Overdose epidemic linked to the prescription of opioid analgesics in the United States. / Epidemia de sobredosis relacionada con la prescripción de analgésicos opioides en Estados Unidos.

Editorial.

Editorial.

Epidemia de sobredosis relacionada con la prescripción de analgésicos opioides en Estados Unidos / Overdose epidemic linked to the prescriptión of opioid analgesics in the United States

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Los Antagonistas de los Receptores Opioides en el Tratamiento del Alcoholismo / Opioid Receptor Antagonists in the Treatment of Alcoholism

Objetivos: A partir de los recientes progresos en la farmacoterapia del alcoholismo, hemos efectuado una revisión sobre los fármacos antagonistas de los receptores opioides, que tienen aprobada la indicación para el tratamiento del alcoholismo, como son naltrexona y nalmefeno. Metodología: Hemos revisado más de 100 publicaciones sobre péptidos y receptores opioides, el efecto de los fármacos antagonistas de los receptores opioides sobre el consumo de alcohol, tanto en animales como en humanos, tanto en el laboratorio como para el tratamiento del alcoholismo. También se describen las características farmacológicas de naltrexona y de nalmefeno y su utilidad en la práctica clínica. Resultados: Múltiples evidencias han demostrado la eficacia de naltrexona y nalmefeno para reducir el consumo de alcohol, tanto en animales de laboratorio como también en personas estudiadas en situación de bar experimental, aunque debido al diferente perfil receptorial, nalmefeno ha sido relacionado con una mayor eficacia para la reducción del consumo de alcohol, en ratas que presentan dependencia del alcohol. Además, un gran número de ensayos clínicos controlados han demostrado la eficacia de naltrexona para la prevención de recaídas, en personas que presentan un trastorno por dependencia del alcohol. Ensayos clínicos controlados recientes han demostrado la eficacia de nalmefeno "a demanda" para reducir el consumo de alcohol, en personas que presentan un trastorno por dependencia del alcohol de baja gravedad. Conclusiones: Tanto naltrexona como nalmefeno han demostrado ser fármacos seguros, bien tolerados, de manejo sencillo, y eficaces para el tratamiento del trastorno por dependencia del alcohol, (actualmente llamado trastorno por consumo de alcohol). A partir de recientes ensayos clínicos controlados se ha comprobado que nalmefeno produce una reducción significativa del consumo de alcohol, lo cual supone un nuevo objetivo que amplía las posibilidades de tratamiento para los pacientes que no desean la abstención continuada, sino una reducción de su consumo de alcohol

Objectives: On the basis of the recent advances in drug therapy of alcoholism, we conducted a review on opioid receptor antagonist drugs with approved indication for the treatment of alcoholism, such as naltrexone and nalmefene. Methods: We reviewed over 100 publications on peptides and opioid receptors, as well as studies conducted in experimental animals and in humans on the effect of opioid receptor antagonists on alcohol consumption in the treatment of alcoholism. We also reviewed the pharmacological characteristics of naltrexone and nalmefene, and the usefulness of these drugs in clinical practice. Results: Much evidence has demonstrated the efficacy of naltrexone and nalmefene for the reduction of alcohol consumption, in experimental animals as well as in humans examined under experimental bar conditions; however, due to its different receptor profile, nalmefene has been associated with higher efficacy levels in reducing alcohol consumption in alcohol-dependent rats. In addition, a great number of controlled clinical trials have demonstrated the efficacy of naltrexone for relapse prevention in patients with an alcohol dependence disorder. Recent controlled clinical trials have demonstrated the efficacy of nalmefene "as-needed" in the reduction of alcohol consumption in subjects with mild alcohol dependence. Conclusions: Both naltrexone and nalmefene have proved to be safe, well tolerated, easy to manage, and efficient drugs for the treatment of alcohol dependence disorder (currently known as alcohol use disorder). On the basis of recent controlled clinical trials, nalmefene has been shown to result in a significant reduction of alcohol consumption, thereby representing a new objective that extends the therapeutic possibilities for those patients who do not wish for a continuous abstinence, but rather a reduction of alcohol consumption

La reducción del consumo de alcohol. Un nuevo objetivo en el tratamiento del alcoholismo de baja gravedad / The reduction of alcohol consumption. A new treatment target for low severity alcoholism

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Cambio de paradigma en el tratamiento del alcoholismo de baja gravedad / A change of paradigm in the tretment of low-severity alcoholdependent patients

Introducción: Los avances en farmacoterapia del alcoholismo podrían propiciar un cambio de paradigma, basado en los nuevos programas de reducción del consumode alcohol. Material y Método: Este estudio revisa los fundamentos neurobiológicos y farmacoterapéuticos del alcoholismo, centrándose en los antagonistas opioides, el tratamiento orientado a la abstinencia y el orientado hacia la reducción del consumo de alcohol. Resultados: 1. Los programas de tratamiento de la dependencia del alcohol presentan sólo una eficacia pequeña o moderada.2. Los pacientes presentan una elevada motivación para reducir el consumo de alcohol pero una baja motivación para abandonar de manera continuada al consumo de alcohol.3. El programa de reducción continuada del consumo de alcohol, asociado a un tratamiento intermitente con naltrexona, puede ser de utilidad en los pacientes con una baja gravedad de la dependencia del alcohol. Discusión: Aunque los pacientes que presentan una grave dependencia del alcohol deberían ser tratados en programas orientados hacia la abstención continuada, los que presentan una baja gravedad pueden beneficiarse de los programas de reducción del consumo de alcohol, los cuales pueden conseguir a corto plazo una reducción el número de consumiciones por día de consumo y, a largo plazo, incluso una progresiva reducción de la “obsesión” por beber, la conducta de búsqueda de alcohol y los trastornos médicos, conductuales y sociales, causados por el consumo excesivo de alcohol. Para poder llevar a cabo este cambio de paradigma en el tratamiento del alcoholismo, se requieren futuros ensayos clínicos controlados para evaluar su eficacia y su tolerabilidad (AU)

Introduction: Recent pharmacotherapy findings from new alcohol reduction programmes could change the paradigm of alcohol-dependence treatment. Material and Method: This study reviews the neurobiological background and pharmacotherapy of alcohol-dependence disorder, focusing on opioid receptor antagonists, abstinence-oriented treatment and moderation-oriented treatment. Results: 1. Alcohol-dependence treatment programs show only low to moderate efficacy. 2. Patients usually show low motivation to sustain abstinence but high motivation to reduce alcohol use.3. A treatment program based on continued reduction of drinking and associated with intermittent treatment with naltrexone can be useful for low-severity alcohol-dependent patients. Discussion: Although high severity alcohol-dependent patients should stop drinking alcohol, low severity patients may have the option of reducing their alcohol consumption if they take an opioid antagonist medication everyday that they decide to drink alcohol. In the short term, the continuing drinking-reduction programmes may reduce the number of drinks per drinking day and in the long term, they may progressively decrease the obsession for drinking, alcohol seeking behavior, and related medical, behavioral and social disorders. To change the paradigm in the treatment of alcohol–dependence disorder there is a need for further randomized controlled trials in order to assess their efficacy and tolerability (AU)

[Multidimensional alcohol craving scale and [123I] iodobenzamide SPECT as predictors of early relapse in alcohol-dependent patients]. / La Escala Multidimensional de Craving de Alcohol y el SPECT con yodobenzamida[I123] como predictores de recaída precoz en pacientes que presentan dependencia del alcohol.

BACKGROUND: The Multidimensional Alcohol Craving Scale (MACS) and Single Photon Emission Computerized Tomography (SPECT) with (123)I-iodobenzamide ((123)I-IBZM) can be useful tools for assessing relapse risk in early recovery from alcohol-dependency. The aim of this study was to assess possible relationships between MACS score, (123)I-IBZM binding and time to first heavy drinking day (TFHD) after detoxification treatment. METHODS: Nineteen alcohol-dependent in-patients were evaluated by MACS scale and an 123I-IBZM-SPECT, performed following alcohol detoxification treatment. At discharge, participants were advised to take naltrexone 50 mg/day for relapse prevention. TFHD was assessed over a 12-week follow up. RESULTS: The MACS score at the beginning of the detoxification process and naltrexone treatment after detoxification were independent predictive factors for TFHD. CONCLUSIONS: The MACS scale is a better predictor of TFHD than IBZM binding. It is simple, non-invasive and inexpensive and appears to be a useful instrument both for clinical practice and for research.

La Escala Multidimensional de Craving de Alcohol y el SPECT con yodobenzamida[I123] como predictores de recaída precoz en pacientes que presentan dependencia del alcohol / Multidimensional alcohol craving scale and [123I] lodobenzamide SPECT as predictors of early relapse in alcohol-dependent patients

Objetivos: La Escala Multidimensional de Craving de Alcohol (EMCA) yla Tomografía Computarizada por emisión de Fotón Simple (SPECT) con123I-yodobenzamida (IBZM) pueden ser instrumentos válidos para evaluar el riesgo de recaída, durante la etapa inicial de la recuperación del trastorno por dependencia del alcohol. El objetivo de este estudio es evaluarlas posibles relaciones entre la escala EMCA y la captación de IBZM y el tiempo hasta el primer consumo excesivo de alcohol (TPCEA) una vez finalizado el tratamiento de desintoxicación. Metodología: Diecinueve pacientes hospitalizados han sido evaluados mediante la escala EMCA y la SPECT con IBZM al finalizar el tratamiento de desintoxicación del alcohol. En el momento del alta se les aconsejó seguir un tratamiento con naltrexona 50 mg/día para la prevención de recaídas. El TPCEA ha sido evaluado durante 12 semanas de seguimiento. Resultados: La puntuación de la escala EMCA, al inicio del proceso de desintoxicación, y el seguimiento de un tratamiento con naltrexona, posteriormente a dicho proceso, fueron factores predictivos independientes del TPCEA. Conclusiones: La escala EMCA se ha mostrado como un buen predictor del TPCEA mientras que la captación de IBZM parece no serlo. La escala EMCA parece presentar una mayor utilidad, tanto clínica como para la investigación, frente a evaluaciones más complejas, invasivas y costosas (AU)

Background: The Multidimensional Alcohol Craving Scale (MACS) and Single Photon Emission Computerized Tomography (SPECT) with 123I-iodobenzamide (123I-IBZM) can be useful tools for assessing relapse risk in early recovery from alcohol-dependency. The aim of this study was to assess possible relationships between MACS score, 123I-IBZM binding and time to first heavy drinking day (TFHD) after detoxification treatment. Methods: Nineteen alcohol-dependent in-patients were evaluated by MACS scale and an 123I-IBZM-SPECT, performed following alcohol detoxification treatment. At discharge, participants were advised to take naltrexone 50 mg/day for relapse prevention. TFHD was assessed over a 12-week follow up. Results: The MACS score at the beginning of the detoxification process and naltrexone treatment after detoxification were independent predictive factors for TFHD. Conclusions: The MACS scale is a better predictor of TFHD than IBZM binding. It is simple, non-invasive and inexpensive and appears to be a useful instrument both for clinical practice and for research (AU)

A change of paradigm in the treatment of low-severity alcohol-dependent patients.

UNLABELLED: Introduction Recent pharmacotherapy findings from new alcohol reduction programmes could change the paradigm of alcohol-dependence treatment. MATERIAL AND METHOD: This study reviews the neurobiological background and pharmacotherapy of alcohol-dependence disorder, focusing on opioid receptor antagonists, abstinence-oriented treatment and moderation-oriented treatment. RESULTS: 1. Alcohol-dependence treatment programs show only low to moderate efficacy. 2. Patients usually show low motivation to sustain abstinence but high motivation to reduce alcohol use. 3. A treatment program based on continued reduction of drinking and associated with intermittent treatment with naltrexone can be useful for low-severity alcohol-dependent patients. DISCUSSION: Although high severity alcohol-dependent patients should stop drinking alcohol, low severity patients may have the option of reducing their alcohol consumption if they take an opioid antagonist medication every day that they decide to drink alcohol. In the short term, the continuing drinking-reduction programmes may reduce the number of drinks per drinking day and in the long term, they may progressively decrease the obsession for drinking, alcohol seeking behavior, and related medical, behavioral and social disorders. To change the paradigm in the treatment of alcohol-dependence disorder there is a need for further randomized controlled trials in order to assess their efficacy and tolerability.

Is alcohol really good for health?

Several observational follow-up studies about cardiovascular health have found an overlap between moderate drinking and lower mortality from coronary heart disease and other causes. However, such studies have serious methodological limitations. Most non-drinkers were in fact ex-drinkers, that is, people who had had to stop drinking for health reasons. Other variables that may play a decisive role in cardiovascular risk, such as tobacco smoking, exercise and body mass index, were not evaluated, and changes in drinking habits were not assessed periodically. Due to the methodological limitations of these studies, the findings suggest a statistical association but not a causality relationship between moderate alcohol consumption and lower risk of mortality. Furthermore, numerous studies have shown that excessive drinking can cause not only cardiovascular diseases--such as hypertension, arrhythmias, dilated cardiomyopathy and stroke--but also other medical and psychiatric disorders. Alcohol clearly has addictive properties that can contribute to the development of heavy drinking in some people, leading to alcohol-related physical and mental disorders. The public health message should emphasize the potential risk of heavy drinking rather than promote the possible benefits of moderate consumption. A simplistic message that alcohol is good for cardiovascular health may be prejudicial when stated outside the context of the possible adverse consequences of heavy drinking.

¿Es bueno el alcohol para la salud? / Is alcohol really good for health?

Algunos estudios observacionales de seguimiento sobre salud cardiovascular han encontrado una coincidencia entre el consumo moderado de alcohol y una menor mortalidad prematura, debida a un infarto de miocardio o a otras causas. Dichos estudios cuentan con importantes limitaciones metodológicas. La mayoría de personas que pertenecían al grupo de abstemios, en realidad eran ex-bebedores, es decir, personas que habían tenido que dejar de beber alcohol debido a que sufrían alguna enfermedad. Además, no se han evaluado otras variables que influyen decisivamente sobre el riesgo cardiovascular como el tabaquismo, el ejercicio físico, el índicede masa corporal y otras; ni tampoco los posibles cambios de los hábitos de consumo de alcohol con el paso de los años. Por lo tanto, las limitaciones del diseño metodológico de dichos estudios sólo permiten hablar de una “asociación”estadística pero no postular supuestas relaciones de causalidad. Además, existen innumerables estudios que han comprobado reiteradamente que el consumo excesivo de alcohol puede causar diversas enfermedades cardiovasculares (hipertensiónarterial, arritmias, cardiomiopatía, hemorragia cerebral) y todo tipo de enfermedades médicas y trastornos neuropsiquiátricos. Por otro lado, el alcohol tiene propiedades adictivas que pueden contribuir a que determinadas personas desarrollen involuntariamente un consumo excesivo de alcohol. El mensaje a la población debería enfatizar por tanto el daño potencial del consumo excesivo de alcohol en lugar centrarse en algún posible beneficio del su consumo moderado. El mensaje simplista de que el alcohol puede ser bueno para la salud cardiovascular, se convierte en engañoso cuando se descontextualiza del elevado número de enfermedades que puede causar

Several observational follow-up studies about cardiovascular health have found an overlap between moderate drinking and lower mortality from coronary heart disease and other causes. However, such studies have serious methodological limitations. Most non-drinkers were in factex-drinkers, that is, people who had had to stop drinking for health reasons. Other variables that may play a decisive rolein cardiovascular risk, such as tobacco smoking, exercise and body mass index, were not evaluated, and changes in drinking habits were not assessed periodically. Due to the methodological limitations of these studies, the findings suggest a statistical association but not acausality relationship between moderate alcohol consumption and lower risk of mortality. Furthermore, numerous studies have shown that excessive drinking can cause not only cardiovascular diseases - such as hypertension, arrhythmias, dilated cardiomiopathy and stroke - but also other medical andpsychiatric disorders. Alcohol clearly has addictive properties that can contribute to the development of heavy drinking insome people, leading to alcohol-related physical and mental disorders. The public health message should emphasize the potential risk of heavy drinking rather than promote the possible benefits of moderate consumption. A simplistic message that alcohol is good for cardiovascular health maybe prejudicial when stated outside the context of the possible adverse consequences of heavy drinking

Utilidad de la Escala Multidimensional de Craving de Alcohol (EMCA) en la práctica clínica / Utility of the Multidimensional Alcohol Craving Scale (MACS) in the clinical practice

Introducción: El craving es un síntoma central de las conductas adictivas cuya intensidad suele relacionarse con la evolución del paciente. La escala EMCA ha demostrado ser un instrumento válido y fiable para su evaluación. El objetivo es analizar la utilidad de la escala en la evaluación de la eficacia y en la mejora de la planificación del tratamiento del alcoholismo. Pacientes y método: Con una muestra de 151 pacientes con trastorno por dependencia de alcohol, se estudió la relación de la escala EMCA con la intensidad de la dependencia, la comorbilidad psiquiátrica y adictiva y con otras escalas utilizadas en la evaluación del alcoholismo. Finalmente, se evaluó la sensibilidad de la escala para detectar cambios en la evolución de los pacientes en un estudio de seguimiento a seis meses. Resultados: La EMCA discrimina entre el nivel grave de intensidad de la dependencia y los niveles moderado (p<0,001) y leve (p<0,001), así como entre pacientes con y sin comorbilidad adictiva (p=0,011). El factor “deseo de beber” de la EMCA discrimina entre pacientes con y sin comorbilidad psiquiátrica (p=0,041). La EMCA muestra una buena sensibilidad al cambio en el consumo de alcohol a lo largo del seguimiento. Conclusiones: La intensidad del craving parece estar modulada por la intensidad de la dependencia del alcohol y la comorbilidad psiquiátrica y adictiva. La EMCA ha demostrado ser sensible a los cambios en la evolución del curso de los pacientes alcohólicos, y por tanto, ser útil en la planificación y la evaluación de los resultados del tratamiento del alcoholismo

Introduction: Craving is a central symptom of addictive behaviors. Craving levels are usually related to patient’s evolution. The MACS scale has prove a valid and reliable instrument to assess this symptom. The aim of this study is to test the usefulness of MACS to assess the efficacy of treatment and to improve the alcoholism treatment planning. Patients and Method: A sample of 151 alcohol-dependence patients has been used to study the relationship between the MACS scale and dependence severity, psychiatric and addictive comorbidity and other alcoholism scales. Furthermore, the sensitivity of MACS to detect changes in patient’s evolution during a six months follow-up study has been assessed. Results: The MACS discriminate between the severe level of dependence severity and moderate (p<0.001) and slight levels (p<0.0001), as well as between patients with and without addictive comorbidity. The “desire to drink” factor of the MACS discriminate between patients with and without psychiatric comorbidity (p=0.041). The MACS show a good sensitivity to detect changes in alcohol consumption during the follow-up study. Conclusions: The craving severity seems to be modulated by the alcohol-dependence severity and psychiatric and addictive comorbidity. The MACS is sensitive to the changes that happen during the recovery process of alcoholism. Therefore it can be a useful instrument for alcoholism treatment planning and outcome treatment assessment