1
|
Mendes FRS, da Silva AW, Ferreira MKA, Rebouças EDL, Moura Barbosa I, da Rocha MN, Henrique Ferreira Ribeiro W, Menezes RRPPBD, Magalhães EP, Marinho EM, Marinho MM, Bandeira PN, de Menezes JESA, Marinho ES, Dos Santos HS. GABA A and serotonergic receptors participation in anxiolytic effect of chalcones in adult zebrafish. J Biomol Struct Dyn 2023; 41:12426-12444. [PMID: 36644862 DOI: 10.1080/07391102.2023.2167116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 01/03/2023] [Indexed: 01/17/2023]
Abstract
The prevalence of anxiety is a significant public health problem, being the 24th leading cause of disability in individuals affected by this disorder. In this context, chalcones, a flavonoid subclass obtained from natural or synthetic sources, interact with central nervous system (CNS) receptors at the same binding site as benzodiazepines, the primary drugs used in the treatment of anxiety. Thus, our study investigates the anxiolytic effect of synthetic chalcones derived from the natural product 2-hydroxy-3,4,6-trimethoxyacetophenone isolated from Croton anisodontus Müll.Arg. in modulating anxiolytic activity via GABAergic and serotoninergic neurotransmission in an adult zebrafish model. Chalcones 1 and 2 were non-toxic to adult zebrafish and showed anxiolytic activity via GABAA receptors. Chalcone 2 also had its anxiolytic action reversed by the antagonist granisetron, indicating the participation of serotonergic receptors 5HTR3A/3B in the anxiolytic effect. In addition, molecular docking results showed that chalcones have a higher affinity for the GABAA receptor than DZP and binding in the same region of the DZP binding site, indicating a similar effect to the drug. Furthermore, the interaction of chalcones with GABAA and 5-HT3A receptors demonstrates the anxiolytic effect potential of these molecules.Communicated by Ramaswamy H. Sarma.
Collapse
Affiliation(s)
| | | | | | | | - Italo Moura Barbosa
- Graduate Program in Natural Sciences, State University of Ceara, Fortaleza, Ceará, Brazil
| | - Matheus Nunes da Rocha
- Department of Chemistry, Limoeiro do Norte, State University of Ceara, Limoeiro do Norte, Ceará, Brazil
| | | | | | - Emanuel Paula Magalhães
- Department of Clinical and Toxicological Analysis, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Emanuelle Machado Marinho
- Department of Analytical and Physical Chemistry, Federal University of Ceara, Fortaleza, Ceará, Brazil
| | | | | | | | - Emmanuel Silva Marinho
- Graduate Program in Natural Sciences, State University of Ceara, Fortaleza, Ceará, Brazil
- Department of Chemistry, Limoeiro do Norte, State University of Ceara, Limoeiro do Norte, Ceará, Brazil
| | - Hélcio Silva Dos Santos
- Department of Biological Chemistry, Regional University of Cariri, Crato, Ceará, Brazil
- Graduate Program of Biotechnology, State University of Ceara, Fortaleza, Ceará, Brazil
- Graduate Program in Natural Sciences, State University of Ceara, Fortaleza, Ceará, Brazil
- Chemistry Course, State University of Vale do Acaraú, Sobral, Ceará, Brazil
| |
Collapse
|
2
|
Jones JD, Campbell AN, Brandt L, Metz VE, Martinez S, Wall M, Corbeil T, Andrews H, Castillo F, Neale J, Strang J, Ross S, Comer SD. A randomized clinical trial of the effects of brief versus extended opioid overdose education on naloxone utilization outcomes by individuals with opioid use disorder. Drug Alcohol Depend 2022; 237:109505. [PMID: 35709575 PMCID: PMC9472254 DOI: 10.1016/j.drugalcdep.2022.109505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Overdose education and naloxone distribution (OEND) trains people who use opioids (PWUO) in how to intervene in cases of opioid overdose but best practices have not been assessed empirically. METHODS PWUO along with a significant other (SO) were randomized to one of three training conditions. In the Treatment-as-Usual (TAU) condition, participants were randomized to receive minimal overdose-related education. In the extended training (ET) condition, PWUO received an extended training, while their SO received no overdose training. In the final condition, both the participant and SO received the extended overdose training (ETwSO). Outcome measures were naloxone use and overdose knowledge and competency assessed immediately before and after training, and at 1-, 3-, 6-, and 12-month timepoints following training. RESULTS Three hundred and twenty-one PWUO (w/ a SO) were randomized. All intensities of OD training were associated with sustained increases in OD knowledge/ competency (versus pre-training baseline p's < 0.01). PWUO intervened in 166 ODs. The 12-month incidence of naloxone use did not significantly differ between groups. Extended training (ET + ETwSO) compared to TAU resulted in significantly greater naloxone utilization by: 30 days (10.1% vs 4.1%, p = 0.041), 60 days (16.4% vs 5.2%, p<0.001) and 90 days (17.9% vs 9.5%, p = 0.039). CONCLUSIONS All intensities of OD training were associated with sustained increases in OD knowledge and competency, and equivalent rates of successful naloxone use. More extensive training increased naloxone utilization during the first 3 months. However, the benefits of more comprehensive training should be balanced against feasibility.
Collapse
Affiliation(s)
- Jermaine D. Jones
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA,Correspondence to: 1051 Riverside Drive, Unit 120, New York, NY 10032, USA. , (J.D. Jones)
| | - Aimee N. Campbell
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| | - Laura Brandt
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| | - Verena E. Metz
- Kaiser Permanente Division of Research, Center for Addiction and Mental Health Research, 2000 Broadway, Oakland, CA 94612, USA
| | - Suky Martinez
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| | - Melanie Wall
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Thomas Corbeil
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Howard Andrews
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Felipe Castillo
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| | - Joanne Neale
- National Addiction Centre, King’s College London, 4 Windsor Walk, Denmark Hill, London SE5 8BB, United Kingdom
| | - John Strang
- National Addiction Centre, King’s College London, 4 Windsor Walk, Denmark Hill, London SE5 8BB, United Kingdom
| | - Stephen Ross
- Addictive Disorders and Experimental Therapeutics Research Laboratory, New York University Langone Health, New York, NY 10016, USA
| | - Sandra D. Comer
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| |
Collapse
|
3
|
MacDonald T, Gallo AT, Basso-Hulse G, Hulse GK. Outcomes of patients treated with low-dose flumazenil for benzodiazepine detoxification: A description of 26 participants. Drug Alcohol Depend 2022; 237:109517. [PMID: 35688053 DOI: 10.1016/j.drugalcdep.2022.109517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/23/2022] [Accepted: 05/27/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Benzodiazepines are commonly prescribed for a variety of indications and can be employed in the short- and long-term. While they are efficacious, issues arise from long-term use with the emergence of dependence and tolerance to doses within the therapeutic range and beyond. Discontinuation from benzodiazepines can be problematic for patients and may result in a withdrawal syndrome, which can be protracted and last months to years. METHODS 26 participants received low-dose subcutaneous flumazenil infusions (4 mg/24 h for approximately eight days) as part of a randomised control crossover trial. Return to benzodiazepine use was assessed monthly for three months based on the benzodiazepine use in the previous week. Where data was not available, the treating psychiatrist examined patient files and clinical documents to determine benzodiazepine use. Withdrawal and craving scores were also measured. RESULTS Abstinence rates from benzodiazepines at one-, two-, and three-month follow ups were 65.4 %, 50.0 %, and 46.2 % respectively. When considering patient files and clinical documents for those lost to follow-up, abstinence rates were higher at 73.1 %, 65.4 % and 61.5 % at the one-, two-, and three-month follow ups respectively. Withdrawal and craving scores were higher in those that had returned to any benzodiazepine use. CONCLUSION Self-reported rates of abstinence from benzodiazepines at three months was between 46.2 % and 61.5 %. Flumazenil may yield greater success than benzodiazepine tapering from high dose benzodiazepine use (≥30 mg diazepam equivalent). Further research should compare abstinence rates after treatment with flumazenil compared to benzodiazepine tapering in high dose benzodiazepine users.
Collapse
Affiliation(s)
- T MacDonald
- Currumbin Clinic, Currumbin, Queensland, Australia; School of Medicine, Griffith University, Australia.
| | - A T Gallo
- Division of Psychiatry, Medical School, the University of Western Australia, Australia; Fresh Start Recovery Programme, Subiaco, Western Australia, Australia.
| | - G Basso-Hulse
- Division of Psychiatry, Medical School, the University of Western Australia, Australia; Fresh Start Recovery Programme, Subiaco, Western Australia, Australia
| | - G K Hulse
- Division of Psychiatry, Medical School, the University of Western Australia, Australia; School of Medical and Health Sciences, Edith Cowan University, Australia; Fresh Start Recovery Programme, Subiaco, Western Australia, Australia
| |
Collapse
|
4
|
A double-blind randomised crossover trial of low-dose flumazenil for benzodiazepine withdrawal: A proof of concept. Drug Alcohol Depend 2022; 236:109501. [PMID: 35644071 DOI: 10.1016/j.drugalcdep.2022.109501] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/11/2022] [Accepted: 05/14/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Benzodiazepines (BZD) are a class of anxiolytics with varying uses, which primarily act on the GABAA receptor resulting in hyperpolarisation. BZDs are often a difficult drug class to cease once neuroadaptation has occurred; recommendations usually involve gradual dose reductions at variable rates. A growing body of evidence has suggested that low-dose flumazenil, a GABAA receptor antagonist, may be a useful agent to allow for rapid detoxification. AIM To collect pilot data on the safety and efficacy of low-dose subcutaneous flumazenil to reduce BZD use, withdrawal symptoms, and craving in participants taking above and below the therapeutic maximum diazepam equivalent of 30 mg to inform on sample size for future trials. METHOD In a randomised double-blinded crossover study design, participants received low-dose flumazenil first (4 mg/24 h for approximately eight days) or placebo first. Groups were divided into those taking < 30 mg diazepam equivalent and ≥ 30 mg diazepam equivalent at baseline. Main outcome measures were percentage reduction in daily diazepam use, withdrawal symptoms, and craving scores from baseline, difference in diazepam use across the placebo first group, and flumazenil related adverse events. RESULTS Twenty-eight participants were recruited and randomised to flumazenil first (n = 14) and placebo first (n = 14). In participants taking ≥ 30 mg diazepam equivalent at baseline (n = 15), flumazenil significantly reduced diazepam use by 30.5% (p = 0.024) compared to placebo. CONCLUSION Low-dose flumazenil may aid in BZD detoxification in participants taking daily diazepam equivalent doses greater than or equal to the therapeutic maximum (≥30 mg) by reducing the need for diazepam.
Collapse
|
5
|
Abstract
BACKGROUND Anxiety disorders are highly prevalent affecting up to 33.7% of people over a lifetime. Although many treatment options are available, they are often associated with unacceptable side-effect profiles and approximately one in three patients are treatment resistant. Allopregnanolone, a neuroactive steroid acting as a positive allosteric modulator at the GABAA receptor, is synthesised in response to stress and acts to negatively modulate the hypothalamic-pituitary-adrenal axis. FINDINGS After chronic exposure to and withdrawal from allopregnanolone, an increase in α4β2δ GABAA receptors results in a reduced inhibitory effect of allopregnanolone, resulting in decreased inhibition and, therefore, increased neuronal excitability. The relationship between allopregnanolone and increased α4β2δ GABAA receptors has been demonstrated in animal models during methamphetamine withdrawal and puberty, events both associated with stress. The effect of allopregnanolone during these events is anxiogenic, a paradoxical action to its usual anxiolytic effects. Flumazenil, the GABAA receptor antagonist, has been shown to cause receptor internalisation of α4β2δ GABAA receptors, which may results in anxiolysis. CONCLUSION We propose that chronic stress and chronic exposure to and withdrawal from allopregnanolone in anxiety disorders result in alterations in GABAA receptor function, which can be corrected by flumazenil. As such, flumazenil may exhibit anxiolytic properties in patients with increased α4β2δ GABAA receptor expression.
Collapse
Affiliation(s)
- Alexander T Gallo
- Division of Psychiatry, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, WA, Australia
| | - Gary K Hulse
- Division of Psychiatry, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, WA, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia.,Fresh Start Recovery Programme, Subiaco, WA, Australia
| |
Collapse
|
6
|
Casari R, Metastasio A, Zamboni L, Biasioli M, Campagnari S, Lugoboni F. Addiction of High Dose of Benzodiazepine: Verona Detox Approach With Flumazenil. Front Psychiatry 2022; 13:857376. [PMID: 35432044 PMCID: PMC9008883 DOI: 10.3389/fpsyt.2022.857376] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Since the 1990s there has been evidence of the significant role Flumazenil (FLU) has in benzodiazepines (BZD) detoxes. The Verona Detox approach has been developed for high dose BZD and Z-drug detoxification via continuous subcutaneous infusion of FLU, a selective BZD receptor antagonist acting on the BZD subunit of the GABA-A receptor. Flumazenil is licensed in the United Kingdom and other countries to treat only BZD overdose although numerous studies have demonstrated its effectiveness in rapidly resetting GABA-A receptors, quickly reducing tolerance and dependence from BZD, and providing a safe and rapid detox from benzodiazepines. OBJECTIVE The aim of this article is to provide all healthcare professional who are interested in BZD detoxification with an approach and clear practical information on how to administer FLU. METHOD In this article we outline the approach in detail, describing all medical and nursing procedures day by day. This detox treatment is indicated for patients abusing from at least 5 Defined Daily Dose (DDD) of BZDs or Z-drugs. The process lasts 7 days, and is conducted under medical supervision (daily reviews) and continuous nursing (24/7). During this period, 7mg of FLU is administered (1 mg/24) through an elastomeric pump, via continuous subcutaneous infusion. CONCLUSION To this day, the largest database of FLU detoxification was published by our group, showing how this treatment is safe, with very little side effects even in patients with significant medical comorbidities.
Collapse
Affiliation(s)
- Rebecca Casari
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Verona, Italy
| | | | - Lorenzo Zamboni
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Verona, Italy.,Department of Neurosciences, University of Verona, Verona, Italy
| | - Martino Biasioli
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Verona, Italy
| | - Simone Campagnari
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Verona, Italy
| | - Fabio Lugoboni
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Verona, Italy
| |
Collapse
|
7
|
Gallo AT, Hulse G. Pharmacological uses of flumazenil in benzodiazepine use disorders: a systematic review of limited data. J Psychopharmacol 2021; 35:211-220. [PMID: 33426982 DOI: 10.1177/0269881120981390] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The estimated annual prevalence of drug use disorders is as high as 3%, underpinning the need to continually develop more effective treatments. Central nervous system dysregulation, contributing to acute and post-withdrawal syndromes, has traditionally been managed with benzodiazepines; however, a small but growing body of data indicate that the GABAA receptor antagonist, flumazenil, may offer some advantages over traditional management. AIM To review the literature on the safety and efficacy of flumazenil in benzodiazepine use disorders and identify gaps in the literature. METHOD A systematic method was used to identify randomised control trials. Where randomised control trials existed, non-randomised control trials were included to supplement findings. RESULTS Eleven flumazenil trials were included with varying doses, frequencies and routes of administration. The evidence for flumazenil alone showed generally a reduction in withdrawal symptoms with the exception of one study where withdrawal symptoms initially increased. Flumazenil plus benzodiazepine tapering was assessed in one randomised control trial and a series of non-randomised control trials. Randomised control trial results showed that flumazenil plus benzodiazepine tapering was superior at reducing withdrawal symptoms compared to benzodiazepine tapering alone and placebo. Flumazenil was associated with no serious adverse events; however there remains a risk of seizures. CONCLUSION Although flumazenil shows promising efficacy in the management of benzodiazepine use disorders and withdrawal, more randomized control trials are required before a definitive recommendation can be made around its use.
Collapse
Affiliation(s)
- Alexander T Gallo
- Division of Psychiatry, The University of Western Australia, Perth, Australia
| | - Gary Hulse
- Division of Psychiatry, The University of Western Australia, Perth, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, Australia
| |
Collapse
|
8
|
Prevalence and Predictors of Symptoms of Depression Among Individuals Seeking Treatment from Australian Drug and Alcohol Outpatient Clinics. Community Ment Health J 2020; 56:107-115. [PMID: 31515714 DOI: 10.1007/s10597-019-00451-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 09/07/2019] [Indexed: 12/13/2022]
Abstract
This study examined the prevalence of and sociodemographic characteristics associated with elevated symptoms of depression among clients seeking alcohol or other drug (AOD) treatment. Consenting clients attending two AOD outpatient clinics answered demographics, treatment questions and the Patient Health Questionnaire to assess depressive symptoms. Counts and percentages were calculated to determine the prevalence of elevated depressive symptoms. Logistic regression was used to model the odds of having elevated depressive symptoms for client demographics. Of the 203 clients who completed the survey (87% consent rate), 55% (n = 111) demonstrated elevated depressive symptoms. Females were twice as likely to experience elevated symptoms of depression compared to males (OR 2.07; 95% CI 1.05, 4.08; P = 0.037). The high rates of elevated depressive symptoms among individuals seeking AOD treatment highlight the importance of ongoing research to provide effective treatments for this comorbidity. Routine screening and clear treatment pathways may assist with providing high quality care.
Collapse
|
9
|
Zamboni L, Lugoboni F, Zandonai T. Benzodiazepine abuse among athletes: Pain relief or just a weapon against insomnia? A clinical case study. Scand J Med Sci Sports 2019; 29:1937-1940. [DOI: 10.1111/sms.13540] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 07/31/2019] [Accepted: 08/12/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Lorenzo Zamboni
- Unit of Addiction Medicine Department of Internal Medicine Integrated University Hospital of Verona Policlinico “G.B. Rossi” Verona Italy
| | - Fabio Lugoboni
- Unit of Addiction Medicine Department of Internal Medicine Integrated University Hospital of Verona Policlinico “G.B. Rossi” Verona Italy
| | - Thomas Zandonai
- Department of Experimental Psychology Mind, Brain and Behavior Research Center (CIMCYC) University of Granada Granada Spain
- Department of Sport Sciences Sport Research Centre Miguel Hernández University Elche Spain
| |
Collapse
|
10
|
Blum K, Gold M, Modestino EJ, Baron D, Boyett B, Siwicki D, Lott L, Podesta A, Roy AK, Hauser M, Downs BW, Badgaiyan RD. Would induction of dopamine homeostasis via coupling genetic addiction risk score (GARS®) and pro-dopamine regulation benefit benzodiazepine use disorder (BUD)? ACTA ACUST UNITED AC 2018; 4. [PMID: 31750006 PMCID: PMC6865059 DOI: 10.15761/jsin.1000196] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Prescriptions for Benzodiazepines (BZDs) have risen continually. According to national statistics, the combination of BZDs with opioids has increased since 1999. BZDs (sometimes called “benzos”) work to calm or sedate a person by raising the level of the inhibitory neurotransmitter GABA in the brain. In terms of neurochemistry, BZDs act at the GABAA receptors to inhibit excitatory neurons, reducing VTA glutaminergic drive to reduce dopamine release at the Nucleus accumbens. Benzodiazepine Use Disorder (BUD) is very difficult to treat, partly because BZDs are used to reduce anxiety which paradoxically induces hypodopaminergia. Considering this, we are proposing a paradigm shift. Instead of simply targeting chloride channel direct GABAA receptors for replacement or substitution therapy, we propose the induction of dopamine homeostasis. Our rationale is supported by the well-established notion that the root cause of drug and non-drug addictions (i.e. Reward Deficiency Syndrome [RDS]), at least in adults, involve dopaminergic dysfunction and heightened stress. This proposition involves coupling the Genetic Addiction Risk Score (GARS) with a subsequent polymorphic matched genetic customized Pro-Dopamine Regulator known as KB220ZPBM (Precision Behavioral Management). Induction of dopamine homeostasis will be clinically beneficial in attempts to combat BUD for at least three reasons: 1) During detoxification of alcoholism, the potential induction of dopamine regulation reduces the need for BZDs; 2) A major reason for BZD abuse is because people want to achieve stress reduction and subsequently, the potential induction of dopamine regulation acts as an anti-stress factor; and 3) BUD and OUD are known to reduce resting state functional connectivity, and as such, potential induction of dopamine regulation enhances resting state functional connectivity. Future randomized placebo-controlled studies will investigate this forward thinking proposed novel modality.
Collapse
Affiliation(s)
- K Blum
- Western University Health Sciences, Graduate School of Biomedical Sciences, Pomona, CA, USA.,Division of Nutrigenomics, Geneus Health, LLC., San Antonio, TX, USA.,Division of Neuroscience & Addiction Research, Pathway Healthcare, LLc., Birmingham, AL, USA.,Division of Addiction Services, Dominion Diagnostics, LLC. North Kingstown, RI, USA.,Division of Nutrigenomic Research, Victory Nutrition International, Lederach, PA, USA
| | - M Gold
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Mo, USA
| | - E J Modestino
- Department of Psychology, Curry College, Milton, MA, USA
| | - D Baron
- Western University Health Sciences, Graduate School of Biomedical Sciences, Pomona, CA, USA.,Division of Nutrigenomics, Geneus Health, LLC., San Antonio, TX, USA
| | - B Boyett
- Division of Neuroscience & Addiction Research, Pathway Healthcare, LLc., Birmingham, AL, USA
| | - D Siwicki
- Division of Nutrigenomics, Geneus Health, LLC., San Antonio, TX, USA
| | - L Lott
- Division of Nutrigenomics, Geneus Health, LLC., San Antonio, TX, USA
| | - A Podesta
- Department of psychiatry, Tulane University School of Medicine, New Orleans, LA, USA
| | - A K Roy
- Department of psychiatry, Tulane University School of Medicine, New Orleans, LA, USA
| | - M Hauser
- Division of Addiction Services, Dominion Diagnostics, LLC. North Kingstown, RI, USA
| | - B W Downs
- Division of Nutrigenomic Research, Victory Nutrition International, Lederach, PA, USA
| | - R D Badgaiyan
- Department of Psychiatry, Veterans Administration Hospital at San Antonio, San Antonio, TX, USA
| |
Collapse
|
11
|
Hood SD, Bell CJ, Argyropoulos SV, Nutt DJ. Don't panic. A guide to tryptophan depletion with disorder-specific anxiety provocation. J Psychopharmacol 2016; 30:1137-1140. [PMID: 27329165 DOI: 10.1177/0269881116655321] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The 2002 paper "Does 5-HT restrain panic? A tryptophan depletion study in panic disorder patients recovered on paroxetine" by Bell and colleagues - reprinted in this issue of the Journal - reports on a study undertaken in the halcyon days of David Nutt's Psychopharmacology Unit at the University of Bristol, England. In this invited commentary authors of the original work discuss the impact of this paper on the field of acute tryptophan depletion research (especially in the field of clinical anxiety disorders) and the development of disorder-specific anxiogenic provocations over the past decade.
Collapse
Affiliation(s)
- S D Hood
- School of Psychiatry & Clinical Neurosciences (M521), University of Western Australia, Perth, WA, Australia
| | - C J Bell
- Mental Health Clinical Research Unit, Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - S V Argyropoulos
- Centre for Neuropsychopharmacology, Division of Brain Sciences, Imperial College London, London, UK
| | - D J Nutt
- Centre for Neuropsychopharmacology, Division of Brain Sciences, Imperial College London, London, UK
| |
Collapse
|
12
|
Kingston REF, Marel C, Mills KL. A systematic review of the prevalence of comorbid mental health disorders in people presenting for substance use treatment in Australia. Drug Alcohol Rev 2016; 36:527-539. [PMID: 27786426 DOI: 10.1111/dar.12448] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 04/25/2016] [Accepted: 05/24/2016] [Indexed: 11/29/2022]
Abstract
ISSUES The aim of this paper was to conduct a systematic review of the prevalence of comorbid mental health conditions in people accessing treatment for substance use in Australia. APPROACH A systematic review identified studies meeting the following eligibility criteria: reporting original data published in English; sample presenting for substance use treatment in Australia; assessing the prevalence of mental health and substance use conditions and reporting the percentage of participants with co-occurring mental health and substance use conditions. A narrative analysis was conducted because of the heterogeneity of methods used to assess key outcome variables and small number of studies assessing particular mental health outcomes. The abstracts of 1173 records were screened, and 59 full articles were assessed for eligibility. Eighteen studies were included in the review. KEY FINDINGS Prevalence estimates of current mental disorders in substance use treatment clients varied (47 to 100%). Mood and anxiety disorders were particularly prevalent, with the prevalence of current depression ranging from 27 to 85% and current generalised anxiety disorder ranging from 1 to 75%. IMPLICATIONS The high prevalence of mood and anxiety disorders in substance use treatment settings indicates a need for clinicians to screen and assess for these disorders as part of routine clinical care, and be familiar with evidence-based management and treatment strategies. CONCLUSION Although further studies are required to determine the prevalence of the full range of mental health disorders in this population, these findings emphasise the high prevalence of comorbid mental disorders are among individuals accessing substance use treatment in Australia. [Kingston REF, Marel C, Mills KL. A systematic review of the prevalence of comorbid mental health disorders in people presenting for substance use treatment in Australia. Drug Alcohol Rev 2017;36:527-539].
Collapse
Affiliation(s)
- Rosemary E F Kingston
- Centre of Research Excellence in Mental Health and Substance Use, University of New South Wales, Sydney, Australia.,National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Christina Marel
- Centre of Research Excellence in Mental Health and Substance Use, University of New South Wales, Sydney, Australia.,National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Katherine L Mills
- Centre of Research Excellence in Mental Health and Substance Use, University of New South Wales, Sydney, Australia.,National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| |
Collapse
|
13
|
Faccini M, Leone R, Opri S, Casari R, Resentera C, Morbioli L, Conforti A, Lugoboni F. Slow subcutaneous infusion of flumazenil for the treatment of long-term, high-dose benzodiazepine users: a review of 214 cases. J Psychopharmacol 2016; 30:1047-53. [PMID: 27166362 DOI: 10.1177/0269881116647505] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Despite the first reports concerning benzodiazepine dependence being published in the early 1960s literature, the risk of benzodiazepine addiction is still greatly debated. The severe discomfort and life threatening complications usually experienced by long-term benzodiazepine users who suddenly interrupt benzodiazepine intake have led to the development of several detoxification protocols. A successful strategy used by our Addiction Unit is abrupt benzodiazepine cessation by administering flumazenil slow subcutaneous infusion (FLU-SSI) with an elastomeric pump. Although some studies proved the efficacy of flumazenil infusion more than 20 years ago, only a few centres in the world offer this method to their patients. This paper reports the data related to 214 subjects addicted to high doses of benzodiazepine and treated with the FLU-SSI method between 2012 and 2014. This technique is less invasive and requires less nursing intervention than intravenous infusion. Our data support FLU-SSI as a possible efficient strategy for the treatment of patients with long-term, high-dose benzodiazepine addiction, and could become a routine therapy as long as the necessary further studies on dose, duration of infusion and safety issues are carried out.
Collapse
Affiliation(s)
- Marco Faccini
- Department of Internal Medicine, Addiction Unit, Verona University Hospital, Verona, Italy
| | - Roberto Leone
- Department of Diagnostics and Public Health, Pharmacology Unit, Verona University Hospital, Verona, Italy
| | - Sibilla Opri
- Department of Diagnostics and Public Health, Pharmacology Unit, Verona University Hospital, Verona, Italy
| | - Rebecca Casari
- Department of Internal Medicine, Addiction Unit, Verona University Hospital, Verona, Italy
| | - Chiara Resentera
- Department of Internal Medicine, Addiction Unit, Verona University Hospital, Verona, Italy
| | - Laura Morbioli
- Department of Internal Medicine, Addiction Unit, Verona University Hospital, Verona, Italy
| | - Anita Conforti
- Department of Diagnostics and Public Health, Pharmacology Unit, Verona University Hospital, Verona, Italy
| | - Fabio Lugoboni
- Department of Internal Medicine, Addiction Unit, Verona University Hospital, Verona, Italy
| |
Collapse
|
14
|
Mariani JJ, Malcolm RJ, Mamczur AK, Choi JC, Brady R, Nunes E, Levin FR. Pilot trial of gabapentin for the treatment of benzodiazepine abuse or dependence in methadone maintenance patients. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2016; 42:333-40. [PMID: 26962719 DOI: 10.3109/00952990.2015.1125493] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Benzodiazepine use disorders are a common clinical problem among methadone maintenance treatment patients and have adverse effects on clinical outcomes. OBJECTIVES To evaluate gabapentin for the outpatient treatment of benzodiazepine abuse or dependence in methadone maintenance patients. METHODS Participants (n = 19) using benzodiazepines at least 4 days per week were enrolled into an 8-week randomized double-blind placebo-controlled outpatient pilot trial. All participants received a manual-guided supportive psychotherapy aimed to promote abstinence. Study medication was titrated over a 2-week period to a maximum dose of gabapentin 1200 mg or placebo three times a day. Benzodiazepine use was assessed using urine toxicology confirmed self-report. Benzodiazepines were not provided as part of study participation; participants were provided guidance to gradually reduce benzodiazepine intake. RESULTS Sixteen participants had post-randomization data for analysis. Retention at week eight was 50%. The mean dose of gabapentin achieved by titration was 2666 mg/day (SD = ± 1446). There were no significant between group differences on benzodiazepine use outcomes (amount benzodiazepine per day [Mann-Whitney U = 27, p = 0.745], abstinent days per week [U = 28, p = 0.811]) and Clinical Instrument Withdrawal Assessment (CIWA)-benzodiazepines scale (U = 29.0, p = 0.913). One participant in the gabapentin group discontinued study medication because of peripheral edema. Two participants in the placebo group requested admission for inpatient detoxification treatment. CONCLUSION In outpatient methadone-maintained patients with benzodiazepine use disorder, gabapentin did significantly decrease benzodiazepine use relative to placebo. The small sample recruited for this trial may have limited the ability to detect a group difference.
Collapse
Affiliation(s)
- John J Mariani
- a Division on Substance Abuse , New York State Psychiatric Institute , New York , NY , USA.,b Department of Psychiatry , College of Physicians and Surgeons of Columbia University , New York , NY , USA
| | | | - Agnieszka K Mamczur
- a Division on Substance Abuse , New York State Psychiatric Institute , New York , NY , USA
| | - Jean C Choi
- d Division of Biostatistics , New York State Psychiatric Institute , New York , NY , USA
| | | | - Edward Nunes
- a Division on Substance Abuse , New York State Psychiatric Institute , New York , NY , USA.,b Department of Psychiatry , College of Physicians and Surgeons of Columbia University , New York , NY , USA
| | - Frances R Levin
- a Division on Substance Abuse , New York State Psychiatric Institute , New York , NY , USA.,b Department of Psychiatry , College of Physicians and Surgeons of Columbia University , New York , NY , USA
| |
Collapse
|
15
|
Abstract
The large class of CNS-depressant medications-the benzodiazepines-have been extensively used for over 50 years, anxiety disorders being one of the main indications. A substantial proportion (perhaps up to 20-30 %) of long-term users becomes physically dependent on them. Problems with their use became manifest, and dependence, withdrawal difficulties and abuse were documented by the 1980s. Many such users experience physical and psychological withdrawal symptoms on attempted cessation and may develop clinically troublesome syndromes even during slow tapering. Few studies have been conducted to establish the optimal withdrawal schedules. The usual management comprises slow withdrawal over weeks or months together with psychotherapy of various modalities. Pharmacological aids include antidepressants such as the SSRIs especially if depressive symptoms supervene. Other pharmacological agents such as the benzodiazepine antagonist, flumazenil, and the hormonal agent, melatonin, remain largely experimental. The purpose of this review is to analyse the evidence for the efficacy of the usual withdrawal regimes and the newer agents. It is concluded that little evidence exists outside the usual principles of drug withdrawal but there are some promising leads.
Collapse
Affiliation(s)
- Malcolm Lader
- National Addiction Centre, Addictions Department, Institute of Psychiatry, Psychology and Neurosciences, King's College London, Denmark Hill, London, SE5 8AF, UK.
| | - Andri Kyriacou
- National Addiction Centre, Addictions Department, Institute of Psychiatry, Psychology and Neurosciences, King's College London, Denmark Hill, London, SE5 8AF, UK
| |
Collapse
|
16
|
Hood SD, Norman A, Hince DA, Melichar JK, Hulse GK. Benzodiazepine dependence and its treatment with low dose flumazenil. Br J Clin Pharmacol 2014; 77:285-94. [PMID: 23126253 DOI: 10.1111/bcp.12023] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 10/30/2012] [Indexed: 11/29/2022] Open
Abstract
Globally benzodiazepines remain one of the most prescribed medication groups, especially in the primary care setting. With such high levels of prescribing it is not surprising that benzodiazepine dependence is common, cutting across all socioeconomic levels. Despite recognition of the potential for the development of iatrogenic dependence and the lack of any effective treatment, benzodiazepines continue to be widely prescribed in general practice. Conventional dependence management, benzodiazepine tapering, is commonly a protracted process over several weeks or months. It is often associated with significant withdrawal symptoms and craving leading to patient drop out and return to use. Accordingly, there is a worldwide need to find effective pharmacotherapeutic interventions for benzodiazepine dependence. One drug of increasing interest is the GABAA benzodiazepine receptor antagonist/partial agonist, flumazenil. Multiple bolus intravenous infusions of low dose flumazenil used either with or without benzodiazepine tapering can reduce withdrawal sequelae, and/or longer term symptoms in the months following withdrawal. Preliminary data suggest that continuous intravenous or subcutaneous flumazenil infusion for 4 days significantly reduces acute benzodiazepine withdrawal sequelae. The subcutaneous infusion was shown to be tissue compatible so the development of a longer acting (i.e. several weeks) depot flumazenil formulation has been explored. This could be capable of managing both acute and longer term benzodiazepine withdrawal sequelae. Preliminary in vitro water bath and in vivo biocompatibility data in sheep show that such an implant is feasible and so is likely to be used in clinical trials in the near future.
Collapse
Affiliation(s)
- Sean David Hood
- School of Psychiatry and Clinical Neurosciences, The University of Western Australia, Perth, WA, Australia
| | | | | | | | | |
Collapse
|
17
|
Lugoboni F, Quaglio G. Exploring the dark side of the moon: the treatment of benzodiazepine tolerance. Br J Clin Pharmacol 2014; 77:239-41. [PMID: 23617374 DOI: 10.1111/bcp.12148] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 02/05/2013] [Indexed: 11/28/2022] Open
Affiliation(s)
- Fabio Lugoboni
- Medical Service for Addictive Disorders, University of Verona, GB Rossi Hospital, 37134, Verona, Italy
| | | |
Collapse
|
18
|
Lugoboni F, Mirijello A, Faccini M, Casari R, Cossari A, Musi G, Bissoli G, Quaglio G, Addolorato G. Quality of life in a cohort of high-dose benzodiazepine dependent patients. Drug Alcohol Depend 2014; 142:105-9. [PMID: 25001277 DOI: 10.1016/j.drugalcdep.2014.06.020] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 06/03/2014] [Accepted: 06/04/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Benzodiazepines (BZD) are among the most widely prescribed drugs in developed countries. Since BZD can produce tolerance and dependence even in a short time, their use is recommended for a very limited time. However, these recommendations have been largely disregarded. The chronic use of BZD causes a number of serious side effects, i.e., cognitive impairment, falls, traffic accidents, dependence and tolerance. The aim of the present study was to evaluate quality of life (QoL) in a cohort of 62 consecutive high-dose BZD-dependent patients seeking a BZD detoxification. METHODS Patients seeking BZD detoxification were evaluated using the General Health Questionnaire (GHQ-12) and the short form-36 questionnaire (SF-36). RESULTS Patients showed a significant reduction of QoL as measured by either SF-36 or GHQ-12. In particular, the greater impairment was observed in the items exploring physical and emotional status. Physical functioning was the item more influenced by the length of BZD abuse. Female patients showed a greater reduction of QoL compared to male, at least in some of the explored items. Social functioning scores were greatly reduced. CONCLUSIONS The present study shows for the first time that high-doses BZD dependent patients have a reduced QoL and a reduced social functioning, along with high levels of psychological distress.
Collapse
Affiliation(s)
- Fabio Lugoboni
- Addiction Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Antonio Mirijello
- Alcohol Addiction Unit, Department of Internal Medicine, Catholic University of Rome, Rome, Italy
| | - Marco Faccini
- Addiction Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Rebecca Casari
- Addiction Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Anthony Cossari
- Department of Economics, Statistics and Finance, University of Calabria, Rende, Italy
| | - Gessica Musi
- Addiction Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Giorgia Bissoli
- Addiction Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Gianluca Quaglio
- Addiction Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Giovanni Addolorato
- Alcohol Addiction Unit, Department of Internal Medicine, Catholic University of Rome, Rome, Italy.
| |
Collapse
|
19
|
Endogenous ligands of benzodiazepine binding site have inverse agonistic properties. Med Hypotheses 2013; 81:1075-7. [PMID: 24183322 DOI: 10.1016/j.mehy.2013.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 10/02/2013] [Accepted: 10/08/2013] [Indexed: 11/23/2022]
Abstract
Benzodiazepines have been widely used in clinical praxis for many decades. They act as GABAA receptor agonists and possess muscle-relaxant, hypnotic-sedative, anticonvulsant, and anxiolytic properties. Flumazenil acts as a benzodiazepine receptor antagonist (subunits α1, α2, α3, and α5) or partial agonist (subunits α4 and α6). It competitively inhibits the activity at the benzodiazepine recognition site on the GABA/benzodiazepine receptor complex, thereby reversing the effects of benzodiazepines. In our experiments, administration of flumazenil in rabbits was surprisingly associated with anxiolytic effects similar to those of midazolam. Additionally, flumazenil significantly and dose-dependently decreased the total number of vocalizations in rats, i.e. it was anxiolytic. These observations seem to be in contrast to the effect of flumazenil in humans, where it is believed to produce mainly anxiogenic effects. It seems that in individuals, who exhibit anxiogenic behavior or in individuals with anticipation anxiety, flumazenil acts as an anxiolytic agent, while in individuals without any signs of anxiety, flumazenil can also act as anxiogenic agent. Thus, we hypothesize that flumazenil is associated with decreased intensity of anticipatory anxiety due to occupancy of benzodiazepine binding sites by an endogenous ligand with inverse agonistic properties.
Collapse
|
20
|
Hulse G, O'Neil G, Morris N, Bennett K, Norman A, Hood S. Withdrawal and psychological sequelae, and patient satisfaction associated with subcutaneous flumazenil infusion for the management of benzodiazepine withdrawal: a case series. J Psychopharmacol 2013; 27:222-7. [PMID: 22596209 DOI: 10.1177/0269881112446532] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Our group and others internationally have previously reported data on the use of low-dose flumazenil administered intravenously for the management of benzodiazepine withdrawal. This paper describes the first reported use of subcutaneous flumazenil infusion in the management of acute benzodiazepine withdrawal. Self-reported withdrawal symptoms and psychological state and anxiety sequelae were collected at baseline and then at intervals to 5 days following initiation of subcutaneous flumazenil infusion. Data indicate that patient subjective benzodiazepine withdrawal symptoms were well managed, with significant reduction in psychological distress seen over the duration of treatment. Perceived difficulty in performing everyday functions was positively correlated with withdrawal severity and improved over treatment. Patients reported high treatment comfort, willingness to undertake a future subsequent treatment using this technique, and willingness to recommend this treatment to a friend. This small proof-of-concept study indicates that subcutaneous flumazenil infusion has excellent tolerability, efficacy and improvement on measures of psychological distress. Given this technique is less invasive and requires fewer staff resources compared with intravenous administration, it may prove a significant asset in the management of benzodiazepine withdrawal.
Collapse
Affiliation(s)
- Gary Hulse
- School of Psychiatry and Clinical Neurosciences, The University of Western Australia, Perth, Australia.
| | | | | | | | | | | |
Collapse
|
21
|
Divljaković J, Milić M, Namjoshi OA, Tiruveedhula VV, Timić T, Cook JM, Savić MM. βCCT, an antagonist selective for α(1)GABA(A) receptors, reverses diazepam withdrawal-induced anxiety in rats. Brain Res Bull 2012; 91:1-7. [PMID: 23149168 DOI: 10.1016/j.brainresbull.2012.10.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Revised: 10/29/2012] [Accepted: 10/31/2012] [Indexed: 10/27/2022]
Abstract
The abrupt discontinuation of prolonged benzodiazepine treatment elicits a withdrawal syndrome with increased anxiety as a major symptom. The neural mechanisms underlying benzodiazepine physical dependence are still insufficiently understood. Flumazenil, the non-selective antagonist of the benzodiazepine binding site of GABA(A) receptors was capable of preventing and reversing the increased anxiety during benzodiazepine withdrawal in animals and humans in some, but not all studies. On the other hand, a number of data suggest that GABA(A) receptors containing α(1) subunits are critically involved in processes developing during prolonged use of benzodiazepines, such are tolerance to sedative effects, liability to physical dependence and addiction. Hence, we investigated in the elevated plus maze the level of anxiety 24 h following 21 days of diazepam treatment and the influence of flumazenil or a preferential α(1)-subunit selective antagonist βCCt on diazepam withdrawal syndrome in rats. Abrupt cessation of protracted once-daily intraperitoneal administration of 2 mg/kg diazepam induced a withdrawal syndrome, measured by increased anxiety-like behavior in the elevated plus maze 24 h after treatment cessation. Acute challenge with either flumazenil (10mg/kg) or βCCt (1.25, 5 and 20 mg/kg) alleviated the diazepam withdrawal-induced anxiety. Moreover, both antagonists induced an anxiolytic-like response close, though not identical, to that seen with acute administration of diazepam. These findings imply that the mechanism by which antagonism at GABA(A) receptors may reverse the withdrawal-induced anxiety involves the α(1) subunit and prompt further studies aimed at linking the changes in behavior with possible adaptive changes in subunit expression and function of GABA(A) receptors.
Collapse
Affiliation(s)
- Jovana Divljaković
- Department of Pharmacology, Faculty of Pharmacy, University of Belgrade, Vojvode Stepe 450, 11221 Belgrade, Serbia
| | | | | | | | | | | | | |
Collapse
|
22
|
Quaglio G, Pattaro C, Gerra G, Mathewson S, Verbanck P, Des Jarlais DC, Lugoboni F. High dose benzodiazepine dependence: description of 29 patients treated with flumazenil infusion and stabilised with clonazepam. Psychiatry Res 2012; 198:457-62. [PMID: 22424905 DOI: 10.1016/j.psychres.2012.02.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Revised: 02/03/2012] [Accepted: 02/06/2012] [Indexed: 11/30/2022]
Abstract
The withdrawal syndrome from benzodiazepine (BZD) can be severe and in some cases may impede cessation of the use of the drug. We present here a case series of benzodiazepine detoxification by flumazenil infusion, stabilised with clonazepam. Patients were treated with flumazenil 1.35 mg/day for a median of 7 days. Self-reported physical withdrawal symptoms were recorded daily. In addition to flumazenil, antidepressants were given before treatment commenced and clonazepam was administered nightly with both being continued after discharge. Twenty-nine patients were treated. No patients dropped out from the treatment programme. Nine patients (31%) required a temporary reduction/cessation of the infusion. The linear trend in the reduction of the daily withdrawal scores in the overall study population was significant. The linear trends were also significant in the group of patients for whom a temporary reduction/suspension of the flumazenil was required. Six months after treatment, 15 patients (53%) were abstinent from clonazepam and other BZDs. For five (21%) the BZD dependence were reinstated. More than two-thirds of the subjects tolerated the procedure well and about half had a good long term response. Slow flumazenil infusion appears to merit consideration as a possible future treatment. Suggestions for future research are examined.
Collapse
Affiliation(s)
- Gianluca Quaglio
- Medical Service for Addictive Disorders, University of Verona, Italy.
| | | | | | | | | | | | | |
Collapse
|
23
|
|
24
|
Lingford-Hughes AR, Welch S, Peters L, Nutt DJ. BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP. J Psychopharmacol 2012; 26:899-952. [PMID: 22628390 DOI: 10.1177/0269881112444324] [Citation(s) in RCA: 154] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The British Association for Psychopharmacology guidelines for the treatment of substance abuse, harmful use, addiction and comorbidity with psychiatric disorders primarily focus on their pharmacological management. They are based explicitly on the available evidence and presented as recommendations to aid clinical decision making for practitioners alongside a detailed review of the evidence. A consensus meeting, involving experts in the treatment of these disorders, reviewed key areas and considered the strength of the evidence and clinical implications. The guidelines were drawn up after feedback from participants. The guidelines primarily cover the pharmacological management of withdrawal, short- and long-term substitution, maintenance of abstinence and prevention of complications, where appropriate, for substance abuse or harmful use or addiction as well management in pregnancy, comorbidity with psychiatric disorders and in younger and older people.
Collapse
|
25
|
Faccini M, Leone R, Pajusco B, Quaglio G, Casari R, Albiero A, Donati M, Lugoboni F. Lormetazepam addiction: data analysis from an Italian medical unit for addiction. Risk Manag Healthc Policy 2012; 5:43-8. [PMID: 22792010 PMCID: PMC3393115 DOI: 10.2147/rmhp.s31745] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background The purpose of this study was to determine, in the context of a hospital addiction unit, which benzodiazepines were abused and to look for correlations with the characteristics of detoxified patients. Methods A retrospective study was carried out using the database of hospital admissions to the addiction unit for detoxification from 2003 to 2010. Results Of 879 admissions to the addiction unit during the seven-year period, 281 were for benzodiazepines. The percentage of patients addicted only to benzodiazepines was higher among females than males. Benzodiazepine consumption had started as a drug addiction behavior in only 10% of cases. The main sources of prescription identified were general practitioners (52% of cases) or compliant pharmacists (25%). Overall, 15 different benzodiazepines were abused, with lormetazepam being the most commonly used (by 123 patients, 43.8% of the total). Conclusion Our data show that, outside the population of multidrug addicts, there is an underestimated group of chronic benzodiazepine consumers who are often not referred to medical institutions for treatment. Even in the group of patients addicted to one substance only, we observed an abnormal number of requests for detoxification from lormetazepam, which appears to be more “popular” than other benzodiazepines. This drug should be prescribed according to stricter criteria and submitted to closer control.
Collapse
Affiliation(s)
- Marco Faccini
- Department of Internal Medicine, Addiction Unit, Reference Center for Education and Communication within the World Health Organization Program for International Drug Monitoring, University Hospital of Verona, Verona, Italy
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Quaglio G, Faccini M, Vigneau CV, Casari R, Mathewson S, Licata M, Lugoboni F. Megadose Bromazepam and Zolpidem Dependence: Two Case Reports of Treatment with Flumazenil and Valproate. Subst Abus 2012; 33:195-8. [DOI: 10.1080/08897077.2011.638735] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
27
|
Albiero A, Brigo F, Faccini M, Casari R, Quaglio G, Storti M, Fiaschi A, Bongiovanni LG, Lugoboni F. Focal nonconvulsive seizures during detoxification for benzodiazepine abuse. Epilepsy Behav 2012; 23:168-70. [PMID: 22200495 DOI: 10.1016/j.yebeh.2011.11.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Revised: 11/05/2011] [Accepted: 11/05/2011] [Indexed: 10/14/2022]
Abstract
Chronic benzodiazepine (BDZ) abuse is currently treated with detoxification using a low-dose flumazenil infusion, a relatively recently developed and promising procedure. Given the possibility reported in the literature of the occurrence of generalized seizures during therapeutic BDZ detoxification, we usually administer preventive antiepileptic drug (AED) therapy. We describe two patients with no previous history of seizures or evidence of intracerebral lesions who, during detoxification for benzodiazepine abuse, developed repetitive focal nonconvulsive seizures instead of generalized seizures, even with appropriate doses of preventive AED therapy. There are no previous reported cases of focal nonconvulsive seizures occurring during this procedure or, more generally, during abrupt BDZ discontinuation. The cases we describe suggest that during detoxification for BDZ abuse, not only generalized, but also focal nonconvulsive seizures may occur. In this context, the focal seizures probably result from a diffuse decrease in the seizure threshold (caused by a generalized excitatory rebound), which may trigger focal seizures arising from cortical regions with higher intrinsic epileptogenicity. Detoxification for benzodiazepine abuse, even if performed with adequate-dosage AED treatment, may not be as safe a procedure as previously considered, because not only convulsive, but also nonconvulsive seizures may occur and go unnoticed. It is therefore strongly advisable to perform this detoxification under close medical supervision and to maintain a low threshold for EEG monitoring in the event of sudden onset of behavioral changes.
Collapse
Affiliation(s)
- Anna Albiero
- Department of Medicine D, Addiction Unit, University of Verona, Verona, Italy
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Abstract
AIMS To re-examine various aspects of the benzodiazepines (BZDs), widely prescribed for 50 years, mainly to treat anxiety and insomnia. It is a descriptive review based on the Okey Lecture delivered at the Institute of Psychiatry, King's College London, in November 2010. METHODS A search of the literature was carried out in the Medline, Embase and Cochrane Collaboration databases, using the codeword 'benzodiazepine(s)', alone and in conjunction with various terms such as 'dependence', 'abuse', etc. Further hand-searches were made based on the reference lists of key papers. As 60,000 references were found, this review is not exhaustive. It concentrates on the adverse effects, dependence and abuse. RESULTS Almost from their introduction the BZDs have been controversial, with polarized opinions, advocates pointing out their efficacy, tolerability and patient acceptability, opponents deprecating their adverse effects, dependence and abuse liability. More recently, the advent of alternative and usually safer medications has opened up the debate. The review noted a series of adverse effects that continued to cause concern, such as cognitive and psychomotor impairment. In addition, dependence and abuse remain as serious problems. Despite warnings and guidelines, usage of these drugs remains at a high level. The limitations in their use both as choice of therapy and with respect to conservative dosage and duration of use are highlighted. The distinction between low-dose 'iatrogenic' dependence and high-dose abuse/misuse is emphasized. CONCLUSIONS The practical problems with the benzodiazepines have persisted for 50 years, but have been ignored by many practitioners and almost all official bodies. The risk-benefit ratio of the benzodiazepines remains positive in most patients in the short term (2-4 weeks) but is unestablished beyond that time, due mainly to the difficulty in preventing short-term use from extending indefinitely with the risk of dependence. Other research issues include the possibility of long-term brain changes and evaluating the role of the benzodiazepine antagonist, flumazenil, in aiding withdrawal.
Collapse
Affiliation(s)
- Malcolm Lader
- Addiction Research Centre, Institute of Psychiatry, King's College London, London, UK.
| |
Collapse
|
29
|
Lugoboni F, Faccini M, Quaglio GL, Albiero A, Casari R, Pajusco B. Intravenous flumazenil infusion to treat benzodiazepine dependence should be performed in the inpatient clinical setting for high risk of seizure. J Psychopharmacol 2011; 25:848-9. [PMID: 21262854 DOI: 10.1177/0269881110393050] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- F Lugoboni
- Department of Internal Medicine, Addiction Unit, Verona University Hospital, Verona, Italy
| | - M Faccini
- Department of Internal Medicine, Addiction Unit, Verona University Hospital, Verona, Italy
| | - GL Quaglio
- Department of Internal Medicine, Addiction Unit, Verona University Hospital, Verona, Italy
| | - A Albiero
- Department of Internal Medicine, Addiction Unit, Verona University Hospital, Verona, Italy
| | - R Casari
- Department of Internal Medicine, Addiction Unit, Verona University Hospital, Verona, Italy
| | - B Pajusco
- Department of Internal Medicine, Addiction Unit, Verona University Hospital, Verona, Italy
| |
Collapse
|
30
|
Lugoboni F, Faccini M, Quaglio G, Casari R, Albiero A, Pajusco B. Agonist substitution for high-dose benzodiazepine-dependent patients: let us not forget the importance of flumazenil. Addiction 2011; 106:853. [PMID: 21320225 DOI: 10.1111/j.1360-0443.2010.03327.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
31
|
Authier N, Balayssac D, Sautereau M, Zangarelli A, Courty P, Somogyi A, Vennat B, Llorca PM, Eschalier A. Benzodiazepine dependence: Focus on withdrawal syndrome. ANNALES PHARMACEUTIQUES FRANÇAISES 2009; 67:408-13. [DOI: 10.1016/j.pharma.2009.07.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Revised: 07/16/2009] [Accepted: 07/22/2009] [Indexed: 11/28/2022]
|
32
|
Authier N, Boucher A, Lamaison D, Llorca PM, Descotes J, Eschalier A. Second Meeting of the French CEIP (Centres d’Évaluation d’Information sur la Pharmacodépendance). Part II: Benzodiazepine Withdrawal. Therapie 2009; 64:365-70. [DOI: 10.2515/therapie/2009051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2009] [Indexed: 11/20/2022]
|