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Guiraud J, Spanagel R, van den Brink W. Substitution therapy for patients with alcohol dependence: Mechanisms of action and efficacy. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2024; 175:187-239. [PMID: 38555116 DOI: 10.1016/bs.irn.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
New approaches for the treatment of alcohol dependence (AD) may improve patient outcomes. Substitution maintenance therapy is one of the most effective treatment options for opioid and nicotine use disorders. So far, there has been little attention to substitution therapy for the treatment of AD. Here, we explain the mechanistic foundations of alcohol substitution maintenance therapy. Alcohol has many primary targets in the brain (and other organs) and the physical interaction of ethanol molecules with these specific ethanol-sensitive sites on a variety of ionotropic receptors (e.g. GABA-A, NMDA, and nicotinic acetylcholine (nACh) receptors) and ion channels provides the rationale for substitution. As such, a variety of compounds can interact with those ethanol-sensitive sites and can thus substitute for some of the effects of alcohol. For some of these compounds, alcohol discrimination studies have shown their substitution potential. Accordingly, potential substitution treatments include agonists acting at GABA receptors such as sodium oxybate, baclofen and benzodiazepines, NMDA receptor antagonists such as ketamine and memantine, or nAChRs agonists such as varenicline. All these compounds are already approved for other indications and we present clinical evidence for these drugs in the treatment of alcohol withdrawal syndrome (AWS) and in the long-term treatment of AD, and outline future steps for their acceptance as substitution treatment in AD. Finally, we discuss the substitution approach of managed alcohol programs for the most severely affected homeless populations. Results showed that sodium oxybate is probably the closest to a substitution therapy for AD and is already approved for the treatment of AWS and in the long-term treatment of AD in some countries. In conclusion, we argue that better AD treatment can be provided if substitution maintenance treatments for alcohol are implemented at a similar scale as for opioid and nicotine use disorder.
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Affiliation(s)
- Julien Guiraud
- Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Amsterdam, The Netherlands; Vergio, Clichy, France.
| | - Rainer Spanagel
- Institute of Psychopharmacology, Central Institute of Mental Health, Heidelberg University, Mannheim, Germany
| | - Wim van den Brink
- Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Amsterdam, The Netherlands
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Aubin HJ. Repurposing drugs for treatment of alcohol use disorder. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2024; 175:153-185. [PMID: 38555115 DOI: 10.1016/bs.irn.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Repurposing drugs for the treatment of alcohol dependence involves the use of drugs that were initially developed for other conditions, but have shown promise in reducing alcohol use or preventing relapse. This approach can offer a more cost-effective and time-efficient alternative to developing new drugs from scratch. Currently approved medications for alcohol use disorder (AUD) include acamprosate, disulfiram, naltrexone, nalmefene, baclofen, and sodium oxybate. Acamprosate was developed specifically for AUD, while disulfiram's alcohol-deterrent effects were discovered incidentally. Naltrexone and nalmefene were originally approved for opioids but found secondary applications in AUD. Baclofen and sodium oxybate were repurposed from neurological conditions. Other drugs show promise. Topiramate and zonisamide, anticonvulsants, demonstrate efficacy in reducing alcohol consumption. Another anticonvulsant, gabapentin has been disappointing overall, except in cases involving alcohol withdrawal symptoms. Varenicline, a nicotinic receptor agonist, benefits individuals with less severe AUD or concurrent nicotine use. Ondansetron, a 5-HT3 antagonist, has potential for early-onset AUD, especially when combined with naltrexone. Antipsychotic drugs like aripiprazole and quetiapine have limited efficacy. Further investigation is needed for potential repurposing of α1 adrenergic receptor antagonists prazosin and doxazosin, glucocorticoid receptor antagonist mifepristone, the phosphodiesterase inhibitor Ibudilast, the cysteine prodrug N-acetylcysteine, and the OX1R and OX2R blocker Suvorexant. This review supports repurposing drugs as an effective strategy for expanding treatment options for AUD.
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Affiliation(s)
- Henri-Jean Aubin
- Université Paris-Saclay, Inserm, CESP, Villejuif, France; AP-HP, Université Paris Saclay, Villejuif, France.
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Guiraud J, Addolorato G, Aubin HJ, Bachelot S, Batel P, de Bejczy A, Benyamina A, Caputo F, Couderc M, Dematteis M, Goudriaan AE, Gual A, Lecoustey S, Lesch OM, Maremmani I, Nutt DJ, Paille F, Perney P, Rehm J, Rolland B, Scherrer B, Simon N, Söderpalm B, Somaini L, Sommer WH, Spanagel R, Walter H, van den Brink W. Sodium Oxybate for Alcohol Dependence: A Network Meta-Regression Analysis Considering Population Severity at Baseline and Treatment Duration. Alcohol Alcohol 2023; 58:125-133. [PMID: 36617267 PMCID: PMC10008102 DOI: 10.1093/alcalc/agac070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/17/2022] [Accepted: 12/06/2022] [Indexed: 01/09/2023] Open
Abstract
AIMS The estimated effect of sodium oxybate (SMO) in the treatment of alcohol dependence is heterogeneous. Population severity and treatment duration have been identified as potential effect modifiers. Population severity distinguishes heavy drinking patients with <14 days of abstinence before treatment initiation (high-severity population) from other patients (mild-severity population). Treatment duration reflects the planned treatment duration. This study aimed to systematically investigate the effect of these potential effect moderators on SMO efficacy in alcohol-dependent patients. METHODS Network meta-regression allows for testing potential effect modifiers. It was selected to investigate the effect of the above factors on SMO efficacy defined as continuous abstinence (abstinence rate) and the percentage of days abstinent (PDA). Randomized controlled trials for alcohol dependence with at least one SMO group conducted in high-severity and mild-severity populations were assigned to a high-severity and mild-severity group of studies, respectively. RESULTS Eight studies (1082 patients) were retained: four in the high-severity group and four in the mild-severity group. The high-severity group was associated with larger SMO effect sizes than the mild-severity group: abstinence rate risk ratio (RR) 3.16, P = 0.004; PDA +26.9%, P < 0.001. For PDA, longer treatment duration was associated with larger SMO effect size: +11.3% per extra month, P < 0.001. In the high-severity group, SMO showed benefit: abstinence rate RR 2.91, P = 0.03; PDA +16.9%, P < 0.001. In the mild-severity group, SMO showed benefit only in PDA for longer treatment duration: +23.9%, P < 0.001. CONCLUSIONS In the retained studies with alcohol-dependent patients, high-severity population and longer treatment duration were associated with larger SMO effect sizes.
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Affiliation(s)
- Julien Guiraud
- Corresponding author: Vergio, 31 rue Fernand Pelloutier, 92110 Clichy–France. E-mail: ;
| | - Giovanni Addolorato
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Rome, Rome, 00168, Italy
- CEMAD Digestive Disease Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Catholic University of Rome, Rome, 00168, Italy
| | - Henri-Jean Aubin
- French Institute of Health and Medical Research (Inserm), Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Universite Paris-Saclay, 94807, Villejuif, France
- Addiction Research and Treatment Center, Paul Brousse Hospital, Paris-Sud University, 94804, Villejuif, France
| | | | - Philippe Batel
- Addiction Unit of Charente, Camille Claudel Hospital, 16400 La Couronne, France
| | - Andrea de Bejczy
- Section of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, 41328, Gothenburg, Sweden
| | - Amine Benyamina
- Addiction Research and Treatment Center, Paul Brousse Hospital, Paris-Sud University, 94804, Villejuif, France
| | - Fabio Caputo
- Department of Internal Medicine, SS. Annunziata Hospital, University of Ferrara, 44042, Cento (Ferrara), Italy
- Centre for the Study and Treatment of Alcohol-Related Diseases, Department of Translational Medicine, University of Ferrara, 44042, Cento (Ferrara), Italy
| | | | - Maurice Dematteis
- Grenoble Alpes University, Faculty of Medicine and Grenoble-Alpes University Hospital, Department of Pharmacology and Addiction Medicine, 38043 Grenoble, France
| | - Anna E Goudriaan
- Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Meibergdreef 5, 1105AZ Amsterdam, The Netherlands
- Arkin, Dept. of Research and Quality of Care, Amsterdam Public Health Research Institute, 1033 NN Amsterdam, The Netherlands
| | - Antoni Gual
- Emeritus Researcher, GRAC (Addictions Research Group), IDIBAPS, 08036, Barcelona, Spain
| | | | - Otto-Michael Lesch
- University Clinic of Psychiatry and Psychotherapy, Department of Social Psychiatry, Medical University of Vienna, 1090, Vienna, Austria
| | - Icro Maremmani
- Department of Neurosciences, Santa Chiara University Hospital, University of Pisa, 56100, Pisa, Italy
| | - David J Nutt
- Centre for Neuropsychopharmacology, Imperial College London, W12 0NN, London, United Kingdom
| | - François Paille
- Department of Addiction Treatment, University Hospital, 54500, Vandoeuvre-lès-Nancy, France
| | - Pascal Perney
- Department of Addiction Medicine, CHU Nîmes; French Institute of Health and Medical Research (Inserm), Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Universite Paris-Saclay, Villejuif, 94807, France
| | - Jürgen Rehm
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, M5S2S1, Canada; Dalla Lana School of Public Health & Department of Psychiatry, University of Toronto, Toronto, Ontario, M5T1P8, Canada; Clinical Psychology & Psychotherapy Technical University Dresden, 01187, Dresden, Germany; Department of International Health Projects, Institute for Leadership and Health Management, I.M. Sechenov First Moscow State Medical University, Moscow, 119991, Russian Federation
| | - Benjamin Rolland
- SUAL, HCL, CH Le Vinatier; Univ Lyon; UCBL; INSERM U1028; CNRS UMR5292, Centre de Recherche en Neuroscience de Lyon (CRNL), F-69678, Bron, France
| | - Bruno Scherrer
- Bruno Scherrer Conseil, 78730, Saint Arnoult en Yvelines, France
| | - Nicolas Simon
- Aix Marseille Univ, APHM, INSERM, IRD, SESSTIM, Hop Sainte Marguerite, Department of Clinical Pharmacology, CAP-TV, 13005, Marseille, France
| | - Bo Söderpalm
- Section of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, 41328, Gothenburg, Sweden
| | - Lorenzo Somaini
- Addiction Treatment Center, Local Health Unit, ASL Biella, 13875, Biella, Italy
| | - Wolfgang H Sommer
- Institute of Psychopharmacology, Central Institute of Mental Health, Heidelberg University, D-68159, Mannheim, Germany
- Bethanian Hospital for Psychiatry, Psychosomatics and Psychotherapy, 17489, Greifswald, Germany
| | - Rainer Spanagel
- Institute of Psychopharmacology, Central Institute of Mental Health, Heidelberg University, D-68159, Mannheim, Germany
| | - Henriette Walter
- University Clinic of Psychiatry and Psychotherapy, Department of Social Psychiatry, Medical University of Vienna, 1090, Vienna, Austria
| | - Wim van den Brink
- Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Meibergdreef 5, 1105AZ Amsterdam, The Netherlands
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