Gabapentin shows promise for treating early alcohol withdrawal symptoms

Treating alcohol use disorder (AUD) with gabapentin in the early stages of alcohol withdrawal shows promise, according to a randomized clinical trial reported in JAMA Internal Medicine. The study, “Efficacy of Gabapentin for the Treatment of Alcohol Use Disorder in Patients With Alcohol Withdrawal Symptoms: A Randomized Clinical Trial,” by Raymond F. Anton, M.D., and colleagues, evaluated gabapentin versus placebo in 145 treatment‐seeking people who met Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria for AUD, 96 of whom were in recent alcohol withdrawal and randomized to treatment after three abstinent days. Daily drinking was recorded, and a heavy drinking blood marker was collected at baseline and monthly. The percentage of individuals with total abstinence and those with no heavy drinking days were compared between treatment groups. The participants had 83% heavy drinking days (four drinks a day for women, five for men) at baseline. More gabapentin‐treated individuals had no heavy drinking days (12 of 44 participants [27%]) compared with placebo (four of 46 participants [9%]), and more total abstinence (eight of 44 [18%]) compared with placebo (two of 46 [4%]). The prestudy high‐alcohol‐withdrawal group had positive gabapentin effects on no heavy drinking days and total abstinence compared with placebo, while within the low‐alcohol‐withdrawal group, there were no significant differences. These findings were similar for other drinking variables, where gabapentin was more efficacious than placebo in the high‐alcohol‐withdrawal group only. Gabapentin caused more dizziness, but this did not affect efficacy.     

Underage drinking and the role of parents

Last week's article on underage drinking and DWIs touched on the role of parents in helping to prevent both (see “Binge drinking in 12th grade predicts DWIs, blackouts and ‘extreme’ binge drinking,” ADAW, Feb. 3, https://onlinelibrary.wiley.com/doi/10.1002/adaw.32610 ). The article was based on a study published in Pediatrics, co‐authored by Ralph W. Hingson, Sc.D., M.P.H., director of the Division of Epidemiology and Prevention Research at the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Last week, Hingson, who presented on underage drinking at the annual leadership meeting of Community Anti‐Drug Coalitions of America (CADCA), also explained more about the role of parents. “Parents do have an influence over whether and how much their children drink,” he told us. For example, if a parent binge drinks, their children will be twice as likely to binge drink — and to have alcohol use disorder.     

Heaviest drinkers still drinking during lockdown: UK research

Lockdown due to the COVID‐19 pandemic doesn't necessarily result in an across‐the‐board increase in alcohol consumption, according to research commissioned by Alcohol Change UK and released last month. The study found that 21% of adults who drink alcohol are drinking more often since the March 23 lockdown began in England, but that 35% reduced their frequency of consumption or stopped drinking altogether. Of those surveyed, 6% of previous drinkers chose to stop drinking altogether during lockdown. The study, a representative survey of more than 2,000 people, extrapolates to 8.6 million adults in the United Kingdom drinking more frequently since lockdown, while 14 million are drinking less often or have stopped drinking entirely. In addition, many people are seeking help based on visits to the “Get help now” section of Alcohol Change UK's website increasing 355% between March 23 and April 13, compared to the same period last year.     

Briefly Noted

Compared to light drinkers, heavy drinkers have brains that have less energy due to decreases in glucose metabolism, researchers at the National Institutes of Health have found. In a study published online last week in Nature Communications, the researchers combined measures of the left brain (activity) and the right brain (glucose consumption) to better understand the effects of alcohol on people. “The brain uses a lot of energy compared to other body organs, and the association between brain activity and energy utilization is an important marker of brain health,” said George F. Koob, Ph.D., director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), in a statement accompanying the release of the results. “This study introduces a new way of characterizing how brain activity is related to its consumption of glucose, which could be very useful in understanding how the brain uses energy in health and disease.” The research was led by Ehsan Shokri‐Kojori, Ph.D., and Nora D. Volkow, M.D., both of the NIAAA Laboratory of Neuroimaging. Volkow is also the director of the National Institute on Drug Abuse. “The findings from this study highlight the relevance of energetics for ensuring normal brain function and reveal how it is disrupted by excessive alcohol consumption,” said Volkow. “We measured power by observing to what extent brain regions are active and use energy,” explained Shokri‐Kojori. “We measured cost of brain regions by observing to what extent their energy use exceeds their underlying activity.” Using a group of healthy volunteers, researchers showed that different brain regions have different power and cost. They then looked at the effects of alcohol on these measures by assessing a group that included light and heavy drinkers, and found that both acute and chronic use affected brain power and cost. “In heavy drinkers, we saw less regional power, for example, in the thalamus, the sensory gateway and frontal cortex of the brain, which is important for decision‐making,” said Shokri‐Kojori. “These decreases in power were interpreted to reflect toxic effects of long‐term exposure to alcohol on the brain cells.” There was also a disruption of visual processing during acute alcohol exposure, and significant decreases in cost of activity during alcohol intoxication.     

Research: AA is better pathway to abstinence than psychotherapy

Alcoholics Anonymous (AA) is the best way to get to abstinence, according to a comprehensive literature review published last week in the Cochrane Database of Systematic Reviews. The study, “Alcoholics Anonymous and other 12‐step programs for alcohol use disorder” evaluates 35 studies and shows that AA was almost always more effective than psychotherapy in achieving alcohol abstinence, and that it was also less expensive. According to co‐author Keith Humphreys, Ph.D., professor of psychiatry and behavioral sciences at the Stanford University School of Medicine, the reason AA works is the social interaction. “If you want to change your behavior, find some other people who are trying to make the same change,” he said.     

When alcohol withdrawal has to be treated on an inpatient basis

Contrary to popular belief, alcohol withdrawal does not have to be treated on an inpatient basis. Two cardinal signs — a history of alcohol‐withdrawal delirium or alcohol‐withdrawal seizures — indicate hospitalization. So do certain comorbidities. Most cases can indeed be treated on an outpatient basis, according to two top experts: Lorenzo Leggio, M.D., Ph.D., senior investigator with the joint National Institute on Alcohol Abuse and Alcoholism (NIAAA)‐National Institute on Drug Abuse (NIDA) Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, and Mark Willenbring, M.D., founder and CEO of Alltyr in St. Paul, Minnesota and former director of the Division of Treatment and Recovery Research at NIAAA. However, even though it can be treated on an outpatient basis, it often isn't, and there's a good reason for that — better safe than sorry, to sum it up.     

Psychodynamic therapy for SUD: Counselor's view

First of all, psychodynamic psychotherapy as treatment for substance use disorder (SUD) works. Ian McLoone, lead therapist with the Alltyr Clinic in Minneapolis, knows that firsthand — he's in recovery from heroin addiction and is in it himself. And despite the fact that addiction therapists aren't taught psychodynamic theory or psychoanalytic psychotherapy in graduate school, where cognitive behavioral therapy (CBT), motivational interviewing (MI) and, to a lesser degree, 12‐Step facilitation are stressed, he became interested in it mainly because of his employer, Mark Willenbring, M.D., a psychiatrist and former medical director of the National Institute on Alcohol Abuse and Alcoholism. We talked to McLoone for this story as a follow‐up to our article on the self‐medication hypothesis of addiction, for which we interviewed its developer, Ed Khantzian, M.D. (see “Psychodynamic psychotherapy: When it helps people in recovery,” ADAW, June 22, https://onlinelibrary.wiley.com/doi/10.1002/adaw.32756 ).     

Briefly Noted

Naltrexone alone is already approved for treating alcohol use disorder, but a new study has opened the door to looking at the combination of naltrexone and bupropion to reduce binge drinking. The study, an open‐label, single‐arm, 12‐week study, recruited 12 people who had at least five (in the case of the men) or three (in the case of the women) binge‐drinking episodes a month. All subjects received both bupropion extended‐release 300 mg/day and naltrexone 50 mg/day and were monitored for three months. Their average number of drinks per binge‐drinking day went from 7.8 to 6.4, and the average percentage of binge‐drinking days per month went from 19' to 5'. Insomnia, headache and nausea/diarrhea were the most common side effects, with the medications well‐tolerated; six subjects stayed on the medication after the trial. The study, “A Preliminary, Open‐Label Study of Naltrexone and Bupropion Combination Therapy for Treating Binge Drinking in Human Subjects,” by Thomas J. Walter and colleagues, was published online Nov. 20 in Alcohol and Alcoholism.     

Letter to the Editor

In “COMBINE follow‐up: Some heavy use of alcohol compatible with recovery” (see ADAW, Aug. 17, https://onlinelibrary.wiley.com/doi/10.1002/adaw.32806 ), we wrote about a study by Katie Witkiewitz, Ph.D., published in Alcoholism: Clinical and Experimental Research, showing that some people can be in recovery but still drink heavily. We received the following commentary from Annie Peters, Ph.D., director of research and education at the National Association of Addiction Treatment Providers (NAATP).     

Sex-Related Alcohol Expectancies Among African American Women Attending an Urban STI Clinic

African American women are disproportionately affected by human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and sexually transmitted infections (STIs). Alcohol use is a significant risk factor for HIV/STI acquisition. Sex-related alcohol expectancies (SRAEs) may partially account for alcohol-related risky sexual behaviors. Using qualitative interviews we explored the link between alcohol use and risky sex among 20 African American women attending an STI clinic who had consumed four or more alcoholic drinks per drinking day (binge drinking) and/or reported vaginal or anal sex while under the influence of alcohol. Four SRAEs emerged, which we named drink for sexual desire, drink for sexual power, drink for sexual excuse, and drink for anal sex. While the desire SRAE has been documented, this study identified three additional SRAEs not currently assessed by expectancy questionnaires. These SRAEs may contribute to high-risk sex when under the influence of alcohol and suggests the importance of developing integrated alcohol–sexual risk reduction interventions for high-risk women.     

Briefly Noted

Carmen Beatrice Pearman Arlt died last December after a long illness. News of her death started circulating throughout the field only last month, however. Arlt, a longtime Indiana resident, was born in 1955. She organized one of the oldest chapters of the National Alliance for Medication Assisted Recovery (NAMA Recovery), the Methadone Advocacy Group (MAG) of Indiana. NAMA Recovery Director Joycelyn Woods recalled last week that Arlt, in the early 1990s, sent an index card to NAMA Recovery with dimes taped to it and a short message saying she could not afford the $10 membership fee. “Like all letters we receive from patients, she received a letter back saying that we would rather have her advocacy than money,” said Woods. One of the things MAG of Indiana did was clean the street around the methadone clinic. “While they were out picking up garbage and sweeping the street, the reverend from the church across the street came out to warn them about those addicts over there. Carmen explained that they were those addicts,” said Woods. “From this encounter, patients were given space in the church to set up 12‐Step groups and to have meetings. The following year, there was a big drug conference in Indiana, and the chapter acted as the color guard for the governor when he entered the arena. I remember Carmen sending a picture of them all dressed in white shirts, navy bowties for women and regular ties for men and navy pants.” Arlt received the Nyswander/Dole Award from the American Association for the Treatment of Opioid Dependence in 2001 for organizing the state provider organization — at the time, Indiana had no opioid treatment program representation and clinics saw one another more as competitors than associates working for a common cause, said Woods. More recently, in addition to being president of NAMA Recovery, Arlt developed the program for women and children at Porter‐Starke Services in Valparaiso. She was continuing her education to get a Ph.D. in social work when she became ill. “NAMA Recovery will miss Ms. Pearman‐Arlt's dedication and compassion to patients and the field,” said Woods..     

NASADAD pushes block‐grant increase for stimulus 4 bill

The National Association of State Alcohol and Drug Abuse Directors (NASADAD) last week wrote to Sen. Patty Murray (D‐ Washington) and Sen. Roy Blunt (R‐Missouri), the Senate co‐chairs of the Labor, Health and Human Services (HHS), Education, and Related Agencies Appropriations Subcommittee, asking specifically for the $1.5 billion in supplemental funding as provided by the House in the HEROES Act for the Substance Abuse Prevention and Treatment (SAPT) block grant (see “Proposed bill for HEROES Act would give $1.5 billion to SAPT block grant,” ADAW, May 18, https://onlinelibrary.wiley.com/doi/10.1002/adaw.32722 ).     

Extreme Ritualistic Alcohol Consumption Among College Students on Game Day

Abstract

Alcohol use and the related consequences associated with college football games are a serious public health issue for university communities. Objective: Examining “Extreme Ritualistic Alcohol Consumption” (ERAC), defined as consuming 10 or more drinks on game day for a male, and 8 or more drinks for a female, is the focus of this study. Participants: In the fall of 2006, college students ages 18 to 24 were randomly selected to complete the Game Day Survey. Methods: Researchers utilized a cross sectional research design to collect data. Results: Sixteen percent of the respondents engaged in ERAC on game day, whereas 36% drank 5 or more drinks (4 or more for females). Male, Caucasian, Greek (members of a social fraternity or sorority), and students of legal drinking age consumed alcohol at disproportionately high rates. Conclusion: Alcohol use is common on game day, with a significant percentage of students placing themselves at risk by drinking large amounts of alcohol.     

AN ECONOMIC THEORY OF WORKAHOLICS AND ALCOHOLICS

This paper considers the role of alcohol in agency problems in order to provide an economic rationale for alcoholics and workaholics. In our model, alcohol reduces productivity, but also can make imbibers blurt private information. We show that in the optimal contract, low‐productivity workers are compelled to over‐indulge in alcohol, while high‐productivity workers overproduce output. Thus, workers are made into “alcoholics” and “workaholics” depending on their productivity. We conclude that excessive drinking (working) may be the result, not the cause, of low (high) productivity of workers. (JEL D82, VSOP)     

The Paranoid Style Revisited: Pseudo‐Conservatism in the 21st Century

Fifty years ago, the Pulitzer Prize‐winning historian Richard Hofstadter published the seminal essay, “The Paranoid Style in American Politics.” In this and related works he examined the rhetoric animating the extreme right‐wing of the country's electorate. In this article I revisit Hofstadter's claims regarding the marginalization of the paranoid style and its connection to status‐based politics. A review of the most popular “pseudo‐conservative” commentators, survey data, the rise of the Tea Party, and the intransigence of the present day Republican Party suggests that a worldview that was once extreme has now become “mainstreme” within the political culture.     

Talbott,patient advocate and OTP owner,leaves BayMark

Zac Talbott's last day with BayMark Health Services, which bought his opioid treatment programs (OTPs), Counseling Solutions Treatment Centers, in Chatsworth, Georgia, and Brasstown, North Carolina, last year (see “From starter OTP to acquisition by BayMark: A 3‐year journey,” ADAW, Sept. 8, 2018, https://onlinelibrary.wiley.com/doi/10.1002/adaw.32095 ), was May 24. He had various options and opportunities that could have resulted in him leaving earlier, but he did not want to leave in the midst of so much change. He opened the first Counseling Solutions clinic in 2015 (see “Methadone patient and advocate to open own OTP in Georgia,” ADAW, Aug. 17, 2015, https://onlinelibrary.wiley.com/doi/10.1002/adaw.30292 ).     

Changing the Culture of Alcohol Abuse on Campus: Lessons Learned From Secondhand Smoke

ABSTRACT

Alcohol abuse is the single greatest public health hazard on American college and university campuses, but the culture of abusive alcohol consumption continues to be highly resistant to change. The author argues that secondhand smoke campaigns can be used as models to change the culture of alcohol abuse on campus. He proposes the implementation of “secondhand alcohol” campaigns and describes their essential components and advantages.     

Briefly Noted

Vaping and nicotine replacement therapy (NRT) were equally effective at decreasing craving and withdrawal symptoms for smokers discharged from smoke‐free residential treatment for substance use disorder, a pilot study has found. The study, a randomized controlled trial to be published in Nicotine & Tobacco Research on behalf of the Society for Research on Nicotine and Tobacco in Australia, also found that retention was greater for the vaping group (96% at 12 weeks) than the NRT group (68%). For the study, 100 patients received telephone Quitline support and a 12‐week supply of either NRT or a vaping device. At 12 weeks, 14% of the vaping group and 18% of the NRT group report not smoking at all in the last seven days. The researchers concluded that their criteria for retention might have been too strict, and that “some leeway and looking at eventual success over the period people continue to engage with the aids would give a better picture of their long‐term potential.” There is a big movement to legalize vaping in Australia. A key point, however, is that patients readily engaged with smoking cessation after treatment when given the chance. “QuitNic: A pilot randomised controlled trial comparing nicotine vaping products with nicotine replacement therapy for smoking cessation following residential detoxification” by Billie Bonevski and colleagues is available open access, go to https://academic.oup.com/ntr/advance‐article/doi/10.1093/ntr/ntaa143/5889985 .     

Briefly Noted

We asked Jerry Rhodes, former top executive at CRC (now Acadia) and a leader in opioid treatment program management, what he thinks of methadone as a medication to be used in primary care to treat opioid use disorder (OUD), as some people — including former Office of National Drug Control Policy Director Michael Botticelli — recommended last year (see ADAW, July 16, 2018). “I take issue with that,” said Rhodes. “Methadone is a dangerous drug in an unregulated environment,” he told ADAW. Buprenorphine is prescribed this way, but “buprenorphine is a relatively safe drug, and methadone isn't,” he said. A veteran of many battles over methadone, including the near‐elimination of opioid treatment programs, Rhodes told ADAW that “you don't give unfettered access to methadone” to patients with OUD. “Be careful what you wish for” is his advice. This has the potential to cause harm, he said. “Only people who don't understand the history of its utilization would recommend this.”