Prevalence of Alcohol Use Disorders NIAAA – National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Any Alcohol Use Disorder 17.6 million (8.5%) Alcohol Abuse 9.7 million (4.7%) Alcohol Dependence 7.9 million (3.8%) NIAAA= National Institute on Alcohol Abuse and Alcoholism Grant BF, et al. Arch Gen Psychiatry. 2004;61:807-816. Epidemiology of Use and Abstention Drank past year Lifetime abstainer 80 Percent 70 60 50 40 30 20 10 0 18-24 25-44 45-64 > 64 Epidemiology of Heavy Use Heavy Use Women: > 1 drink / day Men: > 2 drinks / day 16 14 Percent 12 10 8 6 4 2 0 18-24 25-44 45-64 > 64 12-mo. Prevalence of DSM-IV AUD Diagnoses 25 Abuse Dependence Percent 20 15 10 5 0 18-29 30-44 45-64 Men 65+ 18-29 30-44 56-64 Women 65+ Medications Approved in the US for Treatment of Alcohol Dependence Disulfiram (Antabuse): 1949 Naltrexone (ReVia): 1994 Acamprosate (Campral): 2004 Long-Acting Naltrexone (Vivitrol): 2006 Naltrexone Non-specific opioid receptor antagonist Dose dependent binding to m, d and k opioid receptors FDA approved as adjunctive pharmacotherapy for the treatment of alcoholism Opioids Acute alcohol increases plasma b-Endorphin levels Opioids Opioid antagonists reduce alcohol drinking Clinical trials Naltrexone has been shown to Increase percentage of days abstinent from alcohol Reduce number of drinks/drinking day Increase time to relapse Decrease craving for alcohol Cumulative Proportion with No Relapse Naltrexone (Revia) in the Treatment of Alcohol Dependence 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 Naltrexone (N=35) Placebo (N=35) 0 1 2 3 4 5 6 7 8 9 10 11 12 Number of Weeks Receiving Medication Volpicelli et al., Arch Gen Psychiatry, 1992 Effect of Long-Acting Naltrexone on Maintenance of Abstinence Percent without Relapse Subjects with 4-day lead-in abstinence 100 90 80 70 60 50 40 30 20 10 0 p < 0.025 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Weeks Placebo (n = 28) Vivitrex (n = 28) COMBINE (Anton et al., 2006) ASAM, 2007 VA cooperative study From Krystal et al 2001 Cochrane review (Srisurapanont and Jarusuraisin 2002) NTX treatment can decrease the chance of alcohol relapse for 36% as compared to placebo treatment. In addition, the treatment is likely to reduce the chance of returning to drinking for 13%. Short-term treatment of NTX for alcoholism gives a meaningful benefit in preventing a relapse. Small to Modest efficacy! Identifying predictors of robust treatment response to naltrexone could improve clinical practice Potential predictors of naltrexone response Family history of alcoholism OPRM1 m opioid receptor gene polymorphisms Rohsenow et al., 2007 Higher level of alcohol craving Rubio et al., 2005 Antisocial traits and heavier drinkers Oslin et al., 2003 Age of onset of alcohol abuse Monterosso et al., 2001; Rubio et al., 2005 Volpicelli et al., 1995 Consistent drinking patterns Gueorguieva et al 2007 Laboratory models Human clinical laboratory paradigms can be used to model a variety of behaviors in controlled conditions. Careful experimental manipulations to understand the mechanisms underlying a behavior. Can be used to evaluate medication signals following a shorter treatment period Laboratory models-Alcohol In the field of alcohol research, controlled human laboratory studies have been used to study different populations of drinkers • (e.g., social drinkers, dependent drinkers, women, high-risk individuals), different types of cues • (e.g., stress, social drinking, solitary drinking, peer influences), different types and schedules of alcohol • (e.g., beer, wine, hard liquor, IV alcohol; fixed doses, scheduled administration, ad-lib drinking). Laboratory models to study alcohol-naltrexone interactions Human laboratory-based paradigms have been used to evaluate naltrexone’s effects in Social drinkers • e.g. Swift et al 1994, King et al 1997 Non-treatment seeking alcohol dependent drinkers • e.g. Anton et al 2004; Drobes et al 2004, Krishnan-Sarin et al 2007, O’Malley et al 2002 Importantly, effects observed in laboratory studies similar to those seen in clinical trials Alcohol Self-Administration Model (O’Malley, Krishnan-Sarin et al., 2002) Day 0 Day 6 Day 7 4 pm Outpatient Treatment Choice Block #2 5:00 pm 6:00 pm Alcohol Reactivity • craving Naltrexone pretreatment Choice Block #1 Priming Drink (.03 g/dl) 7 pm Ad-Lib Period •4 drinks per choice period (.015 g/dl) •$12 tab per choice period MET Intervention Discharge Naltrexone and FH of alcoholism F igure 1 # of drinks + S E 6 FH + FH - A : M ales an d F em ales N = 12 N = 21 4 N = 14 N = 12 2 N = 14 N = 19 0 # of drinks + S E 6 B : M ales on ly N=7 N = 18 N = 10 4 N=9 2 N = 16 N = 10 # of drinks + S E 0 6 C : F em ales on ly 4 N=5 N=3 N=4 2 N=3 N=3 N=4 0 0 mg 50 m g 100 m g N altrexone D ose From Krishnan-Sarin et al., 2007