Potential medications for the treatment of alcohol use disorder: An evaluation of clinical efficacy and safety.

Alcohol use disorder (AUD), as currently defined in the Diagnostic and Statistical Manual, 5th Edition (DSM-5), is a heterogeneous disorder stemming from a complex interaction of neurobiological, genetic, and environmental factors. As a result of this heterogeneity, there is no one treatment for AUD that will work for everyone. During the past 2 decades, efforts have been made to develop a menu of medications to give patients and clinicians more choices when seeking a therapy that is both effective and which has limited side effects. To date, 3 medications have been approved by the US Food and Drug Administration (FDA) to treat alcohol dependence: disulfiram, naltrexone, and acamprosate. In addition to these approved medications, researchers have identified new therapeutic targets and, as a result, a number of alternative medications are now being evaluated for treatment of AUD in human studies. Although not approved by the FDA for the treatment of AUD, in some cases, these alternative medications are being used off-label by clinicians for this purpose. These potential medications are reviewed here. They include nalmefene, varenicline, gabapentin, topiramate, zonisamide, baclofen, ondansetron, levetiracetam, quetiapine, aripiprazole, and serotonin reuptake inhibitors. The effectiveness of these medications has been mixed-some show good efficacy with side effects that are mild to moderate in intensity; others have mixed or promising results but are awaiting findings from ongoing studies; and still others show poor efficacy, despite promising preliminary results. Medications development remains a high priority. Key initiatives for the National Institute on Alcohol Abuse and Alcoholism (NIAAA) include supporting the discovery and development of more effective and safer medications, advancing the field of personalized medicine, and forging public and private partnerships to investigate new and more effective compounds.

Characteristics and motives of college students who engage in nonmedical use of methylphenidate.

Methylphenidate (MPH) has a long history of being an effective medication for attention deficit/hyperactivity disorder (ADHD). Recently, the nonmedical use of MPH has increased, particularly among college students. To investigate this, we surveyed 2,087 students regarding MPH misuse. Of 2,087 respondents, 110 (5.3%) used MPH nonmedically at least once. Most obtained MPH free from a friend, acquaintance, or family member. Misuse of Ritalin(R) occurred four times more frequently than Concerta. Among Ritalin abusers, Intranasal use was reported more often than oral. Students reported using MPH nonmedically for recreational reasons as well as to improve academic performance.

Encouraging physicians to screen for and intervene in substance use disorders: obstacles and strategies for change.

The scientific literature was reviewed to identify obstacles and effective ways to improve primary care physician screening, interventions, and management of patient substance use disorders (SUDs). Major obstacles identified are physician lack of skills and self-efficacy in patient counseling, inadequate training at all levels of medical education, and lack of reimbursement and other health care systems support for services to patients. Physician abuse of drugs does not appear to be a major obstacle. Physician attitudes about patients with SUDS and the effectiveness of treatment services need to be addressed. Research points to the use of a multifaceted change strategy. Key components include practice-based training emphasizing screening and counseling skills throughout medical education, clinical systems to ensure regular SUD services (screening, intervention, and referral) to patients, and reimbursement and coverage systems to support physician interventions and patient services.

Uniform standards and case definitions for classifying opioid-related deaths: recommendations by a SAMHSA consensus panel.

Deaths involving prescription and illicit opioids are on the rise, which is an issue of increasing concern to health care professionals, policymakers, and the public. However, because medical examiners, coroners, and other practitioners do not use uniform standards and case definitions in classifying such drug-related deaths, the incidence and prevalence data are challenging to analyze and difficult to interpret, and thus form a poor basis for crafting effective responses. To address this situation, the Substance Abuse and Mental Health Services Administration convened a Consensus Panel and charged it with devising uniform standards and case definitions that can assist medical examiners, coroners, public health officials, and others in consistently distinguishing between deaths that were caused by a certain opioids and deaths in which such a drug was detected but was not a major cause of or contributor to the death. The consensus statement presented here incorporates the panel's recommendations in four key areas.

Safe methadone induction and stabilization: report of an expert panel.

OBJECTIVES: Methadone is a well-studied, safe, and effective medication when dispensed and consumed properly. However, a number of studies have identified elevated rates of overdose and death in patients being treated with methadone for either addiction or chronic pain. Among patients being treated with methadone in federally certified opioid treatment programs, deaths most often occur during the induction and stabilization phases of treatment. To address this issue, the federal Substance Abuse and Mental Health Services Administration invited the American Society of Addiction Medicine to convene an expert panel to develop a consensus statement on methadone induction and stabilization, with recommendations to reduce the risk of patient overdose or death related to methadone maintenance treatment of addiction. METHODS: A comprehensive literature search of English-language publications (1979-2011) was conducted via MEDLINE and EMBASE. Methadone Action Group members evaluated the resulting information and collaborated in formulating the consensus statement presented here, which subsequently was reviewed by more than 100 experts in the field. RESULTS: Published data indicate that deaths during methadone induction occur because the initial dose is too high, the dose is increased too rapidly, or the prescribed methadone interacts with another drug. Therefore, the Methadone Action Group has developed recommendations to help methadone providers avoid or minimize these risks. CONCLUSIONS: Careful management of methadone induction and stabilization, coupled with patient education and increased clinical vigilance, can save lives in this vulnerable patient population.

QT interval screening in methadone maintenance treatment: report of a SAMHSA expert panel.

In an effort to enhance patient safety in opioid treatment programs, the Substance Abuse and Mental Health Saervices Administration convened a multi-disciplinary Expert Panel on the Cardiac Effects of Methadone. Panel members (Appendix A) reviewed the literature, regulatory actions, professional guidances, and opioid treatment program experiences regarding adverse cardiac events associated with methadone. The Panel concluded that, to the extent possible, every opioid treatment program should have a universal Cardiac Risk Management Plan (incorporating clinical assessment, electrocardiogram assessment, risk stratification, and prevention of drug interactions) for all patients and should strongly consider patient-specific risk minimization strategies (such as careful patient monitoring, obtaining electrocardiograms as indicated by a particular patient's risk profile, and adjusting the methadone dose as needed) for patients with identified risk factors for adverse cardiac events. The Panel also suggested specific modifications to informed consent documents, patient education, staff education, and methadone protocols.

Diversion of buprenorphine/naloxone coformulated tablets in a region with high prescribing prevalence.

The purpose of this article was to characterize practices of buprenorphine/naloxone (B/N) diversion in a region with a high prescribing prevalence. A cross-sectional, open-ended survey was administered to individuals entering opioid addiction treatment programs in two New England states. The authors obtained formative information about the knowledge, attitudes, beliefs, practices, and street economy of B/N diversion. The authors interviewed 51 individuals, 49 of which were aware of B/N medication. Of that number, 100% had diverted B/N to modulate opiate withdrawal symptoms arising from attempted "self-detoxification," insufficient funds to purchase preferred illicit opioids, or inability to find a preferred source of drugs. Thirty of 49 (61%) participants obtained the illicit drug from an individual holding a legitimate prescription for B/N. A high proportion of individuals in the study locations who sought treatment for opioid addiction self-reported the purchase and use of diverted B/N. The diversion of B/N may be minimized by modifying educational, treatment, monitoring, and dispensing practices.

School-based administration of ADHD drugs decline, along with diversion, theft, and misuse.

Since 2000 researchers have reported a decline in the administration of attention-deficit/hyperactivity disorder (ADHD) medications given by school nurses, although no decline has been noted in the incidence of ADHD in school-age populations. Government data for the same period show reduced levels of methylphenidate abuse as measured by its involvement in hospital emergency department (ED) admissions. Offsetting this, however, is an increase in the involvement of amphetamine-dextroamphetamine in hospital ED admissions for the same period. Because ADHD medications are often administered in the school setting, a survey of school nurses was undertaken to identify factors related to the administration as well as to the diversion, theft, and misuse of ADHD medications. Of 311 school nurses responding, 295 (95%) reported a significant or moderate decline between 2002 and 2004 in the need for school-based administration of ADHD medications. Respondents also reported reductions in diversion, theft, and misuse of ADHD drugs.