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Heilig M, Witkiewitz K, Ray LA, Leggio L. Novel medications for problematic alcohol use. J Clin Invest 2024; 134:e172889. [PMID: 38828724 PMCID: PMC11142745 DOI: 10.1172/jci172889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
Alcohol-related harm, a major cause of disease burden globally, affects people along a spectrum of use. When a harmful pattern of drinking is present in the absence of significant behavioral pathology, low-intensity brief interventions that provide information about health consequences of continued use provide large health benefits. At the other end of the spectrum, profound behavioral pathology, including continued use despite knowledge of potentially fatal consequences, warrants a medical diagnosis, and treatment is strongly indicated. Available behavioral and pharmacological treatments are supported by scientific evidence but are vastly underutilized. Discovery of additional medications, with a favorable balance of efficacy versus safety and tolerability can improve clinical uptake of treatment, allow personalized treatment, and improve outcomes. Here, we delineate the clinical conditions when pharmacotherapy should be considered in relation to the main diagnostic systems in use and discuss clinical endpoints that represent meaningful clinical benefits. We then review specific developments in three categories of targets that show promise for expanding the treatment toolkit. GPCRs remain the largest category of successful drug targets across contemporary medicine, and several GPCR targets are currently pursued for alcohol-related indications. Endocrine systems are another established category, and several promising targets have emerged for alcohol indications. Finally, immune modulators have revolutionized treatment of multiple medical conditions, and they may also hold potential to produce benefits in patients with alcohol problems.
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Affiliation(s)
- Markus Heilig
- Center for Social and Affective Neuroscience, Linköping University, and Department of Psychiatry, Linköping University Hospital, Linköping, Sweden
| | - Katie Witkiewitz
- Department of Psychology and Center on Alcohol, Substance Use and Addictions, University of New Mexico, Albuquerque, New Mexico, USA
| | - Lara A. Ray
- Department of Psychology, UCLA, Los Angeles, California, USA
| | - Lorenzo Leggio
- Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program and National Institute on Alcohol Abuse and Alcoholism Division of Intramural Clinical and Biological Research, NIH, Baltimore and Bethesda, Maryland, USA
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Marks M, Brendel RW, Shachar C, Cohen IG. Essentials of Informed Consent to Psychedelic Medicine. JAMA Psychiatry 2024; 81:611-617. [PMID: 38598209 DOI: 10.1001/jamapsychiatry.2024.0184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
Importance Interest in administering psychedelic agents as mental health treatment is growing rapidly. As drugmakers invest in developing psychedelic medicines for several psychiatric indications, lawmakers are enacting legal reforms to speed access globally, and health agencies are preparing to approve these treatments. Meanwhile, US states, such as Oregon and Colorado, are making psychedelics available for supervised use outside the conventional health care system. Observations Despite legal change and potentially imminent regulatory approval in some countries, standards for integrating psychedelics into health care have lagged, including norms for designing and implementing informed consent processes. Informed consent is complicated by the unique features of psychedelics and their means of administration. Because no governments have approved any classic psychedelics for general medical or psychiatric use, only clinical researchers have obtained informed consent from trial participants. Accordingly, there is an unmet need for informed consent processes tailored to the challenges of administering psychedelics in nonresearch settings. Conclusions and Relevance Analysis of the challenges of designing and implementing psychedelic informed consent practices revealed 7 essential components, including the possibility of short- and long-term perceptual disturbances, potential personality changes and altered metaphysical beliefs, the limited role of reassuring physical touch, the potential for patient abuse or coercion, the role and risks of data collection, relevant practitioner disclosures, and interactive patient education and comprehension assessment. Because publicly available informed consent documents for psychedelic clinical trials often overlook or underemphasize these essential elements, sample language and procedures to fill the gap are proposed.
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Affiliation(s)
- Mason Marks
- Project on Psychedelics Law and Regulation (POPLAR), Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, Harvard Law School, Cambridge, Massachusetts
- Florida State University College of Law, Tallahassee, Florida
| | | | - Carmel Shachar
- Center for Health Law and Policy Innovation, Harvard Law School, Cambridge, Massachusetts
| | - I Glenn Cohen
- Project on Psychedelics Law and Regulation (POPLAR), Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, Harvard Law School, Cambridge, Massachusetts
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Tap SC. The potential of 5-methoxy-N,N-dimethyltryptamine in the treatment of alcohol use disorder: A first look at therapeutic mechanisms of action. Addict Biol 2024; 29:e13386. [PMID: 38600715 PMCID: PMC11007263 DOI: 10.1111/adb.13386] [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: 09/27/2023] [Revised: 12/24/2023] [Accepted: 02/13/2024] [Indexed: 04/12/2024]
Abstract
Alcohol use disorder (AUD) remains one of the most prevalent psychiatric disorders worldwide with high economic costs. Current treatment options show modest efficacy and relapse rates are high. Furthermore, there are increases in the treatment gap and few new medications have been approved in the past 20 years. Recently, psychedelic-assisted therapy with psilocybin and lysergic acid diethylamide has garnered significant attention in the treatment of AUD. Yet, they require significant amounts of therapist input due to prolonged subjective effects (~4-12 h) leading to high costs and impeding implementation. Accordingly, there is an increasing interest in the rapid and short-acting psychedelic 5-methoxy-N,N-dimethyltryptamine (5-MeO-DMT). This paper offers a first look at potential therapeutic mechanisms for AUD by reviewing the current literature on 5-MeO-DMT. Primarily, 5-MeO-DMT is able to induce mystical experiences and ego-dissolution together with increases in psychological flexibility and mindfulness. This could decrease AUD symptoms through the alleviation of psychiatric mood-related comorbidities consistent with the negative reinforcement and self-medication paradigms. In addition, preliminary evidence indicates that 5-MeO-DMT modulates neural oscillations that might subserve ego-dissolution (increases in gamma), psychological flexibility and mindfulness (increases in theta), and the reorganization of executive control networks (increases in coherence across frequencies) that could improve emotion regulation and inhibition. Finally, animal studies show that 5-MeO-DMT is characterized by neuroplasticity, anti-inflammation, 5-HT2A receptor agonism, and downregulation of metabotropic glutamate receptor 5 with clinical implications for AUD and psychiatric mood-related comorbidities. The paper concludes with several recommendations for future research to establish the purported therapeutic mechanisms of action.
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Affiliation(s)
- Stephan C. Tap
- Department of PsychiatryGroningen University Medical CenterGroningenThe Netherlands
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Romero P, Czakó A, van den Brink W, Demetrovics Z. Psychedelic-assisted therapy for people with gambling disorder? J Behav Addict 2024; 13:6-11. [PMID: 38421388 PMCID: PMC10988418 DOI: 10.1556/2006.2024.00004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 12/16/2023] [Accepted: 01/12/2024] [Indexed: 03/02/2024] Open
Abstract
Gambling disorder is a severe mental health and behavioural problem with harmful consequences, including financial, relationship and mental health problems. The present paper initiates discussion on the use of psychedelics combined with psychotherapeutic support as a potential treatment option for people living with a gambling disorder. Recent studies have shown promising results using psychedelic-assisted therapy (PAT) to treat anxiety, depression, post-traumatic stress disorder, and various substance use disorders. Considering the similarities in the underlying psychosocial and neurobiological mechanisms of gambling disorder and other addictive disorders, the authors suggest that psychedelic-assisted therapy could be effective in treating gambling disorder. The paper also underscores the need for further research into the viability and effectiveness of psychedelic-assisted therapy for gambling disorder.
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Affiliation(s)
- Pedro Romero
- Centre of Excellence in Responsible Gaming, University of Gibraltar, Gibraltar, Gibraltar
| | - Andrea Czakó
- Centre of Excellence in Responsible Gaming, University of Gibraltar, Gibraltar, Gibraltar
- Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Wim van den Brink
- Amsterdam University Medical Centers, Department of Psychiatry, Amsterdam, The Netherlands
| | - Zsolt Demetrovics
- Centre of Excellence in Responsible Gaming, University of Gibraltar, Gibraltar, Gibraltar
- Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary
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Vanderijst L, Hever F, Buot A, Dauré C, Benoit J, Hanak C, Veeser J, Morgiève M, Campanella S, Kornreich C, Mallet L, Leys C, Noël X. Psilocybin-assisted therapy for severe alcohol use disorder: protocol for a double-blind, randomized, placebo-controlled, 7-month parallel-group phase II superiority trial. BMC Psychiatry 2024; 24:77. [PMID: 38279085 PMCID: PMC10821548 DOI: 10.1186/s12888-024-05502-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/06/2024] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND A significant number of individuals with alcohol use disorder remain unresponsive to currently available treatments, which calls for the development of new alternatives. In parallel, psilocybin-assisted therapy for alcohol use disorder has recently yielded promising preliminary results. Building on extant findings, the proposed study is set to evaluate the feasibility and preliminary clinical efficacy of psilocybin-assisted therapy when incorporated as an auxiliary intervention during inpatient rehabilitation for severe alcohol use disorder. Moreover, it intends to pinpoint the modifications in the two core neurocognitive systems underscored by dual-process models of addiction. METHODS In this double-blind, randomized, placebo-controlled, 7-month parallel-group phase II superiority trial, 62 participants aged 21-64 years will be enrolled to undergo psilocybin-assisted therapy as part of a 4-week inpatient rehabilitation for severe alcohol use disorder. The experimental group will receive a high dose of psilocybin (30 mg), whereas the control group will receive an active placebo dose of psilocybin (5 mg), both within the context of a brief standardized psychotherapeutic intervention drawing from key elements of acceptance and commitment therapy. The primary clinical outcome is the between-group difference regarding the change in percentage of heavy drinking days from baseline to four weeks posthospital discharge, while safety and feasibility metrics will also be reported as primary outcomes. Key secondary assessments include between-group differences in terms of changes in (1) drinking behavior parameters up to six months posthospital discharge, (2) symptoms of depression, anxiety, trauma, and global functioning, (3) neuroplasticity and key neurocognitive mechanisms associated with addiction, and (4) psychological processes and alcohol-related parameters. DISCUSSION The discussion outlines issues that might arise from our design. TRIAL REGISTRATION EudraCT 2022-002369-14 and NCT06160232.
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Affiliation(s)
- Laetitia Vanderijst
- Laboratory of Medical Psychology and Addictology, Faculty of Medicine, Université libre de Bruxelles, Brussels, Belgium.
- Research Center for the Promotion of Health, Prosocial Behavior and Wellbeing, Faculty of Psychology, Université libre de Bruxelles, Brussels, Belgium.
| | - Felix Hever
- Laboratory of Medical Psychology and Addictology, Faculty of Medicine, Université libre de Bruxelles, Brussels, Belgium
- Psychiatric Institute, University Hospital Brugmann, Brussels, Belgium
| | - Anne Buot
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, CNRS, Inserm, Paris, France
| | - Charles Dauré
- Université de Paris, INSERM UMRS1144, 4 avenue de l'Observatoire, 75006, Paris, France
| | - Janaïna Benoit
- Psychiatric Institute, University Hospital Brugmann, Brussels, Belgium
| | - Catherine Hanak
- Psychiatric Institute, University Hospital Brugmann, Brussels, Belgium
| | - Johannes Veeser
- Psychiatric Institute, University Hospital Brugmann, Brussels, Belgium
| | - Margot Morgiève
- Université Paris Cité, CNRS, Inserm, Cermes3, F-75006, Paris, France
| | - Salvatore Campanella
- Laboratory of Medical Psychology and Addictology, Faculty of Medicine, Université libre de Bruxelles, Brussels, Belgium
| | - Charles Kornreich
- Laboratory of Medical Psychology and Addictology, Faculty of Medicine, Université libre de Bruxelles, Brussels, Belgium
- Psychiatric Institute, University Hospital Brugmann, Brussels, Belgium
| | - Luc Mallet
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, CNRS, Inserm, Paris, France
- Département Médical-Universitaire de Psychiatrie et d'Addictologie, Univ Paris-Est Créteil, DMU IMPACT, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Créteil, France
- Department of Mental Health and Psychiatry, Global Health Institute, University of Geneva, Geneva, Switzerland
| | - Christophe Leys
- Research Center for the Promotion of Health, Prosocial Behavior and Wellbeing, Faculty of Psychology, Université libre de Bruxelles, Brussels, Belgium
| | - Xavier Noël
- Laboratory of Medical Psychology and Addictology, Faculty of Medicine, Université libre de Bruxelles, Brussels, Belgium
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Marks M, Cohen IG. How Should the FDA Evaluate Psychedelic Medicine? N Engl J Med 2023; 389:1733-1735. [PMID: 37929835 DOI: 10.1056/nejmp2308940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Affiliation(s)
- Mason Marks
- From the Project on Psychedelics Law and Regulation, Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School (M.M., I.G.C.), and Harvard Law School (I.G.C.) - both in Cambridge, MA; and Florida State University College of Law, Tallahassee (M.M.)
| | - I Glenn Cohen
- From the Project on Psychedelics Law and Regulation, Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School (M.M., I.G.C.), and Harvard Law School (I.G.C.) - both in Cambridge, MA; and Florida State University College of Law, Tallahassee (M.M.)
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