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Assessment of Alcohol Withdrawal: The Revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar)
Abstract
A shortened 10-item scale for clinical quantitation of the severity of the alcohol withdrawal syndrome has been developed. This scale offers an increase in efficiency while at the same time retaining clinical usefulness, validity and reliability. It can be incorporated into the usual clinical care of patients undergoing alcohol withdrawal and into clinical drug trials of alcohol withdrawal.
... A ferramenta mais utilizada no mundo para isto é a The Clinical Institute of Withdrawal Assessment for Alcohol Revised (CIWA-Ar) 11 . Trata-se de uma escala composta por 10 itens, cujo escore final classifica a gravidade da SAA e fornece subsídios para o planejamento da intervenção imediata (Quadro 2). ...
... Por meio do escore total da CIWA-Ar, a SAA pode ser categorizada em leve (≤ 9), moderada 10 a 15 pontos ou grave (≥16 pontos) 11,12 . ...
... Nestas situações, o haloperidol, um antipsicótico de primeira geração, pode ser utilizado como adjuvante. A dose recomendada é de 2,5mg a 5mg VO ou IM 10,11 . Recomenda-se que a medicação seja utilizada pontualmente, conforme necessidade e exacerbação dos sintomas do paciente 10 , visto que o uso de antipsicóticos, de modo geral, contribui para redução do limiar convulsivo. ...
A síndrome de abstinência alcoólica (SAA) é uma das principais complicações do uso patológico do álcool, podendo ocorrer em até 50% dos pacientes que reduzem ou cessam o uso de etílicos. É caracterizada por um estado de hiperativação autonômica, e possui alta morbimortalidade devido a sua associação com quadros de pneumonia aspirativa, distúrbios hidroeletrolíticos, arritmias, crises convulsivas e delirium tremens (DT). O objetivo principal deste artigo é introduzir o estudante de graduação em medicina e o médico não especialista na identificação e no manejo adequado dessa condição. Os autores discutem aspectos epidemiológicos, etiológicos, clínicos e terapêuticos da SAA.
... 8 Alcohol withdrawal symptoms assessed by CIWA-Ar exhibit multidimensionality. 9 A 10-item scale has been created to clinically assess the severity of alcohol withdrawal syndrome, providing enhanced efficiency without compromising its clinical utility, validity and reliability. This scale is suitable for integration into routine patient care during alcohol withdrawal and in clinical trials evaluating withdrawal treatments 10 The Total severity assessment Scale is the another widely used Scale to measure the severity of Alcohol withdrawal Syndrome. Gross et al. (1973) developed the TSA scale to develop the degree of severity in alcohol withdrawal and to simplify the quantification of the withdrawal syndrome. ...
... Medical history and laboratory biomarkers are the two most important methods for the identification of patients at high risk. 28 It appears that the most robust predictor for an incident occurrence of DT or seizures is a history of a similar event 10 Clinical findings such as elevated heart rate, systolic blood pressure and temperature are all easily verifiable in the initial patient assessment, although their predictive value to identify patients with AWS who are more likely to develop DT is not high. 29 In a patient with impaired consciousness, laboratory markers represent helpful tools to confirm the suspected clinical diagnosis of an AUD. ...
Alcohol Withdrawal Syndrome (AWS) presents a significant clinical challenge due to its complex
neurochemical underpinnings and varied symptom severity. This review explores the predictors
of severe AWS, focusing on the pathophysiology driven by neuroadaptive changes in GABAergic
and glutamatergic systems. Key findings indicate that early identification and accurate
assessment are critical for managing AWS effectively and preventing severe complications such as
delirium tremens and seizures. Tools like the Clinical Institute Withdrawal Assessment for Alcohol
(CIWA-Ar) and the Total Severity Assessment Scale (TSA) are essential for evaluating withdrawal severity and guiding treatment. Predictive factors, including the history of alcohol use, presence
of comorbid conditions and individual patient characteristics, significantly influence treatment
outcomes. This article highlights the critical importance of understanding and managing Alcohol
Withdrawal Syndrome (AWS) through early identification and intervention to improve patient
outcomes.
Keywords: Alcohol Withdrawal Syndrome, Glutamate, Tremors, Seizures, Neurochemical
Imbalances.
... Genetic screening for a mutation of Aldolase B gene and Transferrin gene was performed. Breath alcohol and Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) score was used to rule out signs of alcohol intoxication and withdrawal [27]. Transferrin isoforms were analyzed using HPLC. ...
Attention deficit hyperactivity disorder (ADHD) is a relatively common disorder in clinical psychiatry. Patients often suffer from symptoms long before the diagnosis due to an overlap with other psychiatric differential diagnosis. Importantly, alcohol addiction and other illicit drug dependence and withdrawal symptoms mimicking ADHD symptoms should be ruled out. Here we present a rare case of a young female patient with symptoms of ADHD and an extremely high carbohydrate-deficient transferrin (CDT) of 19,6% (< 1,3%) indicating the presence of a congenital disorder of glycosylation (CDG). A thorough diagnostic workup excluded alcohol addiction as a cause of the constantly high CDT levels. The CDT test was positive due a transferrin mutation affecting the glycosylation site. Nevertheless, psychiatric symptoms can be due to metabolic disorders which should be considered. Further, substance-use disorders (SUD) are a critical and potentially complicated differential diagnosis concerning diagnostic procedures and treatment in ADHD.
... While patients were eligible to be approached after 3 days in the program, typically at least a week was allotted before doing so, to allow time for detoxification and stabilization. This is guided by the Clinical Institute Withdrawal Assessment for Alcohol (CIWA; Sullivan et al. [51]) and Clinical Opiate Withdrawal Scale (COWS; Wesson et al., [56]) protocols at the treatment facility. Staff worked closely with patients to maximize attendance and coordinate with discharge dates, but due to co-occurring conditions, legal issues, or medical emergencies, some participants were discharged before completing all sessions. ...
Background
Posttraumatic stress disorder (PTSD) is highly comorbid with substance use disorders (SUDs), resulting in high prevalence of PTSD among individuals in residential SUD care. However, there is limited research on integrating trauma treatment into residential SUD care settings. The aim of the present project was to conduct an initial evaluation of the effects of group-based Written Exposure Therapy (WET) on PTSD and depressive symptoms that was integrated into programming for individuals in residential SUD treatment.
Methods
Participants were 48 Veterans with comorbid PTSD-SUD from a 28 day residential SUD program at a Veterans Affairs Medical Center. Eligible participants were enrolled in 5 sessions of WET, delivered twice-weekly in an adapted group format. PTSD symptoms and depressive symptoms were assessed at each session with the Posttraumatic Stress Disorder Checklist, DSM-5 version (PCL-5) and the Patient Health Questionnaire (PHQ-9).
Results
Over 5 months, 76.2% of the target population were successfully enrolled. Of the enrolled sample, 48 participants, 92% ( n = 44) completed 3 sessions, while 56% ( n = 28) completed 5 sessions. Generalized Estimating Equations (GEE) showed significant within-person reductions in PTSD symptoms over time, with an average decrease of 3.18 per session (χ² = 23.21, p = .006) and moderate effect sizes ( d = 0.46 and d = 0.51 at mid- and post-treatment). In addition, there were significant reductions in depressive symptoms within-persons over time, with an average per-session reduction of 1.13 (χ² = 23.10, p = .006).
Conclusion
Findings demonstrate that brief, group-delivered WET is feasible and shows promise for addressing PTSD and depressive symptoms in residential SUD treatment. Results of the present evaluation could inform further efficacy testing and implementation of PTSD treatment into residential SUD settings.
... Fifty-six participants were recruited as part of a larger trial evaluating the superiority of topiramate treatment compared to naltrexone in alcohol dependence (Morley et al. 2018) with the primary outcomes reported . Inclusion criteria for that trial included: (i) an AUD diagnosis according to DSM-5 criteria; (ii) Age 18-70; (iii) Adequate cognition and English language skills to give valid consent and complete research interviews; (iv) Willingness to give written informed consent; (v) Abstinence from alcohol for between 3 and 21 days leading up to randomization; (vi) Resolution of any clinically evident alcohol withdrawal (CIWA-Ar; Sullivan et al. 1989). Exclusion criteria were: (i) Active major mental disorder associated with psychosis or significant suicide risk, (ii) Pregnancy or lactation, (iii) Concurrent use of any psychotropic medication other than antidepressants (provided these were taken at stable doses for at least two months); (iv) Currently taking any tricyclic antidepressant; (vi) Use of antiretroviral dolutegravir; (vii) Dependence on any substance other than nicotine; (viii) Clinically decompensated liver disease (jaundice or other signs of liver failure); (ix) History of nephrolithiasis; (x) history of glaucoma; (xi) Lack of stable housing, (xii) Previous hypersensitivity to topiramate or naltrexone; (ix) Any alcohol pharmacotherapy within the past month. ...
Rationale
Both topiramate and naltrexone have been shown to affect neural alcohol cue reactivity in alcohol use disorder (AUD). However, their comparative effects on alcohol cue reactivity are unknown. Moreover, while naltrexone has been found to normalize hyperactive localized network connectivity implicated in AUD, no studies have examined the effect of topiramate on intrinsic functional connectivity or compared functional connectivity between these two widely used medications.
Objective
This study compared topiramate versus naltrexone on alcohol cue-elicited brain activation and intrinsic functional connectivity in patients with alcohol use disorder.
Methods
Forty-seven participants with alcohol use disorder received daily topiramate (titrating the dose up to 200 mg/day n = 21) or naltrexone (50 mg/day, n = 26) for at least 6 weeks. Using functional magnetic resonance imaging (fMRI), we examined intrinsic functional connectivity during rest and alcohol cue-elicited neural activation during a visual alcohol cue reactivity task 120 min following treatment administration. Functional connectivity and alcohol cue reactivity and percentage of heavy drinking days (% HDD) associations were assessed.
Results
No differences in either intrinsic functional connectivity or alcohol cue-elicited neural activity were seen between topiramate and naltrexone-treated groups. Overall, participants showed increased alcohol cue-elicited activation in three clusters spanning occipital regions involved in visual recognition of stimuli, and hypoactivation to both alcohol and control cues in three clusters involved in salience attribution and processing of emotional valence of external stimuli. No differences between topiramate versus naltrexone were observed for either functional measure or associations with post-scan % HDD.
Conclusions
Topiramate and naltrexone enacted comparable alcohol cue reactivity and intrinsic functional connectivity patterns. Some overall responses of increased brain activation to alcohol cues in visual processing regions coupled with reduced activation to alcohol and control cues were evidenced for both treatments. These activation patterns were in regions expected to show attenuation of brain activity resulting from treatment. Topiramate and naltrexone may thus enact functional effects through similar modulation of functional neural activity in individuals with AUD.
Trial registration
ClinicalTrials.gov, NCT03479086 https://www.clinicaltrials.gov/study/NCT03479086.
... We administered Kreek-McHugh-Schluger-Kellogg alcohol scale [25] (KMSK) to evaluate lifetime alcohol use, with a higher score reflecting greater exposure to alcohol. All participants were assessed using the Clinical Institute Withdrawal Assessment of Alcohol Scale [26] (CIWA-Ar) for alcohol withdrawal symptoms, with a higher score indicating more severe alcohol withdrawal. All were evaluated with Hamilton Depression Rating Scale-17 [27] (HAMD-17), a clinician-administered depression assessment scale with semistructured interview, with a higher score indicating more severe depression. ...
Objective
The independent rôle of impulsivity in alcoholism patient’s suicidality is less elucidated. In this study, we intended to investigate how impulsivity and depression contribute to suicidality in patients with alcohol use disorder (AUD).
Methods
We recruited 27 adult patients with AUD and major depressive disorder (AUD with MDD) and 33 with AUD only (AUD without MDD). We assessed suicidality, alcohol use severity, depression severity, impulsivity, and other psychiatric comorbidities. Suicidality was quantified for the frequency of previous history of suicide attempts and for current suicide intent/tendency. Impulsivity was measured using the Barratt Impulsiveness Scale (BIS). We addressed how impulsivity contributed to both suicidality indices in multiple ordinal regressions.
Results
Patients with AUD with MDD versus those with AUD without MDD showed significantly higher suicidality ( p < 0.001), significantly more severe alcohol ( p < 0.01), significantly more polysubstance use ( p < 0.05), significantly more anxiety comorbidities ( p < 0.05), and significantly higher BIS scores ( p < 0.001). In a better-fitting final model using regression with stepwise elimination, the BIS total score was independently and significantly associated with current suicide tendency ( p < 0.05) and frequency of previous suicide attempts ( p < 0.01). In contrast, the Hamilton Depression Rating Scale-17 score was significantly associated only with current suicidal tendencies ( p < 0.01), but not with the frequency of previous attempts.
Conclusion
Depressed patients relative to nondepressed individuals with AUD showed higher suicidality, Barratt impulsivity, and severity of alcohol use. Across groups, BIS impulsivity but not the severity of depression was found to predict suicidality. We suggest that suicide prevention efforts may include assessment of impulsivity in AUD patients.
... Clinical severity scoring systems, such as GCS, National Institutes of Health Stroke Scale, mFS, ICH score, Sequential Organ Failure Assessment, and Clinical Institute Withdrawal Assessment for Alcohol, have been widely used for triaging and guiding interventions and treatment for several illnesses [21][22][23][24][25][26][27] Table 3. eSAH score a /DCI subscore b . a eSAH score is calculated by scoring each category point and summing them up. ...
We developed a simple quantifiable scoring system that predicts aneurysmal subarachnoid hemorrhage (aSAH) mortality, delayed cerebral ischemia (DCI), and modified Rankin scale (mRS) outcomes using readily available SAH admission data with SAH volume (SAHV) measured on computed tomography (CT). We retrospectively analyzed a cohort of 277 patients with aSAH admitted at our Comprehensive Stroke Center at Mayo Clinic in Jacksonville, Florida, between January 5, 2012, and February 24, 2022. We developed a mathematical radiographic model SAHV that measures basal cisternal SAH blood volume using a derivation of the ABC/2 ellipsoid formula (A = width/thickness, B = length, C = vertical extension) on noncontrast CT, which we previously demonstrated is comparable to pixel-based manual segmentation on noncontrast CT. Data were analyzed using t test, χ² test, receiver operator characteristics curve, and area under the curve (AUC) analysis. Multivariate logistic regression analysis with stepwise elimination of variables not contributing to the model (0.05 significance level for entry into the model) was used to develop an enhanced SAH (eSAH) scoring system. Using multivariate logistic regression, we found that age, Glasgow Coma Scale score, and SAHV were significantly associated with mRS outcomes at discharge, in-hospital DCI, and in-hospital mortality. Using these factors, we developed a weighted eSAH score, ranging from 0 to 5, that was strongly predictive of mRS outcomes (AUC = 0.89), DCI (AUC = 0.75), and in-hospital mortality (AUC = 0.88). Our proposed eSAH score, a simple quantitative model based on SAHV, Glasgow Coma Scale score, and age, appears to predict mortality and outcomes in patients with aSAH. A larger cohort validation study is planned.
... It does not take in consideration delirium tremens, which could have other etiologies beside ethanol withdrawal. It's a numeric scale which assigns to symptoms a value regarding their severity, but it's quite subjective (23,24,25). In refractory withdrawal, barbiturates are associated, especially phenobarbital. ...
... AUD participants were assessed with the Clinical Institute Withdrawal Assessment-Alcohol revised (CIWA-Ar)36 at admission and then approximately every 2 h until withdrawal ceased within the first week. If the CIWA-Ar scores were ≥8 on admission, patients were provided with benzodiazepines (oxazepam or diazepam) to treat withdrawal symptoms. ...
The human brain consists of functionally segregated networks, characterized by strong connections among regions belonging to the same network and weak connections between those of different networks. Alcohol use disorder (AUD) is associated with premature brain aging and neurocognitive impairments. Given the link between decreased brain network segregation and age‐related cognitive decline, we hypothesized lower brain segregation in patients with AUD than healthy controls (HCs). Thirty AUD patients (9 females, 21 males) and 61 HCs (35 females, 26 males) underwent resting‐state functional MRI (rs‐fMRI), whose data were processed to assess segregation within the brain sensorimotor and association networks. We found that, compared to HCs, AUD patients had significantly lower segregation in both brain networks as well as poorer performance on a spatial working memory task. In the HC group, brain network segregation correlated negatively with age and positively with spatial working memory. Our findings suggest reduced brain network segregation in individuals with AUD that may contribute to cognitive impairment and is consistent with premature brain aging in this population.
... The CIWA-Ar protocol utilizes a CIWA-Ar score based on 10 items (nausea and vomiting; tremors; sweating; anxiety; agitation; tactile disturbances; auditory disturbances; visual disturbances; headache; and disorientation or clouding of the sensorium) to quantify the severity of withdrawal manifestations on a range of 0 to 67 points (Sullivan et al. 1989) and administer lorazepam based on the severity score. A score 0-9 do not receive lorazepam treatment; a score of 10-12 receives 1 mg of lorazepam orally or intravenously (PO/IV); a score of 13-14 receives 2 mg of lorazepam PO/ IV; a score of 15-17 receives 3 mg of lorazepam PO/IV; and a score of 18 or greater receives 4 mg of lorazepam PO/IV. ...
Objective
Alcohol withdrawal syndrome (AWS) during pregnancy is under-researched despite growing concerns about increased alcohol use among pregnant women. This study aims to explore the severity of AWS and its impact on maternal and fetal outcomes.
Methods
This retrospective study reviewed the medical records of patients admitted to the Mayo Clinic who underwent the CIWA-Ar protocol for AWS from June 2019 through June 2022. Pregnant women identified in this cohort had their pregnancy, labor, and neonatal data analyzed for alcohol-related complications and outcomes.
Results
Out of the medical records reviewed, 8 cases involved pregnant women experiencing AWS. These cases showed a high severity of withdrawal symptoms, with a median peak CIWA-Ar score of 17 (IQR = 14). Maternal complications included a high rate of ICU admissions (37.5%; n = 3) and significant rates of miscarriage and stillbirth (37.5%; n = 3). Fetal outcomes were concerning, with 1 out of 5 (20%) neonates requiring NICU admission and experiencing conditions such as respiratory failure and neonatal abstinence syndrome. Developmental problems were noted in 2 out of 5 (40%) newborns.
Conclusions
The findings highlight the severe implications of AWS during pregnancy, impacting both maternal and fetal health. The severity of AWS requires attentive clinical management and preventative interventions. Future research should focus on larger, prospective studies to better understand and address the risks associated with AWS in pregnant women and to improve health outcomes for mothers and their children.
Article Highlights
• Severe AWS during pregnancy leads to high ICU admissions and adverse neonatal outcomes.
• 37.5% of pregnant women with AWS experienced miscarriage or stillbirth.
• 20% of newborns from mothers with AWS required NICU admission for serious conditions; 40% of newborns had developmental problems.
• Findings underscore the need for specialized treatment protocols to improve outcomes for pregnant women and their newborns.
... Symptoms tracked using revised CIWA-Ar scale (Sullivan 1989) First line: long-acting benzodiazepines (e.g. diazepam or chlordiazepoxide) Supportive strategies: IV fluids to dehydrated patients, vitamin repletion (i.e., thiamine) Significant liver dysfunction: lorazepam Refractory cases: phenobarbital (either in lieu of or in combination with benzodiazepines), propofol In suspected mixed picture benzodiazepines still employed, at least initially (Mart 2021 ...
Delirium frequently occurs among hospital in-patients, with significant attributable healthcare costs. It is associated with long-term adverse outcomes, including an eightfold increased risk of subsequent dementia. The purpose of this article is to inform clinicians of the best practices for spotting, stopping and treating delirium and provide guidance on common challenging clinical dilemmas. For spotting delirium, suggested screening tools are the 4 ‘A's Test (in general medical settings) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Prevention is best achieved with multicomponent interventions and targeted strategies focusing on: (a) avoiding iatrogenic causes; (b) brain optimisation by ensuring smooth bodily functioning; (c) maintaining social interactions and normality. Non-pharmacological approaches are the first line for treatment; they largely mirror prevention strategies, but the focus of empirical evidence is on prevention. Although sufficient evidence is lacking for most pharmacological approaches, an antipsychotic at low doses for short durations may be of utility for highly distressing or high-risk situations, particularly in hyperactive delirium, but only as a last resort.
... Alcohol consumption 90-days before the screening was assessed by the Timeline Follow-Back (TLFB), Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar)-a 10-item scale that determines the stage or severity of alcohol withdrawal (Sullivan et al., 1989), alcohol urge questionnaire (AUQ) (Bohn et al., 1995), and the alcohol craving questionnaire (ACQ) (Singleton, 1995). ...
Background
This study shows the first evidence for pannexin 1 channels as a new target to develop medications for alcohol use disorder (AUD). Due to its history of long‐term safe clinical use and preclinical evidence of reducing excessive alcohol intake in rodents, probenecid has clinical potential for AUD.
Methods
We conducted a Phase I/IIa randomized, double‐blind, placebo‐controlled, crossover trial investigating the safety, tolerability, and efficacy of an oral dose of probenecid (2 g) when administered with alcohol (0.08 g/dL) in individuals who regularly consume alcohol to the 0.08 g/dL level (N = 35) and in individuals with mild to severe AUD. Alcohol pharmacokinetics and subjective responses were evaluated to assess potential interactions between probenecid and alcohol. Alcohol craving, inflammatory biomarkers, cognitive assessments, and hemodynamics were assessed as additional alcohol research domains. All outcomes were assessed both in the ascending and descending limb of alcohol intoxication using Generalized Estimating Equation.
Results
Probenecid did not exert any significant effect on alcohol pharmacokinetics and did not affect alcohol stimulation or sedation. Probenecid, compared to placebo, significantly decreased alcohol craving during the alcohol ascending limb. Inflammatory biomarkers, cognitive performance following alcohol ingestion, and hemodynamics were likewise not affected by probenecid administration. Analysis of sex as a biological variable revealed no differences of probenecid compared to placebo.
Conclusions
Taken together, our data support the potential of probenecid for treatment of AUD and suggest that pannexin 1 channels represent a novel emerging therapeutic target for the development of new pharmacotherapies for treating AUD.
... HR individuals were also recruited from the community and classified as such based on an Alcohol Use Disorders Identification Test (AUDIT) score exceeding eight [15]. To ensure diagnostic accuracy, all participants underwent a Composite International Diagnostic Interview (CIDI) to exclude alcohol dependence according to the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV) criteria in HR and LR groups and to rule out any history of other substance use disorders [16,17]. ...
Background
Acute gamma-aminobutyric acid (GABAergic) effects of alcohol consumption are well-known, whereas prior research has yielded inconsistent findings regarding on adaptations of the GABAergic neurotransmitter system to chronic alcohol use. Previous studies indicate either elevated or reduced GABA levels in cortical regions such as the anterior cingulate cortex (ACC) in persons with alcohol use disorder (AUD). We tested the hypothesis that active alcohol consumption compared to abstinence contributes to GABA levels as observed in prior research on chronic alcohol use.
Methods
We investigated GABA levels in the ACC of 31 healthy controls (low risk, LR), 38 high risk individuals providing an active drinking pattern (high risk, HR) and 27 recently detoxified alcohol-dependent (AD) subjects via proton magnetic resonance spectroscopy (1H-MRS).
Results
GABA levels in the ACC were significantly lower in HR compared with AD, but did neither differ between LR and AD nor between LR and HR. Also, we observed a quadratic effect indicating a distribution of GABA levels in the ACC as follows: LR > HR < AD. GABA levels were not associated with abstinence duration in AD.
Conclusions
This study suggests that the GABAergic neurotransmitter system is blunted in AUD. More precisely GABA levels in the ACC seem to be higher in recently detoxified AD patients than in individuals at high risk which might suggest that GABA levels may increase after abstinence. No correlation was found between GABA levels and abstinence duration. Longitudinal studies are required to investigate alterations in the GABAergic system throughout the development and maintenance of AUD.
Clinical Trial Registration
No: NCT02094196. Registered 20 March 2014, https://clinicaltrials.gov/study/NCT02094196.
... Eligible participants were treatment-seeking for AUD (NCT03594435), met criteria for a current DSM-5 diagnosis of AUD (moderate-to-severe), and drank >14 (males) or >7 drinks/week (females) in the 30 days prior to screening. Exclusion criteria were past year DSM-5 diagnosis of substance use disorders (excluding alcohol or nicotine), lifetime diagnosis of psychotic disorders (i.e., schizophrenia, bipolar disorder), clinically significant alcohol withdrawal as indicated by a score of ≥10 on the Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar (Sullivan et al., 1989)), positive urine screen for narcotics, amphetamines, or sedative hypnotics, AST, ALT, or GGT ≥3 times upper normal limit, current use of any medications for AUD or any psychotropic medications (e.g., psychostimulants and benzodiazepines) with the exception of stable antidepressants (stable dose for ≥4 weeks), or the use of medications or medical conditions that would interfere with safe study participation. Women of a childbearing age had to be practicing effective contraception and could not be pregnant or nursing. ...
Background
Insomnia commonly co‐occurs with alcohol use disorder (AUD) and predicts poorer outcomes for those with AUD. Insomnia and AUD are individually associated with increases in systemic inflammation. Insomnia and inflammation both serve as risk factors for relapse in AUD. However, little is known about the relationship between insomnia and systemic inflammation in individuals with AUD. Therefore, the present study examined the relationship between the severity of insomnia symptoms and plasma levels of inflammatory cytokines in a sample of treatment‐seeking individuals with an AUD.
Methods
This secondary analysis included 101 (61M/40F) individuals with an AUD. Participants were categorized into groups based on their scores on the Insomnia Severity Index: no insomnia (n = 47), subthreshold insomnia (n = 37), and clinical insomnia (n = 17). Participants provided blood samples to measure plasma levels of four peripheral markers of inflammation (IL‐6, IL‐8, TNF‐α, and CRP). Inflammatory marker levels were compared between groups. Interactive effects of sex and AUD severity were examined.
Results
There was a significant main effect of insomnia group on log IL‐8 levels (F = 6.52, p = 0.002), such that individuals with AUD and clinical insomnia had higher log IL‐8 levels compared to both the no insomnia and subthreshold insomnia groups (ps ≤ 0.05). Sex and AUD severity interacted with this relationship, such that men with clinical insomnia and AUD and individuals with severe AUD had higher log IL‐8 levels. There were no significant effects of insomnia on IL‐6, TNF‐α, or CRP levels.
Conclusion
The present study identified a specific elevation in IL‐8 levels in individuals with an AUD and clinical insomnia that was not identified in other markers of peripheral inflammation (IL‐6, TNF‐α, CRP). Sex and AUD severity interacted with insomnia symptoms, indicating that those with clinical insomnia and severe AUD or male sex may be the most vulnerable to the inflammatory consequences associated with AUD and clinical insomnia symptoms.
... Diversas organizaciones y centros asistenciales han recomendado el uso de instrumentos, tales como el CIWA (Escala de Valoración de la Abstinencia al Alcohol del Instituto Clínico-(Tabla 2) que no sólo proporciona la magnitud de la clínica sino también las recomendaciones terapéuticas. (16) A través de esta Escala CIWA-AR, de fácil aplicabilidad y fiabilidad, que consta de 10 apartados, tiene una puntuación máxima de 67 y clasifica el SAA en leve CIWA (<10), moderado CIWA (entre 10 y 20) y grave CIWA (>20). Si categorizamos un CIWA grave el ingreso hospitalario es lo indicado. ...
Mass consumption of alcohol as a phenomenon social development, both in societiesindustrialized as in the zones a call for attention to the needs of the population.Health Teams to find strategies that lead to some solution to this problem.
... alcohol cue reactivity, alcohol use disorder, fMRI, food, social reward processing (Sullivan et al., 1989) score >10) at any study visit; (5) report a history of neurological disease, traumatic brain injury, or loss of consciousness from a head injury lasting >5 min; (6) report current suicidal or homicidal ideation; ...
Background
Alcohol use disorder (AUD) is thought to bias the neurocircuitry underlying reward processing and motivation to preferentially attend to conditioned alcohol cues over natural rewards. The present case–control pilot study evaluated this hypothesis using novel natural reward paradigms.
Methods
Twenty‐eight participants (AUD, n = 14, light drinkers, n = 14) were recruited—AUD participants reported 44.0% heavy drinking days (%HDD) and 4.67 drinks/day over the preceding 90 days. Functional magnetic resonance imaging (fMRI) data were acquired during the administration of three separate picture‐viewing paradigms of alcohol cues, food scenes, and social reward, respectively. Independent samples t‐tests were performed to compare groups' fMRI data and exploratory correlation analyses were performed to examine associations with clinical characteristics of AUD.
Results
Food scenes elicited abnormally low reward‐related activation, within the superior frontal gyrus and caudate bilaterally, among AUD participants. Lower activation to food scenes within the superior frontal gyrus was, in turn, associated with higher levels of past‐month %HDD among AUD participants, specifically, along with craving and alcohol dependence severity when examined across the full sample. Contrasting reward types (e.g., alcohol cues vs. food scenes) did not reveal “preferential” activation to differentiate groups.
Conclusions
Heavy drinking appears associated with reduced responsivity to natural rewards, specifically food rather than social cues. Neural mechanisms underlying the high prevalence of malnutrition among individuals with AUD may involve some combination of blunted approach‐related affect and reduced craving‐related motivation to eat when food is present, resulting in limited engagement of cortico‐striato‐thalamic motor circuitry supporting food acquisition. However, given the preliminary nature of this pilot study, such formulations remain tentative until larger follow‐up studies can be conducted. From a potential translational standpoint, the ability of promising therapeutics to demonstrate increased responsivity to natural rewards, specifically nutritive reward may serve as a valuable complementary efficacy indicator for future clinical neuroimaging trials in AUD.
... General inclusion criteria required participants to be between 18 and 65 years old, capable of providing informed consent and completing study procedures, and able to abstain from alcohol and drugs for ≥1 week. Exclusion criteria for all groups included recurrent major depressive disorder, past month electroconvulsive therapy, serious medical illness, clinically significant head injuries (i.e., TBI), current benzodiazepine or antidipsotropic use, current post-traumatic stress disorder, OCD or eating disorder, history of delirium tremens or >1 withdrawal seizures, or significant current alcohol withdrawal (>7 on the Clinical Interview for Withdrawal Assessment for Alcohol-Revised; CIWA-Ar) (Sullivan et al., 1989). ...
Background
Bipolar disorder (BD) and alcohol use disorder (AUD) often co‐occur, with BD + AUD characterized by higher levels of impulsivity relative to either disorder alone. Emotional facets of impulsivity (e.g., “urgency,” measured by the UPPS‐P), however, remain underexplored in this population and could have distinct associations with clinical correlates.
Methods
This cross‐sectional study used a two‐by‐two (BDxAD) factorial design, including groups with BD + AD (n = 28), BD (n = 29), AD (n = 28), and healthy controls (HC) (n = 27), to identify between‐group differences among the five subscales of the UPPS‐P. Associations of UPPS‐P subscales with Barratt Impulsiveness Scale (BIS) total scores and clinical variables of interest were also examined.
Results
BD + AD had the highest scores for every UPPS‐P subscale but Sensation Seeking, with the Positive and Negative Urgency subscales having the largest main effects for both BD and AD. BIS‐11 total scores were most correlated with the urgency subscales of the UPPS‐P. Negative Urgency was found to be uniquely relevant to clinical measures in the BD + AD group. Rapid cycling was associated with both urgency subscales and BIS‐11 scores, and the Alcohol Dependence Scale was most correlated with the Premeditation subscale.
Limitations
Cross sectional design and predominantly white sample.
Conclusions
Unlike the BIS‐11, UPPS‐P is able to distinguish emotional from nonemotional facets of impulsivity, something especially relevant to people with co‐occurring BD + AD, where fluid emotionality is a key part of symptom presentation. For this reason, the UPPS‐P should be utilized in future studies and clinical settings measuring trait impulsivity in this population.
... Home-based withdrawal is unlikely to be suitable for clients at risk of severe alcohol withdrawal, such as severe tremor, severe tachycardia, seizures, delirium, or hallucinations; nor for clients who have a history of severe withdrawal symptoms (Haber & Lintzeris, 2021). The Clinical Institute Withdrawal Assessment for Alcohol Revised (CIWA-AR; Sullivan et al., 1989) is useful for assessment and to guide decision-making regarding management of alcohol withdrawal. Table 2.1 provides an overview of the integrated components and suggested session structure. ...
Social anxiety disorder (SAD) and alcohol use disorder (AUD) are prevalent disorders that often co-occur. SAD onset typically precedes that of AUD, and co-occurrence of the two disorders is associated with greater symptom severity than either condition alone. This chapter reviews current evidence about psychological treatment of co-occurring SAD and AUD. While people with co-occurring SAD-AUD can benefit from single-disorder cognitive behavioral therapy (CBT) approaches (either AUD-focused or SAD-focused), treatment efficacy and long-term outcomes are negatively impacted by the co-occurring disorders. Two alternate treatment models have been tested for co-occurring SAD-AUD: (i) dual-focused treatment, and (ii) integrated treatment. In one of two trials, dual-focused CBT for SAD and AUD resulted in worse outcomes, potentially due to the demands of engaging in two separate treatments. By contrast, integrated SAD-AUD treatment involves a synthesized therapeutic protocol (delivered by one therapist) to address SAD, AUD and the inter-connection between these disorders. To date, two trials have found that integrated CBT for co-occurring SAD-AUD improved outcomes compared to AUD-focused treatment. The remainder of the chapter provides a comprehensive overview of the therapeutic strategies and clinical application of integrated CBT for co-occurring SAD and AUD. A clinical vignette illustrates the treatment, common challenges, and provides example worksheets and therapeutic dialogue.
... Breath alcohol concentration of 0.00 mg/dL was confirmed prior to imaging. Participants with AUD were monitored for withdrawal symptoms throughout the day using the Clinical Withdrawal Assessment for Alcohol -revised (CIWA-Ar; Sullivan et al., 1989). The CIWA-Ar is a 10-item scale that queries canonical physical, motor, and mental symptoms of alcohol withdrawal. ...
Cigarette smoking is associated with elevated risk of disease and mortality and contributes to heavy healthcare-related economic burdens. The nucleus accumbens is implicated in numerous reward-related behaviors, including reinforcement learning and incentive salience. The established functional connectivity of the accumbens includes regions associated with motivation, valuation, and affective processing. Although the high comorbidity of cigarette smoking with drinking behaviors may collectively affect brain activity, there could be independent effects of smoking in alcohol use disorder that impact brain function and behavior. We hypothesized that smoking status, independent of alcohol use, would be associated with aberrations of nucleus accumbens functional connectivity to brain regions that facilitate reward processing, salience attribution, and inhibitory control. Resting state functional magnetic resonance imaging data from thirty-one nonsmokers and nineteen smoking individuals were analyzed using seed-based correlations of the bilateral accumbens with all other brain voxels. Statistical models accounted for drinks consumed per week. The smoking group demonstrated significantly higher functional connectivity between the left accumbens and the bilateral insula and anterior cingulate cortex, as well as hyperconnectivity between the right accumbens and the insula. Confirmatory analyses using the insula and cingulate clusters generated from the original analysis as seed regions reproduced the hyperconnectivity in smokers between the bilateral insular regions and the accumbens. In conclusion, smoking status had distinct effects on neural activity; hyperconnectivity between the accumbens and insula in smokers may reflect enhanced encoding of the reinforcing effects of smoking and greater orientation toward smoking-associated stimuli.
... 16 The Clinical Institute Withdrawal Assessment for Alcohol Scale-Revised (CIWA-Ar) was used to assess withdrawal symptoms. 17 interview to capture recent alcohol, cigarette and cannabis use. 22 Alcohol use was converted to standard drinks, and drinks per drinking day (DPDD) were calculated from the interview data. ...
Inflammation appears to be a critical mechanism in the development of alcohol use disorder (AUD) and a consequence of chronic alcohol use. The potential anti‐inflammatory properties of cannabis may modulate the proinflammatory effects of alcohol. This study sought to extend previous work investigating the relationship between alcohol consumption, cannabis use and circulating interleukin (IL)‐6 levels in a sample with AUD. One hundred and thirty‐three individuals with an AUD provided blood samples to assess IL‐6 and answered questions regarding alcohol and cannabis use. An ordinary least squares multiple regression analysis was conducted to assess the effect of alcohol and cannabis use on IL‐6. A moderation analysis examined cannabis use as a potential moderator of the relationship between alcohol use and circulating IL‐6 levels. Alcohol use was predictive of higher log IL‐6 levels (standardized β = 0.16, p = 0.03), while cannabis use was not predictive of log IL‐6 levels (p = 0.36). Days of cannabis use moderated the relationship between alcohol use and IL‐6 levels, such that the relationship between alcohol use and IL‐6 levels was only significant in individuals with AUD without recent cannabis use. This study extends previous work to a clinical sample with an AUD and underscores the importance of considering cannabis use in studies on alcohol use and inflammation. This study also indicates the need for in‐depth analyses on cannabinoids and inflammation and the interaction between cannabinoids and alcohol use on inflammation.
... (3) alcohol withdrawal as indicated by a score >10 on the Clinical Institute Withdrawal Assessment for Alcohol (CIWA;Sullivan et al., 1989), (4) >14 days of abstinence from alcohol prior to participation, or (5) use of alcohol <12 h before scanning (confirmed via breathalyzer). Additional details on exclusion criteria can be found in the Supplementary Materials S1. ...
Background
Alcohol craving is related to problematic alcohol use; therefore, pharmacotherapies that modulate alcohol craving are of interest. N‐acetylcysteine, an over‐the‐counter antioxidant, is a candidate pharmacotherapy for adolescent alcohol use with the potential to impact craving. Cue‐reactivity paradigms using functional magnetic resonance imaging (fMRI) can identify neural regions implicated in craving and serve as a screening tool for novel pharmacotherapy options.
Methods
This preliminary study examined the effect of N‐acetylcysteine on neural reactivity to alcohol cues and subjective craving among 31 non‐treatment‐seeking adolescents (17.6–19.9 years old, 55% female) who use alcohol heavily. In a randomized cross‐over design, participants completed three fMRI sessions: baseline and after a 10‐day course of N‐acetylcysteine (1200 mg twice daily) and matched placebo. The primary outcome was neural response to alcohol versus non‐alcohol beverage cues after N‐acetylcysteine versus placebo, with a secondary outcome of self‐reported subjective craving.
Results
In the full sample (n = 31), there was no effect of N‐acetylcysteine versus placebo on neural alcohol reactivity (ps ≥ 0.49; ηp2s = 0.00–0.07) or self‐reported acute alcohol craving (p = 0.18, ηp2 = 0.06). However, N‐acetylcysteine did reduce self‐reported generalized alcohol craving (p = 0.03, ηp2 = 0.15). In a subsample of youth who met criteria for past‐year alcohol use disorder (n = 19), results remained unchanged.
Conclusions
N‐acetylcysteine may not alter neural reactivity to alcohol cues or acute craving; however, it may reduce general subjective alcohol craving among adolescents who consume alcohol heavily.
... All participants had a negative breath alcohol concentration prior to the start of the battery. Participants that were in the inpatient treatment program were tested after completion of detoxification and documentation of no withdrawal symptoms (using the Clinician Institute Withdrawal Assessment, CIWA-Ar [26]). The ANA battery was administered in four testing blocks (Table 1), with the order of the blocks randomized across participants. ...
The Addictions Neuroclinical Assessment (ANA) is a neurobiologically-informed framework designed to understand the etiology and heterogeneity of Alcohol Use Disorder (AUD). Previous studies validated the three neurofunctional domains of ANA: Incentive Salience (IS), Negative Emotionality (NE) and Executive Function (EF) using secondary data. The present cross-sectional observational study assessed these domains in an independent, prospective clinical sample. Adults across the drinking spectrum (N = 300) completed the ANA battery, a standardized collection of behavioral tasks and self-report assessments. Factor analyses were used to identify latent factors underlying each domain. Associations between identified domain factors were evaluated using structural equation models. Receiver operating characteristics analyses were used to determine factors with the strongest ability to classify individuals with problematic drinking and AUD. We found (1) two factors underlie the IS domain: alcohol motivation and alcohol insensitivity. (2) Three factors were identified for the NE domain: internalizing, externalizing, and psychological strength. (3) Five factors were found for the EF domain: inhibitory control, working memory, rumination, interoception, and impulsivity. (4) These ten factors showed varying degrees of cross-correlations, with alcohol motivation, internalizing, and impulsivity exhibiting the strongest correlations. (5) Alcohol motivation, alcohol insensitivity, and impulsivity showed the greatest ability in classifying individuals with problematic drinking and AUD. Thus, the present study identified unique factors underlying each ANA domain assessed using a standardized assessment battery. These results revealed additional dimensionality to the ANA domains, bringing together different constructs from the field into a single cohesive framework and advancing the field of addiction phenotyping. Future work will focus on identifying neurobiological correlates and identifying AUD subtypes based on these factors.
... The scales used to assess AUD included the alcohol dependence scale (ADS), 27 the alcohol use disorder identification test (AUDIT), 28 the cutdown, annoyed, guilty, eye-opener (CAGE) scale, 29 the clinical institute withdrawal assessment-advanced revised (CIWA-Ar) scale, 30 the Michigan alcoholism screening test (MAST), 31 and the obsessive compulsive drinking scale (OCDS). 32 We also used the visual analogue scale (VAS) 33 to evaluate the intensity of desire for alcohol for individuals with AUD. ...
A growing body of evidence indicates the existence of abnormal local and long‐range functional connection patterns in patients with alcohol use disorder (AUD). However, it has yet to be established whether AUD is associated with abnormal interhemispheric and intrahemispheric functional connection patterns. In the present study, we analysed resting‐state functional magnetic resonance imaging data from 55 individuals with AUD and 32 healthy nonalcohol users. For each subject, whole‐brain functional connectivity density (FCD) was decomposed into ipsilateral and contralateral parts. Correlation analysis was performed between abnormal FCD and a range of clinical measurements in the AUD group. Compared with healthy controls, the AUD group exhibited a reduced global FCD in the anterior and middle cingulate gyri, prefrontal cortex and thalamus, along with an enhanced global FCD in the temporal, parietal and occipital cortices. Abnormal interhemispheric and intrahemispheric FCD patterns were also detected in the AUD group. Furthermore, abnormal global, contralateral and ipsilateral FCD data were correlated with the mean amount of pure alcohol and the severity of alcohol addiction in the AUD group. Collectively, our findings indicate that global, interhemispheric and intrahemispheric FCD may represent a robust method to detect abnormal functional connection patterns in AUD; this may help us to identify the neural substrates and therapeutic targets of AUD.
... Patients with major depressive disorder can be considered depending on the stability and duration of their current treatment regimen. 175 and/or other clinician validated assessments) should be included only after withdrawal symptoms have been resolved. • Patients with metabolic syndrome should 'not' be excluded from trials. ...
Most patients with alcohol-associated liver disease (ALD) engage in heavy drinking defined as 4 or more drinks per day (56 g) or 8 (112 g) or more drinks per week for women and 5 or more drinks per day (70 g) or 15 (210 g) or more drinks per week for men. Although abstinence from alcohol after diagnosis of ALD improves life expectancy and reduces the risk of decompensation of liver disease, few studies have evaluated whether treatment of alcohol use disorders will reduce progression of liver disease and improve liver-related outcomes. In November 2021, the National Institute of Alcohol Abuse and Alcoholism commissioned a task force that included hepatologists, addiction medicine specialists, statisticians, clinical trialists and members of regulatory agencies to develop recommendations for the design and conduct of clinical trials to evaluate the effect of alcohol use, particularly treatment to reduce or eliminate alcohol use in patients with ALD. The task force conducted extensive reviews of relevant literature on alcohol use disorders and ALD. Findings were presented at one in-person meeting and discussed over the next 16 months to develop the final recommendations. As few clinical trials directly address this topic, the 28 recommendations approved by all members of the task force represent a consensus of expert opinions.
... Additional exclusion criteria for these participants included: (1) a medical condition that may interfere with safe study participation; (2) attempted suicide in the past 3 years and/or serious suicidal intention/plan in past year; (3) currently on prescription medication that contraindicates use of ibudilast; (4) currently taking medications for AUD or psychotropic medications, except for stable antidepressants (stable dose ≥4 weeks); and (5) AST, ALT, and GGT levels ≥3 times the normal limit. Additionally, participants were required to have (1) a breath alcohol concentration of 0.00 g/dl; (2) Clinical Institute Withdrawal Assessment for Alcohol Withdrawal (CIWA-Ar) [38] score <10; and (3) no active COVID or sickness symptom (i.e., fever) at the beginning of their blood draw visit. The final sample for the CRP analysis included 98 participants. ...
Early life stress (ELS) increases risk for psychiatric illness, including alcohol use disorder (AUD). Researchers have hypothesized that individuals with and without a history of ELS who have the same primary DSM-5 diagnosis are clinically and biologically distinct. While there is strong support for this hypothesis in the context of mood disorders, the hypothesis remains largely untested in the context of AUD. This study investigated the impact of ELS on the neuroclinical phenomenology and inflammatory profile of individuals with AUD. Treatment-seeking adults with AUD ( N = 163) completed the Adverse Childhood Experiences (ACE) Questionnaire and phenotypic battery as part of a pharmacotherapy trial for AUD (NCT03594435). Participants were classified as having “no-ELS,” (ACE = 0) “moderate-ELS,” (ACE = 1, 2 or 3) or “high-ELS” (ACE = 4 + ). The Addictions Neuroclinical Assessment domains incentive salience and negative emotionality were derived and used to assess the neuroclinical phenomenology of AUD. We tested (1) cumulative ELS as a predictor of ANA domains and (2) ELS group differences in ANA domains. A subset of participants ( N = 98) provided blood samples for a biomarker of peripheral inflammation (C-reactive protein; CRP); analyses were repeated with CRP as the outcome variable. Greater ELS predicted higher negative emotionality and elevated CRP, but not incentive salience. The high-ELS group exhibited greater negative emotionality compared with the no-ELS and moderate-ELS groups, with no difference between the latter two groups. The high-ELS group exhibited elevated CRP compared with the no/moderate-ELS group. Findings suggest that high-ELS exposure is associated with a unique AUD neuroclinical presentation marked by greater negative emotionality, and inflammatory profile characterized by elevated peripheral CRP.
... From a practical point of view, the application of a structured interview may be challenging, and it is conceptually unnecessary because individuals experiencing AWS typically exhibit agitation and confusion. (CIWA-A) scale, particularly in its ten-item revised form (CIWA-Ar) 59,75,76 , represents a consolidated tool for assessing the severity of AWS. Table 5 summarizes the items and the score range, with scores <8 indicating mild withdrawal, scores ranging between 8 and 15 indicating moderate withdrawal, and scores above 15 indicating severe withdrawal. ...
Excessive alcohol consumption is linked to several consequences involving health, social, working, relational and economic fields.
Acute alcohol Intoxication is the direct consequence of high alcohol consumption, particularly if consumed in a short time-frame. Traumas (e.g., road accidents, pedestrian injuries, head injuries, falls, crashes), violence (e.g., domestic) and suicide attempts represent
the direct consequences. The number of admissions to emergency departments for acute alcohol intoxication is constantly rising.
Alcohol Withdrawal Syndrome is a potentially
life-threatening clinical syndrome occurring when individuals with severe alcohol use disorder (AUD) abruptly cease or significantly reduce alcohol consumption.
Despite individual’s decision to stop drinking, AWS can develop as a consequence of medical treatments that accelerate ethanol’s metabolism and elimination from plasma.
Both acute alcohol intoxication (AAI) and alcohol withdrawal syndrome (AWS) represent two pivotal and interconnected issues resulting from alcohol abuse.
The present review will highlight the primary manifestations of alcohol-related harm, focusing on the acute consequences of alcohol consumption, namely acute alcohol intoxication, and the subsequent challenges
presented by alcohol withdrawal syndrome. These two facets underscore the complex and multifaceted nature of alcohol misuse.
... Las escalas de síntomas permiten una documentación regular y objetiva de la progresión de dicha patología. Tal es el caso de la Revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar), que a más de 30 años de su publicación en 1989 sigue siendo una de las herramientas más utilizadas por el especialista en medicina de urgencias 8 . La Prediction of Alcohol Withdrawal Severity Scale (PAWSS), publicada en 2014 por Maldonado et al. 9 , se utiliza para la predicción de la aparición de delirium tremens, que ocurre en el 3-5% de los pacientes hospitalizados por supresión etílica. ...
... Participants completed a series of assessments for eligibility and individual differences. These measures included the Structured Clinical Interview for DSM-5 (SCID-5; First et al., 2015) to assess AUD and exclusionary diagnoses, the Clinical Institute Withdrawal Assessment for Alcohol Scale-Revised (CIWA-Ar; Sullivan et al., 1989), and the 30-day Timeline Followback Interview (TLFB; Sobell & Sobell, 1992) for recent alcohol, cigarette, and cannabis use. ...
Background
Alcohol use disorder (AUD) and stress influence overlapping neural circuits in the brain. The literature is mixed regarding the presence of sex differences in the neural response to acute stressors, and this issue has not been examined in individuals with AUD. We validated a stress functional magnetic resonance imaging (fMRI) paradigm in individuals with AUD and tested for sex differences.
Methods
Twenty‐five treatment‐seeking individuals with AUD (15M/10F) were recruited to participate in the neuroimaging study linked to a clinical trial of ibudilast (NCT03594435). To assess social‐evaluative stress, participants completed the Montreal Imaging Stress Task (MIST). Whole brain and amygdala region‐of‐interest analyses were conducted. Subjective ratings of anxiety and distress were collected. Repeated measures ANCOVAs were performed to evaluate the effect of stress on anxiety and distress and to evaluate sex differences.
Results
There were trend‐level effects of stress on anxiety ratings and amygdala activation (p's = 0.06). There was a significant effect of stress in the bilateral thalamus, ventral tegmental area, and paracingulate (Z's > 4.09, p's < 0.03). There was a trend‐level effect of sex on subjective ratings of stress (p's = 0.07). Females had higher amygdala activation in response to stress (p = 0.02). Females also had greater activation than males in the precuneus, posterior cingulate cortex, and right inferior frontal gyrus during acute stress (Z's > 3.56, p's < 0.03).
Conclusions
This study provides an initial validation of the MIST in a sample of individuals with AUD. It also provides preliminary evidence of sex differences in the response to social‐evaluative stress, which is important, given the relevance of stress and negative emotionality as motivators for alcohol use in females.
Background
Heavy alcohol use is common in Malawi among people receiving sexually transmitted infections (STI) care and is a critical barrier to the success of HIV prevention and treatment efforts.
Methods
This protocol presents a pilot hybrid type 1 effectiveness-implementation trial evaluating the short-term effectiveness and implementation of a scalable evidence-based intervention (EBI) to reduce alcohol use and provide HIV prevention and treatment counseling for people with heavy drinking receiving STI care in Malawi. We developed a 3-session intervention, Treat4All, that uses motivational interviewing, problem-solving skills, psychoeducation, alcohol refusal, HIV prevention and treatment skills building, and goal setting to reduce alcohol and facilitate engagement in HIV prevention and treatment. We have also integrated HIV prevention content to focus on persistent PrEP use and HIV treatment adherence to improve antiretroviral therapy (ART) adherence and viral suppression. We will conduct a two-arm pilot randomized controlled trial (RCT) in an STI care setting in urban Malawi to compare the preliminary effectiveness and implementation of Treat4All to usual care for decreasing the proportion of heavy drinking days, corroborated with phosphatidylethanol, an alcohol biomarker, and improving HIV outcomes (viral suppression among PWH; PrEP use among those at risk). We will randomly assign 160 people receiving STI care in Lilongwe who report heavy drinking (n = 80 people with HIV; PWH; n = 80 people at high risk of HIV acquisition) to Treat4All or usual care.
Discussion
Our study will produce a systematically braided, scalable HIV status-neutral EBI for alcohol reduction and optimization of HIV prevention and treatment behaviors to evaluate in a larger effectiveness-implementation trial. Our study will directly expand alcohol reduction and HIV status-neutral programs for alcohol-impacted populations throughout sub-Saharan Africa and other regions where alcohol contributes to the ongoing HIV epidemic.
Clinical trial registration
ClinicalTrials.gov, NCT06668363.
Addiction is a chronic-progressive disease marked by phases of relapse and recovery. Patients with moderate to severe addictions typically have mental illness of some form (they are dual-diagnosis patients) reflecting how mental illness and addiction are biologically and bidirectionally causally interlinked. Addiction psychiatrists are formally cross-trained in the diagnosis and treatment of both addiction and mental illness. They conduct diagnostic workups that fully embrace complex addiction–mental illness comorbidities while longitudinally tracking illness evolution and recovery trajectories. As implemented in the 2 × 4 model blueprint of integrated addiction psychiatry care, repeated diagnostic evaluations guide individualized treatment planning that attends to patient’s stages of change while integrating psychotherapeutic, experiential, medication, and/or neuromodulator treatments. Multiple mental illness and addiction subtypes are simultaneously or sequentially targeted over the course of detoxification-withdrawal treatments, harm reduction, and full remission strategies. The advancing frontier of addiction psychiatry will involve the growth of inpatient and outpatient teams composed of addiction psychiatrists, nurses, and therapists that reject fragmented/siloed/split-care models that segregate addiction from mental illness treatment and professional training. Addiction psychiatry teams will be important for researching new integrative treatments in full recognition of addiction and mental illness as highly neurobiologically interconnected and clinically interrelated brain diseases.
Importance
The neuroimmune system represents a promising target for novel medications for alcohol use disorder (AUD). Ibudilast is a neuroimmune modulator which selectively inhibits phosphodiesterases (PDE) 3, PDE4, PDE10, and PDE11, and macrophage migration inhibitory factor (MIF).
Objective
To test the efficacy of ibudilast for AUD compared with placebo.
Design, Setting, and Participants
This randomized clinical trial was a double-masked, phase 2 trial conducted at an academic research center between October 2018 and April 2023. Eligible participants were adults seeking treatment for moderate or severe AUD. After completing the 12-week treatment period, participants were followed up for an additional 4 weeks.
Interventions
Ibudilast taken twice daily in 50 mg doses for 12 weeks vs placebo.
Main Outcomes and Measures
Percentage of heavy drinking days; secondary efficacy outcomes included drinks per day, drinks per drinking day, and percentage of days abstinent. Registered exploratory analyses tested whether the effects of ibudilast of drinking outcomes were moderated by baseline depressive symptomatology. Registered exploratory analyses also tested whether ibudilast reduced inflammation compared with placebo, as indicated by circulating levels of proinflammatory markers over the 12-week trial. Additionally, a post hoc exploratory analysis investigated whether sex moderated the effect of ibudilast on drinking outcomes. Data were analyzed between October 2018 and April 2023.
Results
A total of 102 participants were enrolled in the study (mean [SD] age, 44.3 [10.8] years; 61 male [59.8%]; 24 Black [23.5%], 32 Hispanic [31.4%], 52 White [51.0%]). Baseline demographic characteristics and alcohol use patterns did not significantly differ between the 2 medication conditions. There was no significant difference between ibudilast vs placebo on percentage of heavy drinking days (β = 0.06, SE = 0.08 [95% CI, −0.09 to 0.21]; P = .46). There were no significant differences between ibudilast vs placebo on registered secondary outcomes. There were no significant effects of ibudilast compared with placebo on peripheral markers of inflammation. Moderation analyses found that baseline depressive symptomology (time 2 for drinks per drinking day: β = 0.25, SE = 0.11 [95% CI, 0.03 to 0.48]; P = .03) and sex (β = −2.48, SE = 1.07 [95% CI, −4.59 to −0.37]; P = .02) may moderate the effects of ibudilast.
Conclusions and Relevance
In this randomized clinical trial of ibudilast for the treatment of AUD, there was no support for the efficacy of ibudilast over placebo; additionally, no effect of ibudilast on markers of peripheral inflammation was observed. As novel treatments for AUD are developed for novel molecular targets, their effects may depend on mechanisms and moderators of efficacy.
Trial Registration
ClinicalTrials.gov Identifier: NCT03594435
Background
Understanding of the mechanism of action of Baclofen as anticraving inalcohol dependence syndrome (ADS) is limited.
Aim
Our study aimed to examine and compareearly changes in brain glutamate and GABA with Baclofen and Acamprosate among patients with alcohol dependence syndrome.
Material and Methods
Forty patients with ADS were recruited with purposive sampling and were randomized into two groups using computer-generated randomization. At the end of detoxification (CIWA-Ar <10) brain glutamate and GABA were measured with proton magnetic resonance spectroscopy (1H-MRS) in the anterior cingulate cortex (ACC) of the brain along with a measure of craving (PACS). Either Acamprosate or Baclofen was started. After 25 days of starting Baclofen or Acamprosate brain glutamate and brain GABA using 1H-MRS and PACS measures were repeat measured.
Results
Both groups had shown comparable changes in brain glutamate ( F = 0.01, P = 0.92, ηp2 = 0.00) and GABA ( F = 0.29, 26 P = 0.59, ηp2 = 0.008) and craving ( F = 0.08, P = 0.77, ηp2 = 0.002) over time. Baclofen and Acamprosate showed a differential relation with the clinical characteristics of participants.
Conclusion
Our study has shown comparable changes in Glutamate and GABA during the early post-detoxification period both for baclofen and acamprosate. Effects of baclofen and acamprosate might correlate differently with the clinical profile of alcohol dependence syndrome which would help in choosing a particular anticraving medication.
Introduction
This consensus statement gives practical advice for the safe management of patients with harmful alcohol intake undergoing elective and emergency surgery. The wide spectrum of alcohol‐related organ dysfunction observed in this cohort of patients may have a profound impact on care, and the additional effects of alcohol withdrawal may further exacerbate postoperative morbidity and mortality.
Methods
A working party was assembled based on clinical and/or academic expertise in the area. Recommendations were formulated using a modified Delphi process. An initial list of recommendations was produced following targeted literature reviews for all relevant phases of patient care throughout the peri‐operative pathway. These recommendations were distributed among the authors who rated each as ‘include’, ‘exclude’; or ‘revise’. Recommendations with ≥ 75% inclusion decision were included.
Results
The working party produced a list of 10 key peri‐operative management recommendations. These include recommendations on how to screen effectively for excessive alcohol usage in the surgical population. To achieve this, a validated point‐of‐care tool is used with additional weighting provided by considering surgical urgency. This is combined with the use of scoring systems to facilitate decisions regarding peri‐operative care including postoperative location. This document also provides clear explanation of the physiological and pharmacological issues relating to alcohol excess, highlighting the direct effects of alcohol and its secondary effects on organ systems.
Discussion
This consensus statement offers strategies and solutions to minimise the impact of harmful alcohol intake on the safe conduct of anaesthesia.
Background
Alcohol-related cognitive deficits (ARCDs) have received little clinical recognition due to doubts regarding the etiopathogenesis and lack of consensus in the diagnostic guidelines.
Aim
The present study aimed at evaluating the pattern of cognitive deficits in patients of alcohol dependence without dementia, and assessing the relationship between these subtle cognitive deficits and alcohol use parameters.
Materials and Methods
The study included randomly selected, consenting, non-delirious patients of alcohol dependence syndrome (ADS) without dementia, admitted in the de-addiction ward. Cognition was assessed by Mini Mental State Examination (MMSE) of the Diagnostic Interview for Genetic Studies at admission and after 7 days of detoxification. “T-test” was used to assess cognitive improvement and residual deficits, while correlation analysis was used to compare the relationship between alcohol use parameters and MMSE scores.
Results
We recruited 63 male patients with mean age of 38.62 (±9.61) years. Significant improvement was noted in cognition post-detoxification. However, most of the subjects had subtle cognitive deficits which may fall within the realm of ARCD, mainly in domains of attention/concentration, recall, language, and visuo-constructional skills ( P < 0.05). The cognitive deficits correlated with duration and severity of alcohol dependence ( P < 0.05), however, were independent of daily alcohol quantity.
Conclusion
Subtle cognitive deficits may persist in patients of ADS without dementia, even after successful detoxification. They may be easily missed despite contact with mental health professionals, as these deficits may only be evident on neuro-psychological testing.
Background
Global alcohol consumption poses a serious threat to humankind. It is estimated that between 5% and 7% of Indian adults struggle with alcohol abuse. Alcoholism is associated with a number of disorders, impacting different organ systems and nutritional status, including symptoms of withdrawal that can vary in severity from moderate symptoms to delirium tremens (DT). An increase in oxidative stress in the body is linked to alcohol withdrawal.
Aim
This study aimed to evaluate the role of vitamins with antioxidant properties on oxidative stress caused by the severe alcohol withdrawal state.
Materials and Methods
60 patients with DT and 30 control subjects were recruited using a purposive sampling method. They were evaluated for liver function test, antioxidant enzyme superoxide dismutase, glutathione peroxidase, and serum vitamin D level on day 0, day 14 and on day 0 of treatment for patients and controls, respectively.
Results
The mean age of the study group was 41.12 years. The mean duration of substance use while coming for treatment was 22 years. Means of liver function test were found to be aspartate transaminase (AST) 196 IU/L, alanine transaminase (ALT) 71 IU/L, and alkaline phosphatase (ALP) 143 IU/L of patients on day 0 of evaluation. When comparisons of liver enzymes and antioxidant enzymes were conducted between cases and controls on day 0, significance was found. Further comparison of day 0 and day 14 levels of liver enzymes and antioxidant enzymes also had shown significant differences. However, no significant correlation was found with vitamin D level and liver enzyme, antioxidant enzyme level.
Conclusion
Oxidative stress evaluated via antioxidant enzyme was found to be at a higher level in patients with DT than in patients with mild withdrawal symptoms. This study has shown an association between antioxidant enzymes with severity of withdrawal; however, no such association with vitamin D level was found.
Background
Individuals experiencing alcohol dependence syndrome (ADS) may struggle with relapse due to various factors, even after receiving successful inpatient treatment. While motivation enhancement therapy (MET) and pharmacotherapy are commonly used interventions for ADS, incorporating task-centered casework (TCP) – a nondirective, goal-oriented, and time-limited approach – may yield promising outcomes.
Aim
This study examined the effects of adjunctive TCP in conjunction with pharmacotherapy and MET on frequently relapsing patients with ADS.
Materials and Methods
This study utilized a case-control design to evaluate the efficacy of combined therapies (pharmacotherapy, MET, and TCP) on 60 male subjects with a diagnosis of ADS and multiple admissions in a tertiary deaddiction center. The participants were divided equally into experimental and control groups, with the experimental group receiving all three therapies and the control group only receiving pharmacotherapy and MET. Both groups maintained their pharmacotherapy regimens throughout the 2-month study period. Assessments were conducted at baseline and the end of the study using various measures, including social–demographic and clinical data, the SAD-Q, ACQ SF-R, SOCRATES-8A, CIWA-Ar, and WHOQOL-BREF Hindi version.
Results
The results of the study indicate that the experimental group exhibited a marked decrease in alcohol cravings, an increased willingness to make positive changes, and overall better treatment outcomes and quality of life compared to the control group. In patients with ADS who underwent treatment with MET, TCP, and pharmacotherapy, it was observed that cravings were a significant predictor of their quality of life and readiness to make changes.
Conclusions
TCP can be complemented with existing addiction therapies in the treatment of addiction because it has additional advantages in the form of nondirectiveness, goal orientation, time-limitedness, and collaboration between the therapist and the patient. ADS patients can benefit from this therapy by discovering their inert potential and identifying their shortcomings.
Gambling, which was previously restricted to physical casinos and card rooms, has become readily accessible through internet platforms and virtual card games as a result of recently developed technological advances. The increase in the prevalence of pathological gambling (PG) disorder has been attributed to the extensive availability of online gambling platforms and the covert advertising that is associated with them. In this case, we examine an individual with a PG disorder who is intrigued by online gambling. This individual also has a co-occurring drug use disorder and is burdened by significant financial debt and family problems. These issues have arisen due to an uncontrollable impulse to gamble in online games. The participants initially achieved transient success in these online games, which led to a strong desire to always participate in them, neglecting their personal and professional responsibilities and overall well-being. After depleting the individual's financial savings entirely, he turned to stealing from his own home in order to continue gambling and recover their losses. This has been facilitated by the ease and convenience of online money transactions through websites and mobile applications, which has resulted in a greater engagement and understanding of online gambling.
Introduction
Despite a well-established direct toxic effect of alcohol on renal cells, there is a salutary dose-dependent effect of alcohol consumption on common laboratory parameters related to kidney performance. Alcohol also impacts thyroid hormones, while thyroid status modulates kidney function. The modulation of kidney parameters with thyrotropin (TSH) and thyroid status indicates a possible interaction between alcohol, kidney, and thyroid functions. This retrospective study was conducted to test the hypothesis that the positive effect of alcohol use on the estimated glomerular filtration rate (eGFR) is mediated by alcohol’s effect on thyroid hormones.
Methods
We reviewed the electronic medical records of 767 hospitalized adult patients free of thyroid disorders who received medical care in the Mayo Clinic Health System from June 2019 through June 2022 and had blood alcohol concentration (BAC), serum TSH, and serum creatinine measured during the hospitalization. We calculated the eGFR using both the re-expressed Modification of Diet in Renal Disease (MDRD II) study equation and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) Creatinine equation.
Results
We found a significant relationship of BAC with eGFR (CKD-EPI) and TSH in males only. BAC had a positive association with eGFR (b = 0.24, p = 0.0001) and negative with TSH (b=-0.17, p = 0.006). The covariance between the two outcomes (eGFR and TSH) was negative (b = -0.12, p = 0.049). The path analyses using the eGFR MDRD II equation were not significant in males, whereas females had no significant path analyses with either of the eGFR equations.
Discussion
We observed that BAC influences both eGFR and TSH, whereas eGFR and TSH influence each other. After considering important covariates (e.g., age, body mass index, diabetes mellitus, cardiovascular disease, chronic kidney disease, and chronic liver disease) and the negative bidirectional effect of TSH and eGFR, a positive impact of BAC on eGFR was observed in males.
Background
Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) commonly co-occur and are associated with more severe symptomatology than either disorder alone, increased risk of suicide, and poorer response to existing treatments. A promising therapeutic intervention is the integration of 3,4-methylenedioxymethamphetamine (MDMA) and psychotherapy. The Food and Drug Administration (FDA) designated MDMA- assisted therapy (MDMA-AT) as a Breakthrough Therapy for PTSD based on results from six Phase 2 clinical trials. Case data from the first study evaluating MDMA-AT study for AUD found the treatment was well tolerated and alcohol use was significantly reduced post treatment.
Methods
This manuscript reports the premise, design, and methodology of the first open-label trial of MDMA-AT for military veterans (N = 12) with PTSD and AUD. Neuroimaging and biomarker data are included to evaluate brain changes, and neuroinflammation, pre-post treatment.
Conclusions
The clinical component (comorbidity) and the regulatory processes (Schedule I drug) for setting up this clinical trial are long and complex. The research community will benefit from this work to establish common clinical trial outcomes, standardized protocols, and risk assessments for FDA approval.
Clinicaltrials.gov
NCT05943665.
Introduction
This study aims to clarify differences in mood, craving, and treatment response between reward and relief/habit individuals in a study of naltrexone, varenicline, and placebo. We hypothesized that relief/habit individuals would have a poorer mood during early abstinence and higher levels of alcohol craving than reward individuals. We hypothesized that reward individuals would demonstrate better drinking outcomes on naltrexone versus placebo.
Methods
Data were culled from a randomized, double-blind, placebo-controlled human trial of 53 individuals (18F/16M) with alcohol use disorder randomized to varenicline (n = 19), naltrexone (n = 15), or matched placebo (n = 19). In this 6-day practice quit trial, participants attempted to abstain from drinking and completed daily diaries. Participants were classified into reward or relief/habit subgroups based on self-reported motivation for drinking. Multilinear models tested differences in mood and alcohol craving between reward and relief/habit individuals. General linear models tested differences between reward and relief/habit individuals’ drinking outcomes on each medication versus placebo.
Results
Relief/habit individuals showed decreases in positive mood and increases in negative mood over the quit attempt across medications, compared to reward individuals (P’s < .05). Reward individuals’ tension decreased on naltrexone, while relief/habit individuals’ tension remained stable (F = 3.64, P = .03). Reward individuals in the placebo group had higher percent days abstinent than relief individuals in the placebo group (P < .001).
Discussion
This study suggests relief/habit individuals’ mood worsens during early abstinence. Our finding that reward individuals’ tension decreased on naltrexone and increased on placebo may suggest a clinical response to the medication.
Background
The association of impaired dopaminergic neurotransmission with the development and maintenance of alcohol use disorder is well known. More specifically, reduced dopamine D2/3 receptors in the striatum of subjects with alcohol dependence (AD) compared to healthy controls have been found in previous studies. Furthermore, alterations of gamma‐aminobutyric acid (GABA) and glutamate (Glu) levels in the anterior cingulate cortex (ACC) of AD subjects have been documented in several studies. However, the interaction between cortical Glu levels and striatal dopamine D2/3 receptors has not been investigated in AD thus far.
Methods
This study investigated dopamine D2/3 receptor availability via 18F‐fallypride positron emission tomography (PET) and GABA as well as Glu levels via magnetic resonance spectroscopy (MRS) in 19 detoxified AD subjects, 18 healthy controls (low risk, LR) controls and 19 individuals at high risk (HR) for developing AD, carefully matched for sex, age and smoking status.
Results
We found a significant negative correlation between GABA levels in the ACC and dopamine D2/3 receptor availability in the associative striatum of LR but not in AD or HR individuals. Contrary to our expectations, we did not observe a correlation between Glu concentrations in the ACC and striatal D2/3 receptor availability.
Conclusions
The results may reflect potential regulatory cortical mechanisms on mesolimbic dopamine receptors and their disruption in AD and individuals at high risk, mirroring complex neurotransmitter interactions associated with the pathogenesis of addiction. This is the first study combining 18F‐fallypride PET and MRS in AD subjects and individuals at high risk.
Objective
There is growing interest in the use of phenobarbital for alcohol withdrawal syndrome in critically ill patients, though experience in neurologically injured patients is limited. The purpose of this study was to compare the safety and effectiveness of phenobarbital-containing alcohol withdrawal regimens versus benzodiazepine monotherapy in the neurocritical care unit.
Methods
We conducted a retrospective cohort study of adult patients admitted to the neurocritical care unit from January 2014 through November 2021 who received pharmacologic treatment for alcohol withdrawal. Treatment groups were defined as benzodiazepine monotherapy versus phenobarbital alone or in combination with benzodiazepines. The primary outcome was the percentage of patients requiring intubation after receiving alcohol withdrawal treatment. Secondary outcomes included all-cause, in-hospital mortality, intensive care unit length of stay, discharge disposition, change in Glasgow Coma Scale (GCS) score, and the use of adjunctive agents.
Results
We analyzed data from 156 patients, with 77 (49%) in the benzodiazepine group and 79 (51%) in the phenobarbital combination group. The groups were well-balanced for baseline characteristics, though more males (67, 85%) were in the phenobarbital group. Only three (1.9%) patients received phenobarbital monotherapy, and the rest (153, 98.1%) received combination therapy. The percentage of patients requiring mechanical ventilation was significantly higher in the phenobarbital combination group compared to benzodiazepine monotherapy (39% (n=31) versus 13% (n=10); OR: 4.33, 95% CI: 1.94-9.66; p<0.001). The use of adjunctive propofol and dexmedetomidine was higher in the phenobarbital group (propofol 35% (n= 28) versus 9% (n=7) and dexmedetomidine 30% (n=24) versus 5% (n=4), respectively). Patients in the phenobarbital group also had lower GCS scores and higher Clinical Institute Withdrawal Assessment of Alcohol (CIWA-Ar) scores during their intensive care unit admission, possibly suggesting more severe alcohol withdrawal. There was no difference in intensive care unit length of stay, all-cause, in-hospital mortality, discharge disposition, or therapeutic adjuncts.
Conclusions
Combination therapy of phenobarbital plus benzodiazepines was associated with higher odds of requiring mechanical ventilation. Few patients received phenobarbital monotherapy. Additional studies are needed to better compare the effects of phenobarbital monotherapy versus benzodiazepines in neurocritical patients.
We evaluated impact on length of stay and possible complications of replacing the Clinical Institute Withdrawal Assessment—Alcohol Revised (CIWA-Ar) scale with a slightly modified Richmond Agitation and Sedation Scale (mRASS-AW) to support managing patients admitted with alcohol withdrawal symptoms in a community hospital. Since mRASS-AW is viewed as easier and quicker to use than CIWA-Ar, provided use of mRASS-AW does not worsen outcomes, it could be a safe alternative in a busy ED environment and offer an opportunity to release nursing time to care.
Retrospective time-series analysis of mean quarterly length of stay. All analyses exclusively used our hospital’s administrative discharge diagnoses database. During April 1st 2012 to December 14th 2014, the CIWA-Ar was used in the ED and in-patient units to guide benzodiazepine dosing decisions for alcohol withdrawal symptoms. After this point, CIWA-Ar was replaced with mRASS-AW. Data was evaluated until December 31st 2020. Primary outcome: mean quarterly length of stay. Secondary outcomes: delirium, intensive care unit (ICU) admission, other post-admission complications, mortality.
N = 1073 patients. No association between length of stay and scale switch (slope change 0.3 (95% CI − 0.03 to 0.6), intercept change, 0.06 (− 0.03 to 0.2). CIWA-Ar (n = 317) mean quarterly length of stay, 5.7 days (95% 4.2–7.1), mRASS-AW (n = 756) 5.0 days (95% CI 4.3–5.6). Incidence of delirium, ICU admission or mortality was not different. However, incidence of other post-admission complications was higher with CIWA-Ar (6.6%) than mRASS-AW (3.4%) (p = 0.020).
This was the first study to compare patient outcomes associated with using mRASS-AW for alcohol withdrawal symptoms outside the ICU. Replacing CIWA-Ar with mRASS-AW did not worsen length of stay or complications. These findings provide some evidence that mRASS-AW could be considered an alternative to CIWA-Ar and potentially may provide an opportunity to release nursing time to care.
Purpose/Background
People who smoke cigarettes and drink alcohol heavily are less likely to quit smoking compared with those who do not drink heavily. The current study examined the effects of a 12-week treatment phase of combination varenicline and nicotine patch compared with placebo and nicotine patch on smoking cessation (primary outcome) and alcohol consumption (secondary outcome) in heavy drinking smokers at 26-week follow-up.
Methods/Procedures
Participants were daily smokers who met heavy drinking criteria. They were randomly assigned to receive either varenicline and nicotine patch (n = 61) or placebo and nicotine patch (n = 61) for 12 weeks. At week 26, self-reports of point prevalence cigarette abstinence were biochemically confirmed, and past-month alcohol drinking days and heavy drinking days were assessed.
Findings/Results
At week 26, smoking quit rates did not differ by treatment group (25% varenicline and 26% placebo). Relative to week 12 outcomes, week 26 quit rates significantly dropped off in the varenicline group but not in the placebo group. Alcohol drinking reductions for the whole sample that were previously observed from baseline to week 12 were sustained at week 26, although they did not differ between treatment groups.
Implications/Conclusions
In heavy drinking smokers, smoking cessation success was evident in a quarter of the total sample at 3 months postmedication discontinuation. At this time, quit rates were the same between those who received varenicline and nicotine patch and those who received nicotine patch alone. Future research is warranted to examine what may aid in longer-term smoking quit rates in heavy drinking smokers.
Background
Detoxification stands as a crucial phase in the treatment of alcohol use disorders (AUD), yet only limited data is available on the outcomes of home-based detoxification. Assisted domiciliary detoxification involves monitoring an individual’s withdrawal progress, while offering psychosocial support and detoxification services in the comfort of their home.
Aim
To study outcomes of assisted over routine domiciliary alcohol detoxification in randomized controlled trials.
Methodology
100 consenting male patients who were advised of domiciliary detoxification were randomized into intervention ( n = 49) and control ( n = 51) groups. A predesigned semi-structured questionnaire was used to assess the socio-demographic and drinking-related variables. Both groups received routine care for alcohol withdrawal from respective treating doctors. Additionally, the intervention group received two sessions of brief intervention for alcohol and daily phone call assistance. Records were kept for adverse events. Phone calls were discontinued once detoxification was completed. Outcomes were measured for successful completion of detoxification and abstention from alcohol at the end of one month.
Results
The intervention group had significantly higher successful detoxification rates (85.7% vs. 62.7%, p = .008) and significantly higher abstinence days at the end of one month compared to the control group (22 vs. 10 days, p < .001) with an effect size of 1.2 (confidence interval (CI) 0.69–1.53).
Conclusion
This study demonstrates that receiving assistance in the acute phase of domiciliary detoxification helps in a successful detoxification and achieving a significant level of abstinence at the end of one month compared to the control group.
Aims:
This study aimed to compare reward, relief, and habit treatment-seeking individuals on recent drinking, alcohol use disorder (AUD) phenomenology, and mood. The second aim of the study was to evaluate the predictive validity of reward, relief, and habit profiles.
Method:
Treatment-seeking individuals with an AUD (n = 169) were recruited to participate in a medication trial for AUD (NCT03594435). Reward, relief, and habit drinking groups were assessed using the UCLA Reward Relief Habit Drinking Scale. Group differences at baseline were evaluated using univariate analyses of variance. A subset of participants were enrolled in a 12-week, double-blind, placebo-controlled medication trial (n = 102), and provided longitudinal drinking and phenomenology data. The predictive validity of group membership was assessed using linear regression analyses.
Results:
At baseline, individuals who drink primarily for relief had higher craving and negative mood than those who drink for reward and habit. Prospectively, membership in the relief drinking group predicted greater alcohol use, greater heavy drinking, and fewer days abstinent compared to those in the reward drinking group. Membership in the relief drinking group also predicted greater alcohol craving, more alcohol-related consequences, and more anxiety symptoms over 12 weeks compared to those in the reward drinking group.
Conclusions:
This study provides support for reward and relief drinking motive profiles in treatment-seeking individuals with an AUD. Membership in the relief drinking motive group was predictive of poorer drinking outcomes and more negative symptomology over 12 weeks, indicating that individuals who drink for relief may be a particularly vulnerable sub-population of individuals with AUD.
The importance of nonpharmacologic and pharmacologic interventions in the treatment of alcohol withdrawal is not known. A randomized, double-blind, placebo-controlled trial was conducted with 41 patients in alcohol withdrawal in an emergency department. The patients received either supportive care (10 min of standardized assessments, reassurance, reality orientation, and nursing care an hour) with three doses of sublingual lorazepam 2 mg every 2 hr (21 patients, drug group) or supportive care with three doses of sublingual placebo every 2 hr (20 patients, no-drug group). Immediately before each drug dose, the clinical course of alcohol withdrawal was assessed hourly by the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A). Interraters reliability in using CIWA-A was high. After each assessment, supportive care was given for 10 min before each dose. After completion of a 7-hr initial phase, patients were discharged and reassessed daily for 5 days. Thirty-seven patients (90.2%) improved in the initial phase. Treatment failures (CIWA-A greater than 10) were more common in the patients treated without drug (3/20, 15%) than in those treated with drug (1/21, 4.8%). Overall variations in intergroup CIWA-A scores during the initial phase were not significant. The rate of improvement of CIWA-A scores over the first 2 hr after drug was slightly faster in patients receiving lorazepam than in the control group. CIWA-A scores were the same during follow-up. These results indicate that most outpatients in mild to moderate alcohol withdrawal without medical complications improve without drug therapy in the emergency department setting.
Delirium tremens and related clinical states have been part of the human condition since antiquity (Zilboorg and Henry, 1941). However little was known and less was written about them until the end of the eighteenth century, when the diagnosis and treatment of this group of illnesses were delineated for the first time (Lettsom, 1787; Pearson, 1801, 1813; Sutton, 1813). This was followed by a series of confirmatory observations, some of which also contributed new data on prognostic factors (Armstrong, 1813; Klapp, 1817; Channing, 1819; Snowden, 1820; Hayward, 1822; Staughton, 1822; Coates, 1827; Wright, 1830; Carter, 1830; Jackson, 1830; Ware, 1838). The subsequent sustained proliferation of publications on these clinical states have increased our knowledge and attest to the continuing interest and importance of this field of study.
We conducted a randomized, double-blind clinical trial of atenolol as compared with placebo in the treatment of patients hospitalized with the alcohol withdrawal syndrome. In addition to receiving customary therapy, 61 patients were randomly assigned to receive atenolol, and 59 to receive placebo. Outcome was assessed daily by the measurement of nine features in three categories: vital signs, clinical signs (e.g., tremor), and behavioral signs (e.g., agitation and anxiety). Compared with placebo patients, atenolol patients had a significant reduction in the mean length of hospital stay (four as compared with five days, P less than 0.02). On each treatment day, significantly fewer patients receiving atenolol required concomitant benzodiazepines, and patients receiving placebo required a significantly higher mean daily dose of benzodiazepines. Among patients who had withdrawal symptoms at base line, vital signs became normal more rapidly in the patients receiving atenolol, and their abnormal behavior and clinical characteristics also resolved more rapidly. We conclude that atenolol is helpful in the treatment of patients with the alcohol withdrawal syndrome.
Alcohol withdrawal therapy can be simplified with a loading dose of diazepam, taking advantage of the kinetic tapering afforded by the drug's long t 1/2s and its metabolites, and of the effectiveness of nonpharmacologic maneuvers. In a double-blind trial, 50 inpatients in moderate to severe alcohol withdrawal received 20 mg oral diazepam and supportive care (n = 25) or placebo and supportive care (n = 25) every 2 hr until they were asymptomatic. Fifty-six percent of patients responded to placebo within 5 +/- 2.9 hr (mean +/- SD), whereas 72% responded to initial diazepam within 6.3 +/- 3.9 hr. Patients treated with diazepam had more rapid and greater improvement than those treated with placebo. Patients who did not respond to six doses of diazepam received further (unblinded) diazepam, 20 mg, every 1 to 2 hr. All patients who did not initially respond (n = 18) improved after more diazepam. Thus all patients who received diazepam (n = 36), during the experimental phase or subsequently, were effectively treated. There were no adverse effects. The median number of 20-mg diazepam doses to treat alcohol withdrawal were three, given over a period of 7.6 hr (range = 1 to 12 and 0.33 to 45 hr). Complications occurred only in those who received placebo during the experimental phase, indicating that delay in therapy may be responsible for the appearance of complications in alcohol withdrawal.
The relative roles of supportive care and pharmacotherapy in the treatment of alcohol withdrawal are not established. A reliable and validated withdrawal severity assessment scale (Clinical Institute Withdrawal Assessment for Alcohol, CIWA-A) was developed to assess initially and then follow the clinical course of 38 hospitalized chronic alcoholics requiring hospitalization for withdrawal but without serious concurrent medical or surgical problems. Supportive care, consisting of standardized half-hourly patient assessment (CIWA-A) and nursing care, was used as the initial treatment for all patients. Twenty-eight (74%) patients with clinical supportive care successes within 8 hours, 75% within 4 hours. Two responding patients subsequently developed evidence of withdrawal at 48 hours (hallucinations) and 72 hours (seizure). Ten patients (26%) did not respond to supportive care and required drug therapy in addition. Responders to supportive care drink more by history and have less severe liver disease than nonresponders. There are no other apparent predictors of the patients who require drug therapy. Three quarters of hospitalized patients, without serious medical complications, in alcohol withdrawal respond to intensive supportive care. However, pharmacotherapy is essential for nonresponders and patients with hallucinations.
Development of optimal alcohol withdrawal tremor./£££ rrawiacnons; 5id treatment tactics for alcohol withdrawal
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alcohol withdrawal tremor./£££ rrawiacnons; 5id
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