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Castle ME, Flanigan ME. The role of brain serotonin signaling in excessive alcohol consumption and withdrawal: A call for more research in females. Neurobiol Stress 2024; 30:100618. [PMID: 38433994 PMCID: PMC10907856 DOI: 10.1016/j.ynstr.2024.100618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/01/2024] [Accepted: 02/14/2024] [Indexed: 03/05/2024] Open
Abstract
Alcohol Use Disorder (AUD) is a leading cause of death and disability worldwide, but current treatments are insufficient in fully addressing the symptoms that often lead to relapses in alcohol consumption. The brain's serotonin system has been implicated in AUD for decades and is a major regulator of stress-related behaviors associated with increased alcohol consumption. This review will discuss the current literature on the association between neurobiological adaptations in serotonin systems and AUD in humans as well as the effectiveness of serotonin receptor manipulations on alcohol-related behaviors like consumption and withdrawal. We will further discuss how these findings in humans relate to findings in animal models, including a comparison of systemic pharmacological manipulations modulating alcohol consumption. We next provide a detailed overview of brain region-specific roles for serotonin and serotonin receptor signaling in alcohol-related behaviors in preclinical animal models, highlighting the complexity of forming a cohesive model of serotonin function in AUD and providing possible avenues for more effective therapeutic intervention. Throughout the review, we discuss what is known about sex differences in the sequelae of AUD and the role of serotonin in these sequelae. We stress a critical need for additional studies in women and female animals so that we may build a clearer path to elucidating sex-specific serotonergic mechanisms and develop better treatments.
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Affiliation(s)
- Megan E. Castle
- Bowles Center for Alcohol Studies, University of North Carolina School of Medicine, Chapel Hill, NC, 27599, USA
| | - Meghan E. Flanigan
- Bowles Center for Alcohol Studies, University of North Carolina School of Medicine, Chapel Hill, NC, 27599, USA
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Iqbal MN, Levin CJ, Levin FR. Treatment for Substance Use Disorder With Co-Occurring Mental Illness. FOCUS: JOURNAL OF LIFE LONG LEARNING IN PSYCHIATRY 2019; 17:88-97. [PMID: 31975963 DOI: 10.1176/appi.focus.20180042] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Substance use disorder is a highly prevalent condition, leading to significant morbidity, mortality, and burden on the health care system. Substance use disorders are overrepresented among individuals with a mental illness. The term "dual diagnosis" was introduced by the World Health Organization in the mid-1990s and refers to the co-occurrence of a substance use disorder with mental illness-a more recently used term is "co-occurring disorders." In the past decade, substantial progress has been made toward expanding psychotherapeutic and pharmacotherapeutic treatments for treating co-occurring disorders. Yet management remains a challenge among clinicians and has been a source of confusion and considerable controversy. This review describes the epidemiology and treatment of co-occurring disorders, with a focus on major depressive disorder, anxiety disorders, and attention-deficit hyperactivity disorder. Substance use may make diagnosis of the underlying psychiatric condition difficult, and a period of abstinence may be necessary. Findings from efficacy studies of medications used to treat co-occurring disorders are reviewed, as are results of preliminary studies of newer treatments, such as topiramate, ketamine, noninvasive brain stimulation, and deep brain stimulation. Treatment recommendations that combine medications and psychosocial interventions are summarized.
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Affiliation(s)
- Muhammad N Iqbal
- Division on Substance Use Disorders, New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University, New York (all authors); Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York (F. Levin)
| | - Charles J Levin
- Division on Substance Use Disorders, New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University, New York (all authors); Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York (F. Levin)
| | - Frances R Levin
- Division on Substance Use Disorders, New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University, New York (all authors); Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York (F. Levin)
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Abstract
Social, cultural, emotional and biological influences determine whether people drink to excess and whether they then experience harm or cause harm to others (Cook, 1994). Psychosocial treatments for alcohol dependence are only modestly successful, with most studies finding that at least 50% of patients return to harmful drinking in the following year. In the past decade there has been new evidence for the role of pharmacological treatments in reducing harm from drinking and in preventing relapse.
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Abstract
Animal models provide rapid, inexpensive assessments of an investigational drug's therapeutic potential. Ideally, they support the plausibility of therapeutic efficacy and provide a rationale for further investigation. Here, I discuss how the absence of clear effective-ineffective categories for alcohol use disorder (AUD) medications and biases in the clinical and preclinical literature affect the development of predictive preclinical alcohol dependence (AD) models. Invoking the analogical argument concept from the philosophy of science field, I discuss how models of excessive alcohol drinking support the plausibility of clinical pharmacotherapy effects. Even though these models are not likely be completely discriminative, they are sensitive to clinically effective medications and have revealed dozens of novel medication targets. In that context, I discuss recent preclinical work on GLP-1 receptor agonists, phosphodiesterase inhibitors, glucocorticoid receptor antagonists, nociception agonists and antagonists, and CRF1 antagonists. Clinically approved medications are available for each of these drug classes. I conclude by advocating a translational approach in which drugs are evaluated highly congruent preclinical models and human laboratory studies. Once translation is established, I suggest the burden is to develop hypothesis-based therapeutic interventions maximizing the impact of the confirmed pharmacotherapeutic effects in the context of additional variables falling outside the model.
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Affiliation(s)
- Mark Egli
- Division of Neuroscience and Behavior, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, USA.
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Williams T, Hattingh CJ, Kariuki CM, Tromp SA, van Balkom AJ, Ipser JC, Stein DJ. Pharmacotherapy for social anxiety disorder (SAnD). Cochrane Database Syst Rev 2017; 10:CD001206. [PMID: 29048739 PMCID: PMC6360927 DOI: 10.1002/14651858.cd001206.pub3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recognition is growing that social anxiety disorder (SAnD) is a chronic and disabling disorder, and data from early trials demonstrate that medication may be effective in its treatment. This systematic review is an update of an earlier review of pharmacotherapy of SAnD. OBJECTIVES To assess the effects of pharmacotherapy for social anxiety disorder in adults and identify which factors (methodological or clinical) predict response to treatment. SEARCH METHODS We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR-Studies and CCMDCTR-References) to 17 August 2015. The CCMDCTR contains reports of relevant RCTs from MEDLINE (1950-), Embase (1974-), PsycINFO (1967-) and CENTRAL (all years). We scanned the reference lists of articles for additional studies. We updated the search in August 2017 and placed additional studies in Awaiting Classification, these will be incorporated in the next version of the review, as appropriate. SELECTION CRITERIA We restricted studies to randomised controlled trials (RCTs) of pharmacotherapy versus placebo in the treatment of SAnD in adults. DATA COLLECTION AND ANALYSIS Two authors (TW and JI) assessed trials for eligibility and inclusion for this review update. We extracted descriptive, methodological and outcome information from each trial, contacting investigators for missing information where necessary. We calculated summary statistics for continuous and dichotomous variables (if provided) and undertook subgroup and sensitivity analyses. MAIN RESULTS We included 66 RCTs in the review (> 24 weeks; 11,597 participants; age range 18 to 70 years) and 63 in the meta-analysis. For the primary outcome of treatment response, we found very low-quality evidence of treatment response for selective serotonin reuptake inhibitors (SSRIs) compared with placebo (number of studies (k) = 24, risk ratio (RR) 1.65; 95% confidence interval (CI) 1.48 to 1.85, N = 4984). On this outcome there was also evidence of benefit for monoamine oxidase inhibitors (MAOIs) (k = 4, RR 2.36; 95% CI 1.48 to 3.75, N = 235), reversible inhibitors of monoamine oxidase A (RIMAs) (k = 8, RR 1.83; 95% CI 1.32 to 2.55, N = 1270), and the benzodiazepines (k = 2, RR 4.03; 95% CI 2.45 to 6.65, N = 132), although the evidence was low quality. We also found clinical response for the anticonvulsants with gamma-amino butyric acid (GABA) analogues (k = 3, RR 1.60; 95% CI 1.16 to 2.20, N = 532; moderate-quality evidence). The SSRIs were the only medication proving effective in reducing relapse based on moderate-quality evidence. We assessed tolerability of SSRIs and the serotonin and norepinephrine reuptake inhibitor (SNRI) venlafaxine on the basis of treatment withdrawal; this was higher for medication than placebo (SSRIs: k = 24, RR 2.59; 95% CI 1.97 to 3.39, N = 5131, low-quality evidence; venlafaxine: k = 4, RR 3.23; 95% CI 2.15 to 4.86, N = 1213, moderate-quality evidence), but there were low absolute rates of withdrawal for both these medications classes compared to placebo. We did not find evidence of a benefit for the rest of the medications compared to placebo.For the secondary outcome of SAnD symptom severity, there was benefit for the SSRIs, the SNRI venlafaxine, MAOIs, RIMAs, benzodiazepines, the antipsychotic olanzapine, and the noradrenergic and specific serotonergic antidepressant (NaSSA) atomoxetine in the reduction of SAnD symptoms, but most of the evidence was of very low quality. Treatment with SSRIs and RIMAs was also associated with a reduction in depression symptoms. The SSRIs were the only medication class that demonstrated evidence of reduction in disability across a number of domains.We observed a response to long-term treatment with medication for the SSRIs (low-quality evidence), for the MAOIs (very low-quality evidence) and for the RIMAs (moderate-quality evidence). AUTHORS' CONCLUSIONS We found evidence of treatment efficacy for the SSRIs, but it is based on very low- to moderate-quality evidence. Tolerability of SSRIs was lower than placebo, but absolute withdrawal rates were low.While a small number of trials did report treatment efficacy for benzodiazepines, anticonvulsants, MAOIs, and RIMAs, readers should consider this finding in the context of potential for abuse or unfavourable side effects.
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Affiliation(s)
- Taryn Williams
- University of Cape TownDepartment of Psychiatry and Mental HealthEducation Centre, Valkenberg HospitalPrivate Bage X1, ObservatoryCape TownSouth Africa7925
| | - Coenie J Hattingh
- University of Cape TownDepartment of Psychiatry and Mental HealthEducation Centre, Valkenberg HospitalPrivate Bage X1, ObservatoryCape TownSouth Africa7925
| | - Catherine M Kariuki
- University of Cape TownDepartment of Psychiatry and Mental HealthEducation Centre, Valkenberg HospitalPrivate Bage X1, ObservatoryCape TownSouth Africa7925
| | - Sean A Tromp
- University of Cape TownFaculty of Health Sciences4 Roughmoor Rd, MowbrayCape TownWestern CapeSouth Africa7700
| | - Anton J van Balkom
- VU‐University Medical Centre and GGZ inGeestDepartment of Psychiatry and EMGO+ InstituteA.J. Ernststraat 887AmsterdamNetherlands1081 HL
| | - Jonathan C Ipser
- University of Cape TownDepartment of Psychiatry and Mental HealthEducation Centre, Valkenberg HospitalPrivate Bage X1, ObservatoryCape TownSouth Africa7925
| | - Dan J Stein
- University of Cape TownDepartment of Psychiatry and Mental HealthEducation Centre, Valkenberg HospitalPrivate Bage X1, ObservatoryCape TownSouth Africa7925
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Patkar OL, Belmer A, Holgate JY, Tarren JR, Shariff MR, Morgan M, Fogarty MJ, Bellingham MC, Bartlett SE, Klenowski PM. The antihypertensive drug pindolol attenuates long-term but not short-term binge-like ethanol consumption in mice. Addict Biol 2017; 22:679-691. [PMID: 27273539 DOI: 10.1111/adb.12359] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 11/03/2015] [Accepted: 12/02/2015] [Indexed: 12/15/2022]
Abstract
Alcohol dependence is a debilitating disorder with current therapies displaying limited efficacy and/or compliance. Consequently, there is a critical need for improved pharmacotherapeutic strategies to manage alcohol use disorders (AUDs). Previous studies have shown that the development of alcohol dependence involves repeated cycles of binge-like ethanol intake and abstinence. Therefore, we used a model of binge-ethanol consumption (drinking-in-the-dark) in mice to test the effects of compounds known to modify the activity of neurotransmitters implicated in alcohol addiction. From this, we have identified the FDA-approved antihypertensive drug pindolol, as a potential candidate for the management of AUDs. We show that the efficacy of pindolol to reduce ethanol consumption is enhanced following long-term (12 weeks) binge-ethanol intake, compared with short-term (4 weeks) intake. Furthermore, pindolol had no effect on locomotor activity or consumption of the natural reward sucrose. Because pindolol acts as a dual beta-adrenergic antagonist and 5-HT1A/1B partial agonist, we examined its effect on spontaneous synaptic activity in the basolateral amygdala (BLA), a brain region densely innervated by serotonin and norepinephrine-containing fibres. Pindolol increased spontaneous excitatory post-synaptic current frequency of BLA principal neurons from long-term ethanol-consuming mice but not naïve mice. Additionally, this effect was blocked by the 5-HT1A/1B receptor antagonist methiothepin, suggesting that altered serotonergic activity in the BLA may contribute to the efficacy of pindolol to reduce ethanol intake following long-term exposure. Although further mechanistic investigations are required, this study demonstrates the potential of pindolol as a new treatment option for AUDs that can be fast-tracked into human clinical studies.
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Affiliation(s)
- Omkar L. Patkar
- Translational Research Institute Queensland University of Technology Brisbane Australia
- Institute of Health and Biomedical Innovation (IHBI) Queensland University of Technology Brisbane Australia
| | - Arnauld Belmer
- Translational Research Institute Queensland University of Technology Brisbane Australia
- Institute of Health and Biomedical Innovation (IHBI) Queensland University of Technology Brisbane Australia
| | - Joan Y. Holgate
- Translational Research Institute Queensland University of Technology Brisbane Australia
- Institute of Health and Biomedical Innovation (IHBI) Queensland University of Technology Brisbane Australia
| | - Josephine R. Tarren
- Translational Research Institute Queensland University of Technology Brisbane Australia
- Institute of Health and Biomedical Innovation (IHBI) Queensland University of Technology Brisbane Australia
| | - Masroor R. Shariff
- Translational Research Institute Queensland University of Technology Brisbane Australia
- Institute of Health and Biomedical Innovation (IHBI) Queensland University of Technology Brisbane Australia
| | - Michael Morgan
- Translational Research Institute Queensland University of Technology Brisbane Australia
- Institute of Health and Biomedical Innovation (IHBI) Queensland University of Technology Brisbane Australia
| | - Matthew J. Fogarty
- School of Biomedical Sciences The University of Queensland Brisbane Australia
| | - Mark C. Bellingham
- School of Biomedical Sciences The University of Queensland Brisbane Australia
| | - Selena E. Bartlett
- Translational Research Institute Queensland University of Technology Brisbane Australia
- Institute of Health and Biomedical Innovation (IHBI) Queensland University of Technology Brisbane Australia
| | - Paul M. Klenowski
- Translational Research Institute Queensland University of Technology Brisbane Australia
- Institute of Health and Biomedical Innovation (IHBI) Queensland University of Technology Brisbane Australia
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Ipser JC, Wilson D, Akindipe TO, Sager C, Stein DJ. Pharmacotherapy for anxiety and comorbid alcohol use disorders. Cochrane Database Syst Rev 2015; 1:CD007505. [PMID: 25601826 PMCID: PMC8931612 DOI: 10.1002/14651858.cd007505.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Anxiety disorders are a potentially disabling group of disorders that frequently co-occur with alcohol use disorders. Comorbid anxiety and alcohol use disorders are associated with poorer outcomes, and are difficult to treat with standard psychosocial interventions. In addition, improved understanding of the biological basis of the conditions has contributed to a growing interest in the use of medications for the treatment of people with both diagnoses. OBJECTIVES To assess the effects of pharmacotherapy for treating anxiety in people with comorbid alcohol use disorders, specifically: to provide an estimate of the overall effects of medication in improving treatment response and reducing symptom severity in the treatment of anxiety disorders in people with comorbid alcohol use disorders; to determine whether specific medications are more effective and tolerable than other medications in the treatment of particular anxiety disorders; and to identify which factors (clinical, methodological) predict response to pharmacotherapy for anxiety disorders. SEARCH METHODS Review authors searched the specialized registers of The Cochrane Collaboration Depression, Anxiety and Neurosis Review Group (CCDANCTR, to January 2014) and the Cochrane Drugs and Alcohol Group (CDAG, to March 2013) for eligible trials. These registers contain reports of relevant randomized controlled trials (RCT) from: the Cochrane Central Register of Controlled Trials (CENTRAL, all years), MEDLINE (1950 to date), EMBASE (1974 to date) and PsycINFO (1967 to date). Review authors ran complementary searches on EMBASE, PubMed, PsycINFO and the Alcohol and Alcohol Problems Science Database (ETOH) (to August 2013). We located unpublished trials through the National Institutes of Health (NIH) RePORTER service and the World Health Organization (WHO) International Clinical Trials Registry Platform (to August 2013). We screened reference lists of retrieved articles for additional studies. SELECTION CRITERIA All true RCTs of pharmacotherapy for treating anxiety disorders with comorbid alcohol use disorders. Trials assessing drugs administered for the treatment of drinking behaviour, such as naltrexone, disulfiram and acomprosate were not eligible for inclusion in this systematic review. DATA COLLECTION AND ANALYSIS A systematic review is a standardised evaluation of all research studies that address a particular clinical issue.Two review authors independently assessed RCTs for inclusion in the review, collated trial data and assessed trial quality. We contacted investigators to obtain missing data. We calculated categorical and continuous treatment effect estimates and their 95% confidence intervals (CI) for treatment using a random-effects model with effect-size variability expressed using Chi(2) and I(2) heterogeneity statistics. MAIN RESULTS We included five placebo-controlled pharmacotherapy RCTs (with 290 participants) in the review. Most of the trials provided little information on how randomization was performed or on whether both participants and study personnel were blinded to the intervention. Two of the three trials reporting superiority of medication compared with placebo on anxiety symptom outcomes were industry funded. We regarded one trial as being at high risk of bias due to selective reporting.Study participants had Diagnostic and Statistical Manual (DSM) III- and DSM IV-diagnosed alcohol use disorders and post-traumatic stress disorder (two studies), social anxiety disorder (SAD; two studies) or generalized anxiety disorder (GAD; one study). Four trials assessed the efficacy of the selective serotonin re-uptake inhibitors (SSRIs: sertraline, paroxetine); one RCT investigated the efficacy of buspirone, a 5-hydroxytryptamine (5-HT) partial agonist. Treatment duration lasted between eight and 24 weeks. Overall, 70% of participants included in the review were male.There was very low quality evidence for an effect of paroxetine on global clinical response to treatment, as assessed by the Clinical Global Impressions - Improvement scale (CGI-I). Global clinical response was observed in more than twice as many participants with paroxetine than with placebo (57.7% with paroxetine versus 25.8% with placebo; risk ratio (RR) 2.23, 95% CI 1.13 to 4.41; 2 trials, 57 participants). However, there was substantial uncertainty regarding the size of the effect of paroxetine due to the small number of studies providing data on clinically diverse patient samples. The second primary outcome measure was reduction of anxiety symptom severity. Although study investigators reported that buspirone (one trial) was superior to placebo in reducing the severity of anxiety symptoms over 12 weeks, no evidence of efficacy was observed for paroxetine (mean difference (MD) -14.70, 95% CI -33.00 to 3.60, 2 trials, 44 participants) and sertraline (one trial). Paroxetine appeared to be equally effective in reducing the severity of post-traumatic stress disorder (PTSD) symptoms as the tricyclic antidepressant desipramine in one RCT. The maximal reduction in anxiety disorder symptom severity was achieved after six weeks with paroxetine (two RCTs) and 12 weeks with buspirone (one RCT), with maintenance of medication efficacy extending to 16 with paroxetine and 24 weeks with buspirone. There was no evidence of an effect for any of the medications tested on abstinence from alcohol use or depression symptoms. There was very low quality evidence that paroxetine was well tolerated, based on drop-out due to treatment-emergent adverse effects. Nevertheless, levels of treatment discontinuation were high, with 43.1% of the participants in the studies withdrawing from medication treatment. Certain adverse effects, such as sexual problems, were commonly reported after treatment with paroxetine and sertraline. AUTHORS' CONCLUSIONS The evidence-base for the effectiveness of medication in treating anxiety disorders and comorbid alcohol use disorders is currently inconclusive. There was a small amount of evidence for the efficacy of medication, but this was limited and of very low quality. The majority of the data for the efficacy and tolerability of medication were for SSRIs; there were insufficient data to establish differences in treatment efficacy between medication classes or patient subgroups. There was a small amount of very low quality evidence that medication was well tolerated. There was no evidence that alcohol use was responsive to medication.Large, rigorously conducted RCTs would help supplement the small evidence-base for the efficacy and tolerability of pharmacotherapy for anxiety and comorbid alcohol use disorders. Further research on patient subgroups who may benefit from pharmacological treatment, as well as novel pharmacological interventions, is warranted.
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Affiliation(s)
- Jonathan C Ipser
- Department of Psychiatry and Mental Health, University of Cape Town, J-Block, Groote Schuur Hospital, Observatory, Cape Town, South Africa, 7925
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Abstract
Anxiety disorders commonly co-occur with substance use disorders both in the general population and in treatment-seeking samples. This co-occurrence is associated with greater symptom severity, higher levels of disability, and poorer course of illness relative to either disorder alone. Little research has been conducted, however, on the treatment of these co-occurring disorders. This gap may not only leave anxiety untreated or undertreated but also increase the risk for relapse and poor substance use outcomes. The aim of this article is to review the current state of the literature on treating co-occurring anxiety and substance use disorders. In addition to presenting a brief overview of the epidemiology of this co-occurrence, the article discusses the challenges in assessing anxiety in the context of a substance use disorder, the evidence for various treatment approaches, and recent advances and future directions in this understudied area. Also highlighted is the need for future research to identify optimal behavioral and pharmacologic treatments for co-occurring anxiety and substance use disorders.
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Anton RF, Schacht JP, Book SW. Pharmacologic treatment of alcoholism. HANDBOOK OF CLINICAL NEUROLOGY 2014; 125:527-42. [PMID: 25307594 DOI: 10.1016/b978-0-444-62619-6.00030-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Progress in understanding the neuroscience of addiction has significantly advanced the development of more efficacious medications for the treatment of alcohol use disorders (AUD). While several medications have been approved by regulatory bodies around the world for the treatment of AUD, they are not universally efficacious. Recent research has yielded improved understanding of the genetics and brain circuits that underlie alcohol reward and its habitual use. This research has contributed to pharmacogenetic studies of medication response, and will ultimately lead to a more "personalized medicine" approach to AUD pharmacotherapy. This chapter summarizes work on clinically available medications (both approved by regulatory bodies and investigational) for the treatment of alcohol dependence, as well as the psychiatric disorders that are commonly comorbid with AUD. Studies that have evaluated genetic influences on medication response and those that have employed neuroimaging to probe mechanisms of medication action or response are highlighted. Finally, new targets discovered in animal models for possible pharmacologic intervention in humans are overviewed and future directions in medications development provided.
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Affiliation(s)
- Raymond F Anton
- Center for Drug and Alcohol Programs, Alcohol Research Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA.
| | - Joseph P Schacht
- Center for Drug and Alcohol Programs, Alcohol Research Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Sarah W Book
- Center for Drug and Alcohol Programs, Alcohol Research Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
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Herron AJ, Mariani JJ, Pavlicova M, Parrinello CM, Bold KW, Levin FR, Nunes EV, Sullivan MA, Raby WN, Bisaga A. Assessment of riboflavin as a tracer substance: comparison of a qualitative to a quantitative method of riboflavin measurement. Drug Alcohol Depend 2013; 128:77-82. [PMID: 22921475 PMCID: PMC3556739 DOI: 10.1016/j.drugalcdep.2012.08.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 07/20/2012] [Accepted: 08/06/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Noncompliance with medications may have major impacts on outcomes measured in research, potentially distorting the validity of controlled clinical trials. Riboflavin is frequently used in trials as a marker of adherence. It can be combined with study medication and is excreted in urine where it fluoresces under UV light. This study compares qualitative visual inspection of fluorescence to quantitative fluorometric analysis of riboflavin concentration in its ability to detect the presence of riboflavin in urine. METHODS Twenty-four volunteers received 0mg, 25mg, and 50mg doses of riboflavin under single-blind conditions, with 20 also receiving a 100mg dose. Five serial urine samples were collected over the following 36h. Quantitative measurement of riboflavin by fluorometric analysis and qualitative assessment of each sample using visual inspection were performed. RESULTS The overall false positive rate for qualitative assessment was 53%. For quantitative assessment, a riboflavin concentration of 900ng/mL was established to classify positive samples. More than 80% of samples were positive 2-24h following ingestion of 25mg and 50mg, and less than 80% were positive at 36h. At least 95% of observations for the 100mg dose were above 900ng/mL at all timepoints. CONCLUSIONS Quantitative fluorometric assessment is superior to qualitative visual inspection alone in determining medication adherence. The combination of 25-50mg of daily riboflavin and a cut-off level of 900ng/mL allows for the acceptable sensitivity of missing detection of non-compliant participants while preserving a high level of power to detect all cases of medication compliance.
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Affiliation(s)
- Abigail J Herron
- St. Luke's Roosevelt Hospital Center, 324 W. 108th Street, #505, New York, NY 10025, USA.
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Brady KT, Haynes LF, Hartwell KJ, Killeen TK. Substance use disorders and anxiety: a treatment challenge for social workers. SOCIAL WORK IN PUBLIC HEALTH 2013; 28:407-423. [PMID: 23731428 PMCID: PMC3775646 DOI: 10.1080/19371918.2013.774675] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Converging evidence from epidemiologic and treatment studies indicate that anxiety disorders and substance use disorders commonly co-occur, and the interaction is multifaceted and variable. Epidemiological studies and investigations within clinical substance abuse populations have found an association between anxiety disorders and substance use disorders. Specific anxiety disorders including generalized anxiety disorder, panic disorder, and post traumatic stress disorder have all been associated with substance use. The association with obsessive-compulsive disorder is less robust, and some research has found a negative association. The risk of nicotine dependence is significantly higher among individuals with an anxiety disorder, and conversely, smoking has been found to be associated with trait anxiety and anxiety disorders. A review of the current literature and the relationship between specific anxiety disorders and alcohol and substance use disorders is discussed in detail. This article, written for social workers in a variety of practice settings, reviews the prevalence, diagnostic, and treatment issues at the interface of substance use disorders and anxiety disorders.
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Affiliation(s)
- Kathleen T Brady
- Department of Psychiatry, Clinical Neuroscience Division, Medical University of South Carolina, Charleston, SC 29425, USA.
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Winhusen T, Brady KT, Stitzer M, Woody G, Lindblad R, Kropp F, Brigham G, Liu D, Sparenborg S, Sharma G, Vanveldhuisen P, Adinoff B, Somoza E. Evaluation of buspirone for relapse-prevention in adults with cocaine dependence: an efficacy trial conducted in the real world. Contemp Clin Trials 2012; 33:993-1002. [PMID: 22613054 PMCID: PMC3408816 DOI: 10.1016/j.cct.2012.05.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Revised: 05/03/2012] [Accepted: 05/13/2012] [Indexed: 11/29/2022]
Abstract
Cocaine dependence is a significant public health problem for which there are currently no FDA-approved medications. Hence, identifying candidate compounds and employing an efficient evaluation process is crucial. This paper describes key design decisions made for a National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) study that uses a novel two-stage process to evaluate buspirone (60 mg/day) for cocaine-relapse prevention. The study includes pilot (N=60) and full-scale (estimated N=264) trials. Both trials will be randomized, double-blind, and placebo-controlled and both will enroll treatment-seeking cocaine-dependent participants engaged in inpatient/residential treatment and scheduled for outpatient treatment post-discharge. All participants will receive contingency management in which incentives are given for medication adherence as evaluated by the Medication Events Monitoring System (MEMS). The primary outcome measure is maximum days of continuous cocaine abstinence, as assessed by twice-weekly urine drug screens (UDS) and self-report, during the 15-week outpatient treatment phase. Drug-abuse outcomes include cocaine use as assessed by UDS and self-report of cocaine use, other substance use as assessed by UDS and self-report of substance use (i.e., alcohol and/or illicit drugs), cocaine bingeing, HIV risk behavior, quality of life, functioning, and substance abuse treatment attendance. Unique aspects of the study include conducting an efficacy trial in community treatment programs, a two-stage process to efficiently evaluate buspirone, and an evaluation of mediators by which buspirone might exert a beneficial effect on relapse prevention.
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Affiliation(s)
- Theresa Winhusen
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH 45220, USA.
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Lev-Ran S, Balchand K, Lefebvre L, Araki KF, Le Foll B. Pharmacotherapy of alcohol use disorders and concurrent psychiatric disorders: a review. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2012; 57:342-9. [PMID: 22682571 DOI: 10.1177/070674371205700603] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Alcohol use disorders (AUDs) are among the most prevalent psychiatric disorders. Epidemiologic studies have shown a high prevalence of concurrent psychiatric disorders among people with AUDs as well as a higher prevalence of AUDs in people with psychiatric disorders than in the general population. Though psychiatric patients with concurrent AUDs are at increased risk for morbidity and mortality, they are commonly undertreated for their alcohol-related disorders. The efficacy of pharmacotherapy for AUDs is well documented. Our paper reviews the common pharmacotherapies available for AUDs and focuses on the available research regarding treatment of AUDs among psychiatric populations with mood, anxiety, and psychotic disorders. Despite the high prevalence of concurrent AUDs and psychiatric disorders, very limited information has been collected using a randomized controlled trial design targeting those concurrent conditions. Several prevalent psychiatric disorders have not been studied when co-occurring with AUDs. Further research of pharmacological treatments for concurrent AUDs and psychiatric diagnoses is urgently needed.
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Affiliation(s)
- Shaul Lev-Ran
- Translational Addiction Research Laboratory, Addictions Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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14
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Hobbs JDJ, Kushner MG, Lee SS, Reardon SM, Maurer EW. Meta-analysis of supplemental treatment for depressive and anxiety disorders in patients being treated for alcohol dependence. Am J Addict 2011; 20:319-29. [PMID: 21679263 DOI: 10.1111/j.1521-0391.2011.00140.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Approximately half of those receiving treatment for an alcohol use disorder (AUD) also suffer with an anxiety or depressive (internalizing) disorder. Because all internalizing disorders mark a poor alcohol treatment outcome, it seems reasonable to supplement AUD treatment with a psychiatric intervention when these disorders co-occur with AUD. However, this conclusion may be faulty given that the various possible interrelationships between AUD and internalizing disorders do not uniformly imply a high therapeutic yield from this approach. Unfortunately, the studies conducted to date have been too few and too small to resolve this important clinical issue with confidence. Therefore, we used a meta-analytic method to synthesize the effects from published randomized controlled trials examining the impact of supplementing AUD treatment with a psychiatric treatment for co-occurring internalizing disorder (N = 15). We found a pooled effect size (d) of .32 for internalizing outcomes and .22 for a composite of alcohol outcomes; however, the alcohol outcomes effect sizes were greater than this for some specific outcome domains. Subgroups that differed in terms of internalizing outcomes included treatment type (medication vs. cognitive behavioral therapy) and treatment focus (anxiety vs. depression). There was also a trend for the studies with better internalizing disorder outcomes to have better alcohol outcomes. These results indicate that clinical outcomes (both psychiatric and alcohol-related) could be somewhat improved by supplementing AUD treatment with psychiatric treatment for co-occurring internalizing disorder.
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Affiliation(s)
- Jennifer D J Hobbs
- Department of Psychiatry, University of Minnesota, Minneapolis, 55454, USA
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15
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Abstract
BACKGROUND Alcohol abuse and dependence represents a most serious health problem worldwide with major social, interpersonal and legal interpolations. Besides benzodiazepines, anticonvulsants are often used for the treatment of alcohol withdrawal symptoms. Anticonvulsants drugs are indicated for the treatment of alcohol withdrawal syndrome, alone or in combination with benzodiazepine treatments. In spite of the wide use, the exact role of the anticonvulsants for the treatment of alcohol withdrawal has not yet bee adequately assessed. OBJECTIVES To evaluate the effectiveness and safety of anticonvulsants in the treatment of alcohol withdrawal. SEARCH STRATEGY We searched Cochrane Drugs and Alcohol Group' Register of Trials (December 2009), PubMed, EMBASE, CINAHL (1966 to December 2009), EconLIT (1969 to December 2009). Parallel searches on web sites of health technology assessment and related agencies, and their databases. SELECTION CRITERIA Randomized controlled trials (RCTs) examining the effectiveness, safety and overall risk-benefit of anticonvulsants in comparison with a placebo or other pharmacological treatment. All patients were included regardless of age, gender, nationality, and outpatient or inpatient therapy. DATA COLLECTION AND ANALYSIS Two authors independently screened and extracted data from studies. MAIN RESULTS Fifty-six studies, with a total of 4076 participants, met the inclusion criteria. Comparing anticonvulsants with placebo, no statistically significant differences for the six outcomes considered.Comparing anticonvulsant versus other drug, 19 outcomes considered, results favour anticonvulsants only in the comparison carbamazepine versus benzodiazepine (oxazepam and lorazepam) for alcohol withdrawal symptoms (CIWA-Ar score): 3 studies, 262 participants, MD -1.04 (-1.89 to -0.20), none of the other comparisons reached statistical significance.Comparing different anticonvulsants no statistically significant differences in the two outcomes considered.Comparing anticonvulsants plus other drugs versus other drugs (3 outcomes considered), results from one study, 72 participants, favour paraldehyde plus chloral hydrate versus chlordiazepoxide, for the severe-life threatening side effects, RR 0.12 (0.03 to 0.44). AUTHORS' CONCLUSIONS Results of this review do not provide sufficient evidence in favour of anticonvulsants for the treatment of AWS. There are some suggestions that carbamazepine may actually be more effective in treating some aspects of alcohol withdrawal when compared to benzodiazepines, the current first-line regimen for alcohol withdrawal syndrome. Anticonvulsants seem to have limited side effects, although adverse effects are not rigorously reported in the analysed trials.
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Affiliation(s)
- Silvia Minozzi
- Department of Epidemiology, ASL RM/E, Via di Santa Costanza, 53, Rome, Italy, 00198
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16
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Moak DH, Anton RF, Malcolm R, Randall CL, Brady K. Alcoholic Subjects With Anxiety Disorder. Am J Addict 2010. [DOI: 10.1111/j.1521-0391.1993.tb00369.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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17
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Kushner MG, Sletten S, Donahue C, Thuras P, Maurer E, Schneider A, Frye B, Van Demark J. Cognitive-behavioral therapy for panic disorder in patients being treated for alcohol dependence: Moderating effects of alcohol outcome expectancies. Addict Behav 2009; 34:554-60. [PMID: 19349122 PMCID: PMC2810649 DOI: 10.1016/j.addbeh.2009.03.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Revised: 02/20/2009] [Accepted: 03/17/2009] [Indexed: 10/21/2022]
Abstract
Anxiety disorders commonly co-occur with alcohol use disorders and reliably mark a poor response to substance abuse treatment. However, treating a co-occurring anxiety disorder does not reliably improve substance abuse treatment outcomes. Failure to account for individual differences in the functional dynamic between anxiety symptoms and drinking behavior might impede the progress and clarity of this research program. For example, while both theory and research point to the moderating role of tension-reduction alcohol outcome expectancies (TR-AOEs) in the association between anxiety symptoms and alcohol use, relevant treatment studies have not typically modeled TR-AOE effects. We examined the impact of a hybrid cognitive-behavioral therapy (H-CBT) treatment for panic disorder (independent variable) on response to a community-based alcohol dependence treatment program (dependent variable) in patients with higher vs. lower TR-AOEs (moderator). The H-CBT treatment was generally effective in relieving participants' panic symptoms relative to controls. However, TR-AOEs interacted with study cohort (H-CBT vs. control) in predicting response to substance abuse treatment. As expected, the H-CBT was most effective in improving alcohol use outcomes among those with the highest TR-AOEs. The study's primary methodological limitations are related to the quasi-experimental design employed.
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Affiliation(s)
- Matt G Kushner
- University of Minnesota, Department of Psychiatry, Fairview-Riverside Hospital, F-282-2A West, 2450 Riverside Ave., Minneapolis, MN 55455, United States.
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18
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Oei TP, Loveday WA. Management of co-morbid anxiety and alcohol disorders: parallel treatment of disorders. Drug Alcohol Rev 2009; 16:261-74. [PMID: 16203435 DOI: 10.1080/09595239800187441] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Co-morbid alcohol-related disorders and anxiety disorders have been found to occur in alcohol treatment populations, anxiety treatment populations and the general community. People suffering from co-occurring alcohol-related and anxiety disorders are more prone to relapse to alcohol abuse, and more likely to re-enter the treatment system for either disorder than sufferers of either disorder without a co-morbid disorder. To review the current state of the management of this disorder, evidence of the prevalence of this co-morbid condition in clinical and community populations is examined, then the theoretical mechanisms that might explain this connection are reviewed. A comparison of the few treatment studies of co-morbid alcohol and anxiety disorders shows a limited number of pharmacological treatment trials and no psychotherapy outcome trials. This review shows that it is no longer sustainable to conceptualize co-morbidity of alcohol and anxiety disorders as a unitary concept, i.e. lumping alcohol-related and anxiety disorders as one global condition, but as separate distinct combinations of particular anxiety disorders, e.g. alcohol dependence and panic disorder, alcohol dependence and generalize anxiety disorder. The recommended treatment approach, supported by the evidence, is to offer separate and parallel therapy for the alcohol-related and anxiety disorder, until empirical evidence from treatment outcome studies suggest otherwise. There is an urgent need to conduct treatment outcome research for the subtypes of co-morbid alcohol and anxiety disorders.
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Affiliation(s)
- T P Oei
- Psychology Department, The University of Queensland, Brisbane, QLD, 4072, Australia
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Mariani JJ, Levin FR. Levetiracetam for the treatment of co-occurring alcohol dependence and anxiety: case series and review. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2008; 34:683-91. [PMID: 18850500 DOI: 10.1080/00952990802308213] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Alcohol dependence is frequently associated with anxiety disorders. The exact nature of the relationship between alcohol dependence and anxiety disorders is unknown, but emerging evidence suggests that in a majority of cases, the anxiety disorder is independent of the alcohol use disorder. There is pre-clinical and clinical evidence that levetiracetam, a newer generation anticonvulsant medication, may be efficacious in the treatment of co-occurring alcohol use and anxiety disorders. METHODS In an open label clinical trial, three patients with alcohol dependence and a co-morbid anxiety disorder were treated with levetiracetam in doses up to 1500 mg twice daily for up to 8 weeks. RESULTS All three participants reported reductions in alcohol consumption and anxiety symptoms during the study period. Levetiracetam was generally well tolerated. CONCLUSION This study suggests that levetiracetam deserves further study in the treatment of alcohol dependence and co-occurring anxiety disorders.
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Affiliation(s)
- John J Mariani
- Division on Substance Abuse, New York State Psychiatric Institute, New York, New York 10032, USA.
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20
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Back SE, Brady KT. Anxiety Disorders with Comorbid Substance Use Disorders: Diagnostic and Treatment Considerations. Psychiatr Ann 2008; 38:724-729. [PMID: 20717489 DOI: 10.3928/00485713-20081101-01] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Sudie E Back
- Sudie E. Back, PhD; and Kathleen T. Brady, MD, PhD, are with the Clinical Neuroscience Division, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston
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22
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Abstract
AIMS Regression to the mean (RTM) refers to the tendency for a group of cases that differ from the population mean to move (regress) towards the mean, on average, when re-assessed, if scores at the two points are less than perfectly correlated. This paper considers factors that affect the magnitude of RTM and how RTM may impact findings from primary studies and reviews of substance use disorder (SUD) treatment. DESIGN AND METHODS The paper is guided largely by A Primer on Regression Artifacts by Campbell and Kenny. It reviews potential RTM effects in three areas of SUD treatment research. One is the extent to which within-group improvement in comparative treatment trials, including 'placebo effects', is a function of RTM. The second is the vulnerability of treatment evaluations employing non-equivalent control group designs to RTM and biased estimates of treatment effects when matching, or statistical equating is used to adjust for pre-existing group differences. The final issue is the impact of RTM in syntheses of research findings on SUD treatments. In particular, the tendency for later studies of a particular intervention to have smaller treatment effect sizes relative to earlier studies is considered as an RTM phenomenon. FINDINGS RTM is a pervasive, but often unrecognized phenomenon that can bias findings in SUD treatment studies and in systematic reviews of that research. CONCLUSION SUD treatment researchers should be aware of RTM, take any available steps to reduce it, and try to diagnose whether it is still affecting research findings.
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Affiliation(s)
- John W Finney
- Center for Health Care Evaluation, VA Palo Alto Health Care System and Stanford University Medical Center, Palo Alto, CA 94025, USA.
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23
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Overstreet DH, Knapp DJ, Breese GR. Drug challenges reveal differences in mediation of stress facilitation of voluntary alcohol drinking and withdrawal-induced anxiety in alcohol-preferring P rats. Alcohol Clin Exp Res 2007; 31:1473-81. [PMID: 17624999 PMCID: PMC3010749 DOI: 10.1111/j.1530-0277.2007.00445.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is controversy over whether exposure to stress precipitates relapse and/or increases alcohol (ethanol) intake. Our laboratory has demonstrated that repeated stress prior to withdrawal from a brief forced exposure to alcohol results in withdrawal-induced anxiety-like behavior. Because anxiety is often regarded as a precipitating factor in relapsing alcoholics, we decided to examine the consequences of stressing alcohol-preferring P rats on both voluntary alcohol drinking and withdrawal-induced anxiety. METHODS P rats were subjected to 3 cycles of 5 days of voluntary alcohol drinking and 2 days of deprivation. Restraint stress (60 min) was applied to some animals during the first and second deprivations/withdrawals (at 4 h). Drugs (flumazenil, buspirone, SB242,084, CP154,526, CRA1000, naloxone, haloperidol, olanzapine, naloxone, and haloperidol) were given to some rats 30 min prior to restraint stress. RESULTS Stressed, deprived P rats exhibited both a longer duration of elevated alcohol drinking and anxiety-like behavior in the social interaction test upon withdrawal after the third cycle of voluntary alcohol drinking. When given prior to each of the restraint stresses, the benzodiazepine receptor antagonist flumazenil (5 mg/kg), the corticotrophin releasing factor receptor antagonists CRA1000 (3 mg/kg) and CP154,526 (10 mg/kg), the serotonin 5-HT(1A) receptor partial agonist buspirone (0.6 mg/kg), and the mixed 5-HT(2C)/D2 receptor antagonist olanzapine were effective in reducing the increased duration of elevated alcohol drinking and the withdrawal-induced anxiety-like behavior. In contrast, while the opiate receptor antagonist naloxone (20 mg/kg), the 5-HT(2C) receptor antagonist SB242084 (3 mg/kg), and the dopamine receptor antagonist haloperidol (0.1 mg/kg) also reduced drinking, they did not significantly alter anxiety like behavior. CONCLUSION These results suggest that stress-induced facilitation of alcohol drinking and withdrawal-induced anxiety-like behavior in P rats may be closely but imperfectly linked.
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Affiliation(s)
- David H Overstreet
- Department of Psychiatry, Bowles Center for Alcohol Studies, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7178, USA.
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24
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Abstract
BACKGROUND Comorbid substance use and mental illness is prevalent and often results in serious consequences. However, little is known about the efficacy of treatments for patients with dual diagnosis. METHODS This paper reviews both the psychosocial and medication treatments for those diagnosed with a substance-related disorder and one of the following disorders: (a) depression, (b) anxiety disorder, (c) schizophrenia, (d) bipolar disorder, (e) severe mental illness, and (f) nonspecific mental illness. We made no restriction of study design to include all published studies, due to the dearth of studies on treatments of patients with dual diagnosis. RESULTS Fifty-nine studies were identified (36 randomized-controlled trials; RCT). Limited number of studies, especially RCTs, have been conducted within each comorbid category. This review did not find treatments that had been replicated and consistently showed clear advantages over comparison condition for both substance-related and other psychiatric outcomes. CONCLUSIONS Although no treatment was identified as efficacious for both psychiatric disorders and substance-related disorder, this review finds: (1) existing efficacious treatments for reducing psychiatric symptoms also tend to work in dual-diagnosis patients, (2) existing efficacious treatments for reducing substance use also decrease substance use in dually diagnosed patients, and (3) the efficacy of integrated treatment is still unclear. This review provides a critique of the current state of the literature, identifies the directions for future research on treatment of dual-diagnosis individuals, and calls for urgent attention by researchers and funding agencies to conduct more and more methodologically rigorous research in this area.
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Affiliation(s)
- Quyen Q Tiet
- Center for Health Care Evaluation, VA Palo Alto Health Care System, Palo Alto, California 94025, USA.
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25
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Goldstein BI, Diamantouros A, Schaffer A, Naranjo CA. Pharmacotherapy of alcoholism in patients with co-morbid psychiatric disorders. Drugs 2006; 66:1229-37. [PMID: 16827599 DOI: 10.2165/00003495-200666090-00005] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
There has been an exponential increase in recent years of literature pertaining to the treatment of individuals with alcohol use disorders and co-morbid psychiatric disorders. Patients with mood and anxiety disorders in particular have a very high prevalence of alcoholism. Alcoholism confers significant morbid risks to patients with psychiatric disorders, and vice versa, including markedly increased risk of suicide. Only recently have studies examined the impact of various psychiatric medications on alcohol use among patients with these disorders. Evidence supporting the benefits of antidepressants for co-morbid alcoholism and depression continues to mount. Although these studies have demonstrated benefits in terms of quantitative decreases in the volume and frequency of consumption, the benefits in terms of remission from alcoholism have yet to be shown conclusively. The first randomised, controlled trial involving subjects with co-morbid alcoholism and bipolar disorder was recently conducted, yielding promising results for valproate in this population. The literature regarding co-morbid alcoholism and anxiety disorders has also seen recent progress, particularly in the study of post-traumatic stress disorder (PTSD). A placebo-controlled study of sertraline suggests some benefit in terms of alcohol use among individuals with early-onset PTSD and less severe alcohol dependence. Atypical antipsychotics such as olanzapine and quetipaine have been examined in several open studies of subjects with alcoholism co-morbid with a variety of psychiatric conditions including bipolar disorder, PTSD and schizophrenia. This paper selectively reviews the evidence that is currently available for the pharmacological management of alcoholism among persons with co-morbid psychiatric illness. Effectiveness, safety and tolerability are considered, and directions for future study are discussed.
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Affiliation(s)
- Benjamin I Goldstein
- Department of Psychiatry, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto, Canada
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26
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Kiefer F, Mann K. New achievements and pharmacotherapeutic approaches in the treatment of alcohol dependence. Eur J Pharmacol 2005; 526:163-71. [PMID: 16266700 DOI: 10.1016/j.ejphar.2005.09.028] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2005] [Revised: 07/12/2005] [Accepted: 09/23/2005] [Indexed: 11/25/2022]
Abstract
The treatment of alcohol dependence mainly consists of psychological, social, and pharmacotherapeutic interventions aiming to reduce physical withdrawal, craving, and alcohol relapse. During the last years, it has become increasingly clear that adjuvant pharmacotherapy is efficacious especially in rehabilitation programs for alcohol dependent patients. The development of alcohol dependence seems to involve adaptive changes in amino acid neurotransmitter systems, stimulation of dopamine and opioid peptide systems, and changes in serotonergic activity. Disulfiram, naltrexone and acamprosate are approved treatments for the management of abstinence maintenance treatment. New compounds are under investigation. This review discusses the neurobiological basis of alcohol addiction, pharmacological targets for relapse prevention treatment and pre-clinical and clinical results with the most promising drugs.
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Affiliation(s)
- Falk Kiefer
- University of Heidelberg, Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health, CIMH, J5, D-68159 Mannheim, Germany.
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27
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Mueller TI, Pagano ME, Rodriguez BF, Bruce SE, Stout RL, Keller MB. Long-term use of benzodiazepines in participants with comorbid anxiety and alcohol use disorders. Alcohol Clin Exp Res 2005; 29:1411-8. [PMID: 16131848 PMCID: PMC2548411 DOI: 10.1097/01.alc.0000175016.01790.f1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although the only widely accepted role for benzodiazepines in alcohol dependence is the treatment of withdrawal syndromes, they are frequently prescribed outside of this clinical setting. There is little empirical evidence to guide the rational use of benzodiazepines in the common clinical situation where anxiety disorders are comorbid with alcohol use disorders (AUD). Since January 1989, the Harvard Anxiety Research Program has naturalistically monitored the prospective clinical course of people with anxiety disorders, some of whom had a history of AUD. Earlier research showed that the use of benzodiazepines was not significantly associated with the presence or absence of a history of an AUD over the first year of follow-up. This report extends that investigation. METHODS Using standard parametric analytic methods, patterns of benzodiazepine use (routinely prescribed medication and as-needed [PRN] use) among participants receiving benzodiazepine treatment was prospectively examined over the course of 12 years. Differences in benzodiazepine usage patterns were examined in each year of follow-up between participants who did (n=120) and did not (n=425) have a new episode of AUD. Using proportional hazards regression analysis, benzodiazepine usage levels were examined as predictors of recovery and recurrence of AUD. Additionally, random-effects regression analyses were used to examine the patterns of benzodiazepine use before and after the onset of a prospectively observed episode of AUD. RESULTS Benzodiazepine usage levels remained stable for the full sample over the course of the 12 years. Benzodiazepine use did not distinguish participants who had a new AUD from those who did not. Over the 12 years of follow-up, participants who had an AUD used more PRN medication in years five to eight. This difference reached statistical significance but was not clinically significant. Benzodiazepine usage levels did not predict recovery or recurrence in AUD subjects. Neither the total dose nor the PRN usage of benzodiazepines was significantly associated with the onset of AUD, but when combined into a measure of any benzodiazepine use, a relationship between increased use and the onset of AUD emerged. CONCLUSIONS For participants in the Harvard Anxiety Research Program with comorbid alcohol dependence and anxiety disorders, there was little association between the use of benzodiazepines and the occurrence of a new AUD. Neither was there a temporal relationship between the use of benzodiazepines and the onset of a new AUD. Whether or not this finding extends to a broader patient population or a group of people who present to addictions treatment awaits further investigation.
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Affiliation(s)
- Timothy I Mueller
- Southern Arizona VA Health Care System, University of Arizona Health Sciences Center, Department of Psychiatry, Tucson, Arizona 85723, USA.
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Polycarpou A, Papanikolaou P, Ioannidis JPA, Contopoulos-Ioannidis DG. Anticonvulsants for alcohol withdrawal. Cochrane Database Syst Rev 2005:CD005064. [PMID: 16034965 DOI: 10.1002/14651858.cd005064.pub2] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Alcohol withdrawal syndrome is a cluster of symptoms that occurs in alcohol-dependent people after cessation or reduction in alcohol use. This systematic review focuses on the evidence of anticonvulsants' use in the treatment of alcohol withdrawal symptoms. OBJECTIVES To evaluate the effectiveness and safety of anticonvulsants in the treatment of alcohol withdrawal. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2004); MEDLINE (1966 to October 2004); EMBASE (1988 to October 2004) and EU-PSI PSI-Tri database with no language and publication restrictions and references of articles. SELECTION CRITERIA All randomized controlled trials examining the effectiveness, safety and overall risk-benefit of an anticonvulsant in comparison with a placebo or other pharmacological treatment or another anticonvulsant were considered. DATA COLLECTION AND ANALYSIS The authors independently assessed trial quality extracted data. MAIN RESULTS Forty-eight studies, involving 3610 people were included. Despite the considerable number of randomized controlled trials, there was a variety of outcomes and of different rating scales that led to a limited quantitative synthesis of data. For the anticonvulsant versus placebo comparison, therapeutic success tended to be more common among the anticonvulsant-treated patients (relative risk (RR) 1.32; 95% confidence interval (CI) 0.92 to 1.91), and anticonvulsant tended to show a protective benefit against seizures (RR 0.57; 95% CI 0.27 to 1.19), but no effect reached formal statistical significance. For the anticonvulsant versus other drug comparison, CIWA-Ar score showed non-significant differences for the anticonvulsants compared to the other drugs at the end of treatment (weighted mean difference (WMD) -0.73; 95% CI -1.76 to 0.31). For the subgroup analysis of carbamazepine versus benzodiazepine, a statistically significant protective effect was found for the anticonvulsant (WMD -1.04; 95% CI -1.89 to -0.20), p = 0.02), but this was based on only 260 randomized participants. There was a non-significant decreased incidence of seizures (RR 0.50; 95% CI 0.18 to 1.34) favouring the patients that were treated with anticonvulsants than other drugs, and side-effects tended to be less common in the anticonvulsant-group (RR 0.56; 95% CI 0.31 to 1.02). AUTHORS' CONCLUSIONS It is not possible to draw definite conclusions about the effectiveness and safety of anticonvulsants in alcohol withdrawal, because of the heterogeneity of the trials both in interventions and the assessment of outcomes. The extremely small mortality rate in all these studies is reassuring, but data on other safety outcomes are sparse and fragmented.
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Affiliation(s)
- A Polycarpou
- Department of Hygiene and Epidemiology, University of Ioannina, School of Medicine, 14 Ch Zoidi Str, Ioannina, Greece, GR45444.
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Abstract
Preclinical studies have contributed greatly to our understanding of the neurochemical pathways associated with the development and maintenance of alcohol-seeking behaviour. These studies have demonstrated the important role of serotonin pathways, particularly as they relate to dopaminergic function, which mediates alcohol-induced reward associated with its abuse liability. Naturally, this has led to the study of serotonergic agents as treatments for alcoholism.SSRIs do not appear to be effective treatment for a heterogeneous alcoholic group. However, they may be useful as treatment for late-onset alcoholics, or alcoholism complicated by comorbid major depression. Buspirone, a serotonin 5-HT1A partial agonist, does not appear to be an effective treatment for alcoholics without comorbid disease. Buspirone may, however, have some utility for treating alcoholics with comorbid anxiety disorder. The 5-HT2 antagonist ritanserin, at pharmacologically relevant clinical doses, does not appear to be an effective treatment for alcoholism. Ondansetron, a 5-HT3 antagonist, is an efficacious and promising medication for the treatment of early-onset alcoholism. Preliminary evidence suggests that combining the mu antagonist naltrexone with the 5-HT3 antagonist ondansetron promises to be more effective for treating alcoholism than either alone. The differential treatment effect of SSRIs and ondansetron among various subtypes of alcoholic is intriguing. Future research is needed to understand more clearly the molecular genetic differences and the interactions of such differences with the environment that typify a particular alcoholic subtype. Such an understanding could enable us to make comfortable predictions as to which alcoholic subtype might respond best to a particular serotonergic agent, which could then be provided.
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Affiliation(s)
- Bankole A Johnson
- University of Virginia Health System, Charlottesville, Virginia 22908-0623, USA.
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Abstract
Mood and anxiety disorders commonly co-occur with substance use disorders. Exploration of the neurobiology of substance use disorders and mood and anxiety disorders have found that the neural circuitry in mood, anxiety, and substance use disorders is clearly overlapping. These discoveries have encouraged the exploration of a number of pharmacotherapeutic agents in the treatment of co-occurring mood, anxiety, and substance use disorders. In this article, recent data on the pharmacotherapeutic treatment of mood and anxiety disorders in individuals with substance use disorders are reviewed. Some of the barriers to the use of pharmacotherapy in individuals with substance use disorders are discussed.
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Affiliation(s)
- Kathleen T Brady
- Institute of Psychiatry, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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31
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Abstract
Alcohol-related disorders are a major public health problem in the United States. Alcohol interacts with several neurotransmitter systems causing both acute and chronic effects in the brain. While the mainstay of treatment of alcohol-related disorders, with the exception of alcohol withdrawal, has historically been psychosocial, pharmacotherapy is increasingly being investigated and incorporated into standard clinical practice. Patients with alcohol use disorders and comorbid psychiatric conditions, most commonly depressive and anxiety disorders, can benefit from symptom-targeted pharmacotherapy, even if the patient fails to achieve abstinence from alcohol. Although benzodiazepines remain the treatment of choice to treat alcohol withdrawal, a variety of other agents is being investigated, particularly in the outpatient setting. Further randomized clinical trials of alcohol-related disorder pharmacotherapy, particularly of comorbid subpopulations, are needed to better inform clinical decision making. The routine exclusion of alcohol-dependent patients from pharmacotherapy trials of psychiatric disorders presents a barrier to gathering more data. Recommendations for future research are discussed.
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Affiliation(s)
- John J Mariani
- Department of Psychiatry, Division on Substance Abuse, Columbia University, College of Physicians and Surgeons, USA.
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Lingford-Hughes AR, Welch S, Nutt DJ. Evidence-based guidelines for the pharmacological management of substance misuse, addiction and comorbidity: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2004; 18:293-335. [PMID: 15358975 DOI: 10.1177/026988110401800321] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- A R Lingford-Hughes
- University of Bristol, Psychopharmacology Unit, Dorothy Hodgkin Building, Bristol, UK.
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Abstract
Over the last 20 years, the role of adjuvant pharmacotherapy in optimising outcome in rehabilitation programmes for alcohol-dependent patients has become increasingly evident. New avenues for rational drug treatment have arisen from better understanding of the neurobiological substrates of alcohol dependence, including adaptive changes in amino acid neurotransmitter systems, stimulation of dopamine and opioid peptide systems, and, possibly, changes in serotonergic activity. Disulfiram, naltrexone and acamprosate are currently the only treatments approved for the management of alcohol dependence. However, there is still no unequivocal evidence from randomised controlled clinical trials that disulfiram improves abstinence rates over the long term. Aversive therapy with disulfiram is not without risk for certain patients, and should be closely supervised. Both naltrexone and acamprosate improve outcome in rehabilitation of alcohol-dependent patients, but seem to act on different aspects of drinking pathology. Naltrexone is thought to decrease relapse to heavy drinking by attenuating the rewarding effects of alcohol. However, data from the naltrexone clinical trial programme are somewhat inconsistent, with several large studies being negative. Acamprosate is believed to maintain abstinence by blocking the negative craving that alcohol-dependent patients experience in the absence of alcohol. The clinical development programme has involved a large number of patients and studies, of which the vast majority have shown a beneficial effect of acamprosate on increasing abstinence rates. Both drugs are generally well tolerated; nausea is reported by around 10% of patients treated with naltrexone, while the most frequent adverse effect reported with acamprosate is diarrhoea. Another opioid receptor antagonist, nalmefene, has shown promising activity in pilot studies, and may have a similar profile to naltrexone. Data from studies of SSRIs in alcohol dependence are somewhat heterogeneous, but it appears that these drugs may indirectly improve outcome by treating underlying depression rather than affecting drinking behaviour per se. Similarly, the anxiolytic buspirone may act by ameliorating underlying psychiatric pathology. Dopaminergic neuroleptics, benzodiazepines and antimanic drugs have not yet demonstrated evidence of activity in large controlled clinical trials. Trials with drugs acting at serotonin receptors have yielded disappointing results, with the possible exception of ondansetron. Because the biological basis of alcohol dependence appears to be multifactorial, the future of management of alcoholism may be combination therapy, using drugs acting on different neuronal pathways, such as acamprosate and naltrexone. Pharmacotherapy should be used in association with appropriate psychosocial support and specific treatment provided for any underlying psychiatric comorbidities.
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Affiliation(s)
- Karl Mann
- Department of Addictive Behaviour and Addiction Medicine, Central Institute of Mental Health, University of Heidelberg, Mannheim, Germany
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Berglund M, Thelander S, Salaspuro M, Franck J, Andréasson S, Ojehagen A. Treatment of alcohol abuse: an evidence-based review. Alcohol Clin Exp Res 2004; 27:1645-56. [PMID: 14574236 DOI: 10.1097/01.alc.0000090144.99832.19] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article represents the proceedings of a symposium at the 2002 annual meeting of the Research Society on Alcoholism in San Francisco, CA, organized and cochaired by Mats Berglund and Sten Thelander. The presentations were (1) Preventive interventions against hazardous consumption of alcohol, by Mikko Salaspuro; (2) Treatment of alcohol withdrawal, by Johan Franck; (3) Psychosocial treatment for alcohol problems, by Sven Andréasson and Agneta Ojehagen; and (4) Pharmacological treatment of alcohol dependence, by Mats Berglund.
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Affiliation(s)
- Mats Berglund
- Department of Clinical Alcohol Research, Malmö University Hospital, Malmö, Sweden.
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Zimmerman M, Sheeran T, Chelminski I, Young D. Screening for psychiatric disorders in outpatients with DSM-IV substance use disorders. J Subst Abuse Treat 2004; 26:181-8. [PMID: 15063911 DOI: 10.1016/s0740-5472(03)00207-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2003] [Revised: 11/02/2003] [Accepted: 11/16/2003] [Indexed: 10/26/2022]
Abstract
Psychiatric disorders are frequent in patients with substance use disorders, and have been associated with increased morbidity and poorer treatment outcome. Because of the clinical importance of comorbid mental disorders, concerns have been raised about the detection of psychiatric disorders in patients with substance use disorders. The Psychiatric Diagnostic Screening Questionnaire (PDSQ) is a brief, psychometrically strong, self-report scale designed to screen for the most common DSM-IV Axis I disorders encountered in outpatient mental health settings. Previously we described the diagnostic performance of the PDSQ in a large sample of psychiatric outpatients. For the present report, we examined the performance of the PDSQ in psychiatric outpatients with drug and alcohol abuse and dependence, and determined whether its performance in patients with substance use disorders is as good as it is in patients without substance use disorders. For the patients with a substance use disorder, 92% of the comorbid mental disorders were detected by the PDSQ subscales (i.e., mean sensitivity across subscales equals 92%) and 97% of the patients who screened negative did not have a disorder (i.e., mean negative predictive value equals 97%). For patients without a substance use disorder, the mean sensitivity and negative predictive values were 88% and 95%, respectively. Receiver Operating Characteristic curves were plotted for each PDSQ subscale for both patient groups, and all areas under the curve were significant and similar in the two groups.
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Affiliation(s)
- Mark Zimmerman
- Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, RI, USA.
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Le Fauve CE, Litten RZ, Randall CL, Moak DH, Salloum IM, Green AI. Pharmacological Treatment of Alcohol Abuse/Dependence With Psychiatric Comorbidity. Alcohol Clin Exp Res 2004; 28:302-12. [PMID: 15112938 DOI: 10.1097/01.alc.0000113413.37910.d7] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This article represents the proceedings of a symposium at the 2003 annual meeting RSA in Fort Lauderdale, FL. It was organized and cochaired by Charlene E. Le Fauve and Carrie L. Randall. The presentations were (1) Introduction, by Charlene E. Le Fauve and Raye Z. Litten; (2) Treatment of co-occurring alcohol use and anxiety disorders, by Carrie L. Randall and Sarah W. Book; (3) Pharmacological treatment of alcohol dependent patients with comorbid depression, by Darlene H. Moak; (4) Efficacy of valproate in bipolar alcoholics: a double blind, placebo-controlled study, by Ihsan M. Salloum, Jack R. Cornelius, Dennis C. Daley, Levent Kirisci, Johnathan Himmelhoch, and Michael E. Thase; (5) Alcoholism and schizophrenia: effects of antipsychotics, by Alan I. Green, Robert E. Drake, Suzannah V. Zimmet, Rael D. Strous, Melinda Salomon, and Mark Brenner; and (6) Conclusions, by Charlene E. Le Fauve; discussant, Raye Z. Litten. Alcohol-dependent individuals have exceptionally high rates of co-occurring psychiatric disorders. Although this population is more likely to seek alcoholism treatment than noncomorbid alcoholics, the prognosis for treatment is often poor, particularly among patients with more severe psychiatric illnesses. Development of effective interventions to treat this population is in the early stages of research. Although the interaction between the psychiatric condition and alcoholism is complex, progress has been made. The NIAAA has supported a number of state-of-the-art pharmacological and behavioral trials in a variety of comorbid psychiatric disorders. Some of these trials have been completed and are presented here. The symposium presented some new research findings from clinical studies with the aim of facilitating the development of treatments that improve alcohol and psychiatric outcomes among individuals with alcohol-use disorders and co-occurring psychiatric disorders. The panel focused on social anxiety disorder, depression, bipolar disorder, and schizophrenia.
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Affiliation(s)
- Charlene E Le Fauve
- Division of Clinical and Prevention Research, Treatment Research Branch, NIAAA, Bethesda, Maryland, USA.
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Abstract
There is clinically important comorbidity between psychiatric and substance use disorders, particularly in women. Women with affective and anxiety disorders are more likely to present with alcohol or drug abuse/dependence. In turn, substance-abusing women are more likely to experience clinically significant depression and anxiety. Emerging evidence is pointing to an etiological role for anxiety disorders in the development of substance abuse/dependence; however, etiologic evidence is not as clear-cut for major depressive disorder. PTSD appears to be a particularly important factor for alcohol and drug dependence in women who have experienced childhood or adult sexual and or physical abuse. Although pharmacotherapy for affective or anxiety disorders is useful for ameliorating psychiatric symptoms, research is mixed on the effectiveness for improving alcohol- and drug-related outcomes. There is some limited evidence that women-specific services can improve treatment retention, substance use outcomes, and possibly psychosocial functioning compared with traditional mixed-gender programs. However, it is clear that women with co-occurring psychiatric and substance use problems are challenging to engage and retain in care. Physicians providing women's reproductive health services can serve a vital role in the identification and referral of substance-abusing women. Particular attention should be focused on screening and assessment of alcohol and drug use and problem severity among women who have identified psychiatric disorders or who are receiving antidepressant or anxiolytic medications. Recognition and referral for both psychiatric and substance use disorders are critical for long-term health and psychosocial improvement.
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Affiliation(s)
- Geetanjali Chander
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, 8033, Baltimore, MD 21287, USA
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38
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Overstreet DH, Knapp DJ, Moy SS, Breese GR. A 5-HT1A agonist and a 5-HT2c antagonist reduce social interaction deficit induced by multiple ethanol withdrawals in rats. Psychopharmacology (Berl) 2003; 167:344-52. [PMID: 12677355 PMCID: PMC2865243 DOI: 10.1007/s00213-003-1425-y] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2002] [Accepted: 02/07/2003] [Indexed: 10/20/2022]
Abstract
RATIONALE Repeated withdrawals from chronic forced ethanol exposure sensitize animals to withdrawal-induced deficits in social interaction behavior. The deficits in social interaction behavior following withdrawal from continuous ethanol exposure can be reduced following acute treatments with 5-HT(2C) antagonists or 5-HT(1A) agonists. OBJECTIVES The present study investigated whether prior treatment with these serotonergic agents during early withdrawals in rats subjected to repeated withdrawals from ethanol exposure would ameliorate the social interaction deficits observed following the final withdrawal. METHODS Sprague-Dawley rats were exposed to three cycles of 5 days forced ethanol (7%, w/v), with 2 days of control diet after the first and second cycles. Drugs were administered IP 4 h after removal of ethanol on the first and second cycles but not the third in one group and 4.5 h after removal of ethanol on the third cycle in another. The social interaction test was performed 5 h after removal of ethanol on the third cycle. Drugs tested included SB-242084, a 5-HT(2C) antagonist; buspirone, a 5-HT(1A) partial agonist; WAY-100635, a 5-HT(1A) antagonist; ketanserin, a 5-HT(2A) antagonist; ritanserin, a mixed 5-HT(2A/2C) antagonist; and Ro-601075, a 5-HT(2C) agonist. RESULTS Both SB-242084 and buspirone reduced ethanol withdrawal-induced deficits in social interaction when given either acutely 30 min before the test or at 4 h after withdrawal from the first and second cycles. WAY-100635 and ketanserin were completely ineffective regardless of mode of treatment. In contrast, the 5-HT(2C) agonist, Ro-601075, accentuated the withdrawal-induced deficit in social interaction behavior in rats exposed to either 4.5 or 7% ethanol diet. CONCLUSIONS These results support the utility of 5-HT(1A) agonists and 5-HT(2C) antagonists in reducing anxiety-like behavior induced by ethanol withdrawal and reducing the adaptive changes associated with repeated withdrawals.
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MESH Headings
- Aminopyridines/pharmacology
- Animals
- Anxiety/psychology
- Buspirone/pharmacology
- Dose-Response Relationship, Drug
- Ethanol/administration & dosage
- Ethanol/adverse effects
- Ethylamines/pharmacology
- Indoles/pharmacology
- Piperazines/pharmacology
- Pyridines/pharmacology
- Rats
- Rats, Sprague-Dawley
- Receptor, Serotonin, 5-HT2A
- Receptor, Serotonin, 5-HT2C
- Receptors, Serotonin/drug effects
- Receptors, Serotonin/physiology
- Receptors, Serotonin, 5-HT1
- Ritanserin/pharmacology
- Serotonin Antagonists/pharmacology
- Serotonin Receptor Agonists/pharmacology
- Social Behavior
- Substance Withdrawal Syndrome/psychology
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Affiliation(s)
- David H Overstreet
- Department of Psychiatry, Bowles Center for Alcohol Studies, University of North Carolina School of Medicine, CB #7178, Chapel Hill, NC 27599-7178, USA.
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39
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Abstract
Although alcohol use disorders are commonly associated with co-morbid drug use and psychiatric disorders, such co-morbidity is frequently underdiagnosed and inadequately treated. This paper reviews the epidemiological, diagnostic, and treatment literature on the co-morbidity of alcoholism, with a focus on the most common co-morbid disorders: drug abuse, mood disorders, anxiety disorders, and antisocial personality disorder. The paper goes on to describe a number of promising approaches to the treatment of these common co-morbid disorders in alcoholics. Despite the difficulties inherent in treating dual diagnosis patients, the clinician must recognize that it is possible to derive valid diagnoses and deliver efficacious treatment to such patients.
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Affiliation(s)
- Henry R Kranzler
- Department of Psychiatry and the Alcohol Research Center, University of Connecticut School of Medicine, Farmington, CT 06030-2103, USA.
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40
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Mattson ME. The search for a rational basis for treatment selection. RECENT DEVELOPMENTS IN ALCOHOLISM : AN OFFICIAL PUBLICATION OF THE AMERICAN MEDICAL SOCIETY ON ALCOHOLISM, THE RESEARCH SOCIETY ON ALCOHOLISM, AND THE NATIONAL COUNCIL ON ALCOHOLISM 2003; 16:97-113. [PMID: 12638633 DOI: 10.1007/0-306-47939-7_9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Affiliation(s)
- Margaret E Mattson
- Treatment Research Branch, National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland 20892, USA
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41
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Pettinati HM, Kranzler HR, Madaras J. The status of serotonin-selective pharmacotherapy in the treatment of alcohol dependence. RECENT DEVELOPMENTS IN ALCOHOLISM : AN OFFICIAL PUBLICATION OF THE AMERICAN MEDICAL SOCIETY ON ALCOHOLISM, THE RESEARCH SOCIETY ON ALCOHOLISM, AND THE NATIONAL COUNCIL ON ALCOHOLISM 2003; 16:247-62. [PMID: 12638641 DOI: 10.1007/0-306-47939-7_18] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Research performed during the past 20 years has shown that serotonin (5-hydroxytryptamine; 5-HT) neurotransmission is related to alcohol dependence. Both theoretical and empirical research have supported the idea that alcohol dependence is a chronic disease and that, in addition, biological vulnerabilities contribute to the pathogenesis of alcohol dependence. Preclinical studies have consistently demonstrated that there is a relationship between 5-HT function and alcohol consumption. Furthermore, there is evidence building that lends support for the existence of distinct alcoholic subtypes that may be differentiated by the type or complexity of their 5-HT dysfunction. Beyond excessive drinking, behaviors that are indicators of 5-HT dysregulation are depression, anxiety, impulsiveness, and early-onset problem drinking. This chapter will discuss the usefulness of 5-HT-selective pharmacotherapy in treating alcohol dependence and will provide both historical and current perspectives on its use.
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Affiliation(s)
- Helen M Pettinati
- Center for the Study of Addictions, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA
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42
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Cornelius JR, Bukstein O, Salloum I, Clark D. Alcohol and psychiatric comorbidity. RECENT DEVELOPMENTS IN ALCOHOLISM : AN OFFICIAL PUBLICATION OF THE AMERICAN MEDICAL SOCIETY ON ALCOHOLISM, THE RESEARCH SOCIETY ON ALCOHOLISM, AND THE NATIONAL COUNCIL ON ALCOHOLISM 2003; 16:361-74. [PMID: 12638646 DOI: 10.1007/0-306-47939-7_24] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
Comorbid psychiatric disorders and drug use disorders (DUDs) are common among alcoholics (Regier, Farmer, Rae, Locke, Keith, Judd, & Goodwin, 1990; Kessler, McGonagle, Zhao, Nelson, Hughes, Eshleman, Wittchen, & Kendler, 1994). These comorbid disorders often predict a shorter time to relapse of alcoholism (Greenfield, Weiss, Muenz, Vagge, Kelly, Bello, & Michael, 1998). However, despite the prevalence and the adverse effects of this comorbidity, few controlled treatment studies have been conducted involving this dual diagnosis population (Litten & Allen, 1999). To date, most of these few studies of alcoholics with comorbid disorders have been restricted to studies of alcoholics with either comorbid major depression or comorbid anxiety disorders (Litten & Allen, 1995). The results of these trials suggest efficacy for SSRI antidepressants and tricyclic antidepressants for treating alcoholics with comorbid major depression and suggest efficacy for buspirone for treating alcoholics with comorbid anxiety disorders (Mason, Kocsis, Ritvo, & Cutler, 1996; Cornelius, Salloum, Ehler, Jarrett, Cornelius, Perel, Thase, & Black, 1997; Kranzler, Burleson, Del Boca, Babor, Korner, Brown, & Bohn, 1994). However, controlled treatment studies involving alcoholics with other comorbid disorders are almost totally lacking. Consequently, to date, no empirically proven treatment exists for most of these comorbid disorders.
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Affiliation(s)
- Jack R Cornelius
- Pittsburgh Adolescent Alcohol Research Center, Center for Education and Drug Abuse Research, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
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43
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Moyer A, Finney JW. Outcomes for untreated individuals involved in randomized trials of alcohol treatment. J Subst Abuse Treat 2002; 23:247-52. [PMID: 12392812 DOI: 10.1016/s0740-5472(02)00264-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Summarizing the relative effects of different treatments for alcohol use disorders is challenging because there is no standard treatment against which experimental treatments can be contrasted and comparisons to no-treatment control groups are rare. As alternative reference points, we examined outcomes and improvement for untreated participants (i.e., those in wait-list, no-treatment, and placebo conditions) in randomized trials of alcohol treatment over the last three decades. At followup, the average abstinence rate was 21% (n = 17 studies) and the mean level of alcohol consumption was 31 drinks per week (n = 29 studies). The reduction in drinking from baseline was.19 of a SD unit, or a 14% decrease from a baseline mean of 37 drinks per week (n = 17 studies). These values provide approximations of success and improvement that an active treatment for alcohol use disorders should surpass to be considered more beneficial than no treatment.
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Affiliation(s)
- Anne Moyer
- Center for Health Care Evaluation, VA Palo Alto Health Care System, MPD-152, 795 Willow Road, Menlo Park, CA 94025, USA.
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44
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Petrakis IL, Buonopane A, O'Malley S, Cermik O, Trevisan L, Boutros NN, Limoncelli D, Krystal JH. The Effect of Tryptophan Depletion on Alcohol Self-Administration in Non-Treatment-Seeking Alcoholic Individuals. Alcohol Clin Exp Res 2002. [DOI: 10.1111/j.1530-0277.2002.tb02629.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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45
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Allen JP, Litten RZ, Strid N, Sillanaukee P. The role of biomarkers in alcoholism medication trials. Alcohol Clin Exp Res 2001. [PMID: 11505042 DOI: 10.1111/j.1530-0277.2001.tb02325.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Increasingly, biomarkers are being incorporated into the research design of clinical trials on medications to reduce drinking in alcoholics. To date, however, there has been little analysis of the unique roles that biomarkers can play in such investigations or of the practical and conceptual considerations that surround their best use in this context. METHODS Clinical trials of alcoholism medications published between 1985 and the present were abstracted to determine how biomarkers were used and how changes in them related to self-report measures of drinking. RESULTS Six uses of biomarkers were identified: determination of subjects to be included or excluded in the trial; description of baseline sample characteristics; primary and secondary outcome assessment; corroboration of self-reports of drinking status; specification of patients likely to respond to the medication; and evaluation of drug safety. CONCLUSION Use of biomarkers in such studies appears warranted, particularly as an objective source of information on treatment efficacy that can be considered with patient self-report measures of drinking status. Biomarkers related to liver functioning also can assist in determination of drug safety for medications metabolized by the liver.
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Affiliation(s)
- J P Allen
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland 20852-7003, USA.
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46
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Myrick H, Brady K. Management of Comorbid Anxiety and Substance Use Disorders. Psychiatr Ann 2001. [DOI: 10.3928/0048-5713-20010401-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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47
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Floyd AS, Hoffmann NG, Karno MP. Diagnosis, self-help, and maintenance care as key constructs in treatment research for "alcohol use disorders" (AUD). Subst Use Misuse 2001; 36:399-419. [PMID: 11346274 DOI: 10.1081/ja-100102634] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE This study examines a sample of alcohol user treatment outcome studies to determine the amount of attention given to three areas of concern and cost-effectiveness in treatment research: patient diagnosis, use of self-help groups (e.g., Alcoholics Anonymous [AA]), and use of maintenance care services (also known as a "aftercare"). METHOD A preliminary sample of 40 studies was coded for the degree of specific information provided to each of the three areas of interest. RESULTS Eight studies in the sample did not mention the diagnostic criteria used to determine patient addiction, 18 did not mention use, referral, or recommendation of AA, and 20 did not mention use, referral, or recommendation of maintenance care services. CONCLUSIONS As cost-effective additions to primary treatment, AA and maintenance care services deserve greater attention in the treatment of "substance abuse disorders." Researchers should also pay greater attention to patient diagnosis as an integral part of patient care. Finally, journal editors should institute minimum requirements for published reports ensuring that sufficient information on patient care is provided.
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Affiliation(s)
- A S Floyd
- Center for Alcohol and Addiction Studies, Brown University, Rhode Island 02912, USA.
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48
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49
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Romach MK, Sellers EM, Kaplan HL, Somer GR, Gomez-Mancilla B. Efficacy of Dexfenfluramine in the Treatment of Alcohol Dependence. Alcohol Clin Exp Res 2000. [DOI: 10.1111/j.1530-0277.2000.tb04572.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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50
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Thevos AK, Roberts JS, Thomas SE, Randall CL. Cognitive behavioral therapy delays relapse in female socially phobic alcoholics. Addict Behav 2000; 25:333-45. [PMID: 10890288 DOI: 10.1016/s0306-4603(99)00067-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The present study was conducted to test the hypothesis that socially phobic alcoholics treated with Cognitive Behavioral therapy (CBT) will have better drinking outcomes than those treated with Twelve-Step Facilitation therapy (TSF). Three hundred ninety-seven treatment-seeking alcoholics with concurrent social phobia were compared retrospectively to a matched sample of 397 alcoholics without social phobia. Treatment was delivered in an outpatient setting, and patients were randomized to either CBT, TSF, or Motivational Enhancement therapy (MET). The groups were compared on self-reported drinking measures (e.g., quantity and frequency of drinking, and time-to-event measures) during treatment period and monthly for 1 year following treatment. Survival analyses revealed that female outpatients with social phobia showed delayed relapse to drinking when treated with CBT rather than TSF; the reverse was true for female outpatients without social phobia. Survival analyses in male outpatients with and without social phobia revealed an opposite trend, though it was not statistically significant. These data suggest that Cognitive Behavioral therapy is superior to Twelve-Step Facilitation therapy for the treatment of alcohol problems in specific populations. namely socially phobic women seeking outpatient treatment.
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Affiliation(s)
- A K Thevos
- Medical University of South Carolina, USA.
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