnia. However, some BZD users develop BZD dependence after a relatively short period of time. Therefore, we aimed to identify the risk factors of BZD dependence.

DESIGN

An observational cohort study.

SETTING

The Netherlands.

PARTICIPANTS

Four hundred and one BZD users of the 2981 participants of the Netherlands Study of Depression and Anxiety (NESDA) were included.

MEASUREMENTS

Socio-demographic, physical, psychological, addiction-related and BZD use-related characteristics were investigated as possible correlates of BZD dependence severity. Dependence severity was measured by the three subscales of the Benzodiazepine Self-Report Questionnaire, comprising problematic use, preoccupation and lack of compliance.

FINDINGS

In multivariate analyses, problematic use was associated with more GP contacts in the past 6 months (β = 0.170, P = 0.001) and severity of insomnia (β = 0.145, P = 0.004). Preoccupation was related to anxiety severity (β = 0.194, P = 0.001), antidepressant use (β = 0.197, P < 0.001), alcohol dependence (β = 0.185, P < 0.001) and a higher daily dosage of BZD (β = 0.160, P = 0.001). Lack of compliance was associated with higher age (β = 0.122, P = 0.03), unemployment (β = 0.105, P = 0.04), insomnia (β = 0.129, P = 0.01), antidepressant use (β = 0.148, P = 0.002) and alcohol dependence (β = 0.108, P = 0.02).

CONCLUSIONS

Insomnia, antidepressant use and alcohol dependence may increase the risk of benzodiazepine dependence among individuals who use benzodiazepines.

Pregabalin for alcohol dependence: a critical review of the literature

INTRODUCTION

Alcohol dependence represents a severe pathological disorder associated with a significant rate of morbidity and mortality. To date, limited pharmacological agents exist to treat this disorder, and there is a growing interest for new therapies. In this context, pregabalin represents a promising strategy. Pregabalin, like gabapentin, selectively binds to the α(2)δsubunit of voltage-gated calcium channels, inhibiting release of excessive levels of excitatory neurotransmitters. The main focus of this review is the clinical use of pregabalin in alcoholic patients, but the authors also reported some data about chemistry, pharmacology, and pharmacokinetics of this drug.

METHODS

The authors conducted a PubMed search of clinical human studies published in English from January 2000 to August 2012 using the following search terms: pregabalin alcohol dependence, pregabalin alcohol withdrawal, pregabalin alcoholism.

RESULTS

The search revealed a total of five studies: two trials for the treatment of alcohol relapse and three articles for the management of alcohol withdrawal syndrome with pregabalin. The critical review of the literature suggests that pregabalin could be a novel and effective treatment option for the management of alcohol relapse in detoxified patients, whereas until now there have been mixed results for the treatment of alcohol withdrawal syndrome. In particular, pregabalin showed a greater beneficial effect on patients with comorbid conditions such as alcoholism and generalized anxiety disorders. The exact mechanism of action of pregabalin in the management of alcoholism is not well understood but it is thought to be due mainly to the modulation of neurotransmitters such as glutamate and norepinephrine by inhibiting activity-dependent calcium influx in nerve terminals.

CONCLUSION

Pregabalin, within a dosage of 150-450 mg/day, showed beneficial effects for alcohol relapse prevention and contrasting results for the treatment of the withdrawal syndrome. Its use appears to be safe and well tolerated.

Pregabalin in clinical psychiatry and addiction: pros and cons

Pregabalin acts as a presynaptic modulator of excitatory neurotransmitter release, binding to the α²-δ subunit protein of voltage-gated calcium channels. Pregabalin use is becoming widespread in the psychiatric scenario. Data are encouraging, with some good evidence for efficacy in anxious spectrum, benzodiazepine abuse/dependence, and alcoholism. The abuse potential, however, is an issue that should be taken into account, mostly in subjects at risk for developing substance/alcohol misuse.

Efficacy and safety of pregabalin in the treatment of alcohol and benzodiazepine dependence

INTRODUCTION

Both alcohol and benzodiazepine dependence (AD, BD) are severe and chronic conditions with devastating physical and mental health effects. The relative scarcity and controversial evidential status of available pharmacological interventions for the treatment of patients' acute withdrawal syndrome and/or relapse prevention call for the clinical investigation of novel safe and efficacious agents.

AREAS COVERED

We review published studies of pregabalin as monotherapy in the treatment of AD and BD in more than 450 patients. Available evidence includes four RCTs, two in AD with active comparator drugs (naltrexone, tiapride, and lorazepam) and one placebo-controlled, and one placebo-controlled in BD. We also review other available studies on pregabalin's potential to reduce benzodiazepine consumption, its side effects, especially cognitive, as well as extant reports on its liability for abuse.

EXPERT OPINION

Available evidence suggests that monotherapy with pregabalin, within the dosage range of 150 - 600 mg/d, is a promising "novel" option for the safe and efficacious relapse prevention of both AD and BD. However, its efficacy as monotherapy in the acute treatment of AD withdrawal syndrome is still controversial. Clinicians should be cautious in prescribing pregabalin to patients with a history of multiple substance recreational use, and monitor its effects on cognition at dosages above 450 mg/d. Further, well-designed clinical research is still needed for the eventual consolidation of pregabalin's place in the treatment of AD and BD.

Effects of pregabalin on smoking behavior, withdrawal symptoms, and cognitive performance in smokers

RATIONALE

In preclinical and clinical studies, medications enhancing the GABA neurotransmission attenuate nicotine reward. Pregabalin, a GABA analogue, presumably interacts with brain glutamate and GABA neurotransmission. The goal of this study was to determine pregabalin's effects on smoking behavior, nicotine withdrawal, craving for cigarettes, and cognitive performance.

METHODS

Twenty-four smokers participated in an outpatient double-blind, placebo-controlled, crossover study. Subjects had a 4-day treatment period with either pregabalin (300 mg/day) or placebo and following a washout period were then crossed over for 4 days to the other treatment. In each treatment period, starting at midnight of day 1, participants were asked to stop smoking until the experimental session on day 4. During the experimental session measures of ad lib smoking behavior, tobacco withdrawal, craving for cigarettes, and cognitive performance were obtained.

RESULTS

Pregabalin treatment, compared to placebo, did not reduce the smoking behavior during the first 3 days of treatment or during ad lib smoking period. Pregabalin treatment attenuated some tobacco withdrawal symptoms including ratings of anxious, irritable, and frustrated in abstinent smokers. Pregabalin treatment also attenuated the subjective ratings of "liking" in response to smoking. Under pregabalin treatment, smokers made more errors in a sustained attention task.

CONCLUSIONS

These findings provide limited support for pregabalin as a treatment for nicotine addiction.

Substitution therapy for alcoholism: time for a reappraisal?

A number of compounds already in use as medications for various indications substitute for ethanol at clinically relevant brain pathways, in particular, at gamma-aminobutyric acid (GABA) receptors. Nevertheless, although substitute medications have been recognized for heroin and tobacco dependence, patients with alcohol dependence are rarely offered an analogous approach. Benzodiazepines may have paradoxical effects, and abuse and dependence are known. Baclofen (GABA(B) agonist) has not been associated with dependence or misuse and has been effective in several trials in preventing relapse, although research is required to establish the optimal dosing regimen. GABA-ergic anticonvulsants, helpful in treating withdrawal, have yet to emerge as effective in relapse prevention. Clomethiazole and sodium oxybate, the latter having been shown to be effective in relapse prevention, have incurred a reputation for dependence and abuse. However, data have emerged showing that the risk of abuse of sodium oxybate is lower than many clinicians had foreseen. For a condition where existing therapies are only effective in a proportion of patients, and which has high morbidity and mortality, the time now seems right for reappraising the use of substitute prescribing for alcohol dependence.

Efficacy and safety of pregabalin in the treatment of alcohol withdrawal syndrome: a randomized placebo-controlled trial

AIMS

The objective of this study was to collect preliminary data on the efficacy and safety of pregabalin in attenuating the severity of alcohol withdrawal symptoms during detoxification treatment in alcohol dependence.

METHODS

Forty-two alcohol-dependent patients with an alcohol withdrawal syndrome (AWS) were included in the prospective randomized double-blind placebo-controlled trial during inpatient alcohol detoxification. For 6 days, participants either received pregabalin or placebo according to a fixed dose schedule starting with 300 mg/day. Depending on the score of the AWS Scale (AWSS), diazepam was additionally administered as a rescue medication. The primary endpoint was the total amount of diazepam required from Day 2 to 6 of detoxification treatment in each of the two groups. Secondary outcome variables were the difference in AWSS and Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scores between Day 2 and 6, tolerability and safety data, drop-out rates as well as changes in the neuropsychological scales.

RESULTS

Pregabalin and placebo were equally safe and well tolerated. However, no statistically significant difference was found comparing the total amount of additional diazepam medication required in the two study groups. Pregabalin and placebo also showed similar efficacy according to alterations of scores of the AWSS, CIWA-Ar and neuropsychological scales. The frequency of adverse events and drop-outs did not differ between the both treatment groups.

CONCLUSIONS

The study demonstrates the relative safety of pregabalin in the treatment of AWS. However, the results do not provide evidence in favor of pregabalin compared with placebo concerning its efficacy in the treatment of AWS.

Efficacy and tolerability of pregabalin versus topiramate in the prophylaxis of chronic daily headache with analgesic overuse: an open-label prospective study

OBJECTIVES

Medication-overuse headache is one of the most disabling headaches. Antiepileptic drugs have been considered a promising strategy as prophylactic treatment in these patients, even if their use often has been limited by low tolerability or safety. The objective of this study was to evaluate the efficacy and safety of pregabalin compared with topiramate for the prophylaxis of chronic daily headache with medication overuse using an open-label prospective study.

METHODS

After a 2-month baseline period (T0), 100 consecutive patients with medication overuse headache were assigned to receive 150 mg/d pregabalin or 100 mg/d topiramate. After a titration period of 4 weeks, a follow-up visit was scheduled every 2 months (T1 and T2) to evaluate headache frequency, the amount of rescue medication intake, and disability.

RESULTS

Of the 46 pregabalin-treated patients, the mean monthly headache frequency significantly decreased from 21.8 ± 4.8 (T0) to 5.1 ± 3.8 (T2), and the monthly number of days with medication intake decreased from 15.1 ± 4.8 (T0) to 2.9 ± 1.9 (T2). Similarly, of the 42 topiramate-treated patients, the mean monthly headache frequency decreased from 21.8 ± 4.9 (T0) to 5.3 ± 3.5 (T2), and the mean monthly number of days with medication intake decreased from 15.1 ± 3.7 (T0) to 2.6 ± 1.5 (T2). A significant improvement of disability score was reported in both groups.

CONCLUSIONS

Similar to topiramate, pregabalin seems to be an effective and well-tolerated preventive therapy in chronic headache and a new option in the management of withdrawal from abused drugs in patients with analgesic overuse, a difficult-to-treat population.

Antiepileptic drugs in the treatment of psychiatric disorders

The clinical interface between psychiatry and neurology is epilepsy; the pharmacological expression of this interface is antiepileptic drugs (AEDs), as they are used to treat both epilepsy and psychiatric disorders, especially bipolar disorders. The prevalence of psychiatric comorbidity and the risk of suicidal behavior/ideation/suicide are markedly increased in patients with epilepsy (PWE). Though AEDs receive initial indications for the treatment of epilepsy, currently the majority of AEDs are used to treat pain and psychiatric disorders. Thus in selecting the appropriate AEDs for treatment of PWE, consideration should be given to which AEDs best treat the epileptic disorder and the psychiatric comorbidity. This review is an overview of 21 AEDs in which negative psychotropic properties, approved indications in psychiatry, off-label studied uses in psychiatry, and principal uses in psychiatry are presented with literature review. A total of 40 psychiatric uses have been identified. Of the 21 AEDs reviewed, only 5 have U.S. Food and Drug Administration and/or European Medicines Agency psychiatric approval for limited uses; the majority of AEDs are used off-label. Many of these off-label uses are based on case reports, open-label studies, and poorly controlled or small-sample-size studies. In some instances, off-label use persists in the face of negative pivotal trials. Further placebo-controlled (augmentation and monotherapy) parallel-arm research with active comparators is required in the complex field of AED treatment of psychiatric disorders to minimize the treatment gap not only for PWE with psychiatric disorders, but also for psychiatric patients who would benefit from properly studied AEDs while minimizing adverse effects.

An approach to the patient with substance use and abuse

Substance use is ubiquitous among medically ill patients. The 2008 National Survey on Drug Abuse and Health survey estimated that 20.1 million Americans aged 12 years or older (8% of the US population) had used an illicit drug during the preceding month. Some licit substances also create havoc. The survey found that slightly more than half (56%) of Americans reported being current drinkers of alcohol. A total of 6.2 million (2.5%) Americans used prescription-type psychotherapeutic drugs for nonmedical purposes and 70.9 million Americans (or 28.4%) used tobacco during the survey period. Substance abuse problems were diagnosed in up to 36% of medically hospitalized patients for whom a psychiatric consultation was requested. Given how prevalent the use of substances is among the medically ill and their potential effect on comorbid medical conditions, it is important for physicians to be mindful of their prevalence and presentation. This article covers the presenting symptoms of intoxication and withdrawal states, addresses the acute management of the most commonly encountered substances, and summarizes all others in a table.