Medication Treatment of Different Types of Alcoholism
Abstract
Alcoholism remains a serious cause of morbidity and mortality despite progress through neurobiological research in identifying new pharmacological strategies for its treatment. Drugs that affect neural pathways that modulate the activity of the cortico-mesolimbic dopamine system have been shown to alter drinking behavior, presumably because this dopaminergic system is closely associated with rewarding behavior. Ondansetron, naltrexone, topiramate, and baclofen are examples. Subtyping alcoholism in adults into an early-onset type, with chronic symptoms and a strong biological predisposition to the disease, and a late-onset type, typically brought on by psychosocial triggers and associated with mood symptoms, may help in the selection of optimal therapy. Emerging adults with binge drinking patterns also might be aided by selective treatments. Although preliminary work on the pharmacogenetics of alcoholism and its treatment has been promising, the assignment to treatment still depends on clinical assessment. Brief behavioral interventions that encourage the patient to set goals for a reduction in heavy drinking or abstinence also are part of optimal therapy.
(Reprinted with permission from Am J Psychiatry 2010; 167:630–639)
Alcohol dependence in the United States ranks third on the list of preventable causes of morbidity and mortality (1). In 2000, there were 20,687 alcohol-related deaths in the United States, excluding accidents and homicides, costing the nation about $185 billion (1).
Alcohol dependence often follows a chronic, relapsing course (2) similar to other medical disorders, such as diabetes. Despite its psychological and social antecedents, alcohol dependence, once established, is essentially a brain disorder. Without a pharmacological adjunct to psychosocial therapy, the clinical outcome is poor, with up to 70% of patients resuming drinking within 1 year (3, 4). Thus, psychosocial intervention alone is not optimal treatment for alcohol dependence. Furthermore, it appears that brief interventions (e.g., brief behavioral compliance enhancement treatment [5] or medical management [6]) are sufficient to optimize an efficacious pharmacological treatment, and there is no need for more formal or intensive psychotherapy. Indeed, intensive psychotherapy has been shown to be less effective than a brief intervention plus a placebo pill for the treatment of alcohol dependence (7). Hence, there is no longer a clinical rationale to delay starting pharmacotherapy, which can be provided with a brief psychosocial intervention in general practice.
SUBTYPES OF ALCOHOLISM
Alcohol dependence is a heterogeneous disorder. Many authorities agree that there are different subtypes of alcoholism, although this is not encapsulated within DSM-IV-TR (8). As adapted from Cloninger's classification scheme (9), there are at least two different subtypes of alcoholism. Type B-like or early-onset alcoholism is characterized by high familial loading, a broad range of impulse-dyscontrol traits, and an early onset (before age 25) of problem drinking (see case 1). In contrast, type A-like or late-onset alcoholism is characterized by a later age at onset of problem drinking (typically age 25 or older), a preponderance of psychosocial morbidity, and low familial loading for alcoholism (see case 2). While several complicated, theoretical, and retrospective constructs have been used to delineate alcoholism subtypes (10–12), it appears that a single question—“At what age did drinking become a problem for you?” (13)—can be applied in clinical practice to distinguish subtypes of alcoholism. The subtype can determine the choice of pharmacotherapy (14), as discussed below; however, subtype classification of alcoholism remains somewhat controversial. For example, some researchers have proposed more elaborate classification schemes, with up to four subtypes that might respond differentially to particular therapeutic agents (15, 16). In the future, more contemporary and accurate alcoholism subtype classification schemes that predominantly employ molecular genetic markers, with or without additional epidemiological or psychosocial determinants, may be more predictive of drinking outcomes and therapeutic response to medications (14).
HAZARDOUS DRINKING IN EMERGING ADULTS
Alcohol use in emerging adulthood is prevalent (17), and much of the drinking occurring during this period could be categorized as hazardous (see case 3). Binge drinking remains frequent among college students despite increased prevention efforts over the past decade (18, 19). Indeed, 40% of college students have binged in the previous 2 weeks, according to the College Alcohol Study surveys (19).
Although college-age binge drinking is often viewed as a rite of passage in the transition to adulthood, hazardous drinking in emerging adults is associated with serious consequences. Approximately 1,500 to 1,700 deaths and 600,000 injuries, including 200,000 serious injuries, occur in the United States each year among college students (20, 21). The range of health risks and psychosocial consequences due to hazardous drinking among emerging adults includes motor vehicle accidents, legal problems, personal injuries, date rape and other types of violence, unwanted or unprotected sex, sexually transmitted diseases, pregnancy, blackouts, and missed classes (22, 23). Indeed, rates of these problems are high. In 2001, nearly 700,000 students 18 to 24 years of age were assaulted by another college student who had been drinking (21). Over 400,000 students had unprotected sex, and 100,000 reported being too intoxicated to know whether or not they had consented to sex (21). Short-term problems associated with drug and alcohol use in emerging adulthood include violence, depression, and unprotected sex (19, 24). The risk for sexually transmitted diseases as a result of multiple sex partners and unprotected sex is elevated during periods such as spring break, when casual sex, impulsivity, and reduced availability of condoms are compounded with increased use of, or bingeing on, alcohol or drugs (25). One-fourth of college students report drinking-related academic problems, such as missing classes, falling behind, performing poorly on examinations and papers, and getting lower grades (19, 26, 27). Alcohol-related consequences are more likely among students classified as hazardous drinkers than among those classified as nonhazardous drinkers (28).
Severe or binge drinking may have long-term negative health consequences, even among those who avoid injuries. Those who drink severely or binge drink between the ages of 18 and 24 are more likely to progress to alcohol abuse or dependence diagnoses (29, 30). Despite being at particularly high risk, college students do not differ from non-college students in rate of meeting criteria for alcohol dependence, although results are mixed on whether the two groups differ in alcohol abuse rates (31, 32). Because episodic severe or binge drinking and alcohol use disorders are common among all emerging adults, research on college students generalizes well to other emerging adults. However, their residence status is related to risk for diagnosis, with more alcohol abuse and less alcohol dependence occurring among students living off campus (31).
Among college students, 31% in one large study met diagnostic criteria for alcohol abuse and 6% for alcohol dependence (33). Emerging adults evidencing an alcohol use disorder generally have associated problems, such as alcohol-related blackouts and increased craving for alcohol (34). The long-term effects can be serious, as severe or binge drinking during college can predict rates of alcohol use disorders up to 10 years later (35, 36).
Three different types of alcoholism
Case 1: Chronic alcoholismA 55-year-old schoolteacher visited his family practitioner complaining of headaches that start soon after awaking at about 4:00 a.m., usually at the beginning of the week. The headaches, which have been getting worse over the past year, have a moderately intense dull and aching quality and are typically located in the back of the patient's head, but the patient is not sure. They are relieved about 1 hour after breakfast, which consists of cereal, and occasionally by taking 1000 mg of acetaminophen.Medical history revealed that the patient's father had the reputation of a “man who could hold his drink” but died in a hunting accident at age 50. The patient reported that he has been married three times, at ages 19, 22, and 25. None of his marriages lasted more than 2 years, and he said that his ex-wives became “controlling and difficult” about his lifestyle.Further inquiry about the patient's lifestyle revealed that he likes to hang out with his buddies on the weekends, starting from happy hour after payday on Thursday. These drinking habits have persisted since he left high school. The patient did not recall exactly how much alcohol he drank but believed that it was “definitely” more than two six-packs each day from Thursday to Sunday. He reported being able to “hold his drink” like his father and denied getting drunk. Indeed, he boasted that he has had no problems driving himself home, although he received a citation for driving while intoxicated about a year ago, a charge that was dismissed on a legal technicality. The patient did not recall the age at which he started to consume alcohol. He denied using any illicit drugs and became angry when asked about this.On physical examination, the patient was obese (body mass index, 29) and hypertensive (blood pressure, 150/100 mm Hg), and his biochemical analysis revealed elevated liver enzymes (alanine aminotransferase, 99 U/liter, aspartate aminotransferase, 80 U/liter, and γ-glutamyltransferase, 210 U/ liter), albumin (28 g/liter), and cholesterol (221 mg/dl).
Case 2: Late-life alcoholismA 66-year-old single retired teacher presented to her family practitioner because she often feels “gloomy.” The patient reported that there was no clear pattern to her gloominess but that watching the news about the financial crisis over the past 2 years had not helped. Indeed, the patient explained that the financial crisis had caused her to lose most of her pension and that she was now considering a return to some kind of work. She was pessimistic about her work prospects. “who would hire me at this age?” she asked. She reported that lately she had been drinking more and now needed a “nightcap” as well as a morning “pick-me-up” to feel like herself. These drinks consisted of two large Bloody Marys. With lunch and dinner, she also usually had two to three glasses of red wine. However, the patient said, “I am not an alcoholic; I have never gotten into any trouble.” She did, however, look forward to her drinks, which she called “comforters,” and said that these are the first items on her shopping list. The patient reported that over the past 6 months, she has tended to drink more to feel “nice” and had occasional headaches in the morning, which she attributed to “getting old.”Further inquiry about the patient's lifestyle revealed that she had few friends and lived in a small retirement community. The patient's sleep was disturbed by awaking early—at about 4:00 a.m.—with difficulty returning to sleep. Her reported energy level was appropriate for her age. Her appetite had lessened over the past month, but her weight had remained unchanged.
Case 3: Alcoholism in collegeA 21-year-old college student was seen in the emergency department after falling off his bicycle. The patient had suffered some minor abrasions to his forearm and bruising to his head. A skull X-ray revealed an old calcified linear fracture that had healed, from a previous fall about 4 months earlier.The emergency physician elicited from the patient that he had frequent episodes of falling off his bike, usually in the early evening or late at night. When questioned about his drinking, the patient replied that he is the “usual” college kid and only drinks on weekends with friends from his fraternity. The patient did not recall how much alcohol he consumed over the weekend—“perhaps a few kegs between me and three friends”—but admitted that getting up for classes on Monday was “a drag” and that he often only makes his afternoon classes. He said that sometimes a little drink in the morning helps to “calm the nerves.” The patient also reported that he always looks forward to spring break as he has “the time of his life”—the only time when girls “do not even care about using condoms.” The patient started to drink when he was 16 years old, having been “initiated” by an uncle. He said that over the past year he has been better able to keep up with his friends to “feel good,” but he still consumed less than his friends did. While the patient denied that drinking was a problem, he admitted that his mother and an older brother had attended Alcoholics Anonymous meetings “just to see what happened there.” He also reported that he sometimes shares a joint of marijuana with his friends but does not use any other illicit drugs.
ALCOHOL DEPENDENCE AND DEPRESSION
“Alcohol dependence is treatable, and the use of efficacious pharmacotherapies has opened up the potential of office-based treatment by nonspecialists.”
Data on 43,000 adults from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (37) indicated that the rate of alcohol use disorders was 14% among those with a 12-month history of major depressive disorder and 40% among those with a lifetime history (38). The NESARC data also showed that among those with major depression, the odds ratio for alcohol dependence ranges from 1.3 to 2.1 (38); higher ratios, however, ranging from 4 to 7, have been reported by others (39, 40), suggesting some shared genetic linkages (41). Older women who live alone may be particularly prone to alcohol misuse and depression resulting from loneliness (see case 2) (42). Depressive symptoms also occur frequently among those with alcohol dependence, especially during withdrawal, when insomnia, anxiety, and dysphoric mood (43) can complicate the course of the illness (44). Therefore, all practitioners, when presented with an alcohol-dependent patient, should routinely examine for depressive symptoms, including suicidal ideation.
NEUROBIOLOGY OF ALCOHOL DEPENDENCE
New pharmacological treatments target modulation of the cortico-mesolimbic dopamine system, a network that governs alcohol's reinforcing effects, which are associated with its abuse liability (45). As shown in Figure 1, several neurotransmitter systems interact and modulate the cortico-mesolimbic dopamine system (46). The expression of the reinforcing effects of alcohol is a summation of neurotransmitter systems involved with drive, mood, and cognition. Interestingly, the more promising agents for the reduction of heavy drinking or the prevention of relapse to heavy drinking appear to be those that modulate the cortico-mesolimbic dopamine system through the opioid, glutamate, γ-aminobutyric acid (GABA), or serotonin (5-HT) systems. Indeed, because of counterregulatory neuroadaptation, agents that block cortico-mesolimbic dopamine system neurons directly typically lack therapeutic efficacy and might even provoke an increase in alcohol consumption (47). In recent years, research has improved our understanding of how stress-related neurotransmitters (e.g., corticotropin-releasing factor) in the hypothalamic-pituitary-adrenal axis, as well as neuroregulators and neuropeptides (e.g., hypocretin, vasopressin, and neuropeptide Y) in the external amygdala, modulate the reinforcing effects of alcohol and other drugs of abuse (48). Medications that target these antistress pathways, which go beyond the corticomesolimbic theory and have been coined romantically as the “dark side” of addiction, are being explored as putative therapeutic agents to decrease or prevent relapse.
Figure 1. Neuronal Pathways Involved With the Reinforcing Effects of Alcohol and Other Drugs of Abusea
a
Cholinergic inputs arising from the caudal part of the pedunculopontine tegmental nucleus (PPTg) and laterodorsal tegmental nucleus (LDTg) can stimulate ventral tegmental area dopamine neurons. The ventral tegmental area dopamine neuron projection to the nucleus accumbens and cortex, the critical substrate for the reinforcing effects of drugs of abuse (including alcohol), is modulated by a variety of inhibitory (γ-aminobutyric acid [GABA] and opioid) and excitatory (nicotinic [NIC-R], glutamate [GLU], and cannabinoid-1 receptor [CB1-R]) inputs. The glutamate pathways include those that express α-amino-3-hydroxy-5-methylisoxazole-4-propionate (AMPA), kainate, and N-methyl-d-aspartate (NMDA) receptors. Serotonin-3 receptors (5-HT3-R) also modulate dopamine release in the nucleus accumbens. The glycine system, orexins, and corticotropin-releasing factor also are shown. CRF-R1, CRF-R2 = corticotropin-releasing factor receptors 1 and 2; DRD1, DRD2, DRD3 = dopamine receptors D1, D2, and D3; GlyR = glycine receptor; LH/PFA = perifornical region of the lateral hypothalamus; OXR1, OXR2 = orexin receptor types 1 and 2; PVN = paraventricular nucleus. Adapted and embellished from Johnson (46) (copyright © 2006 American Medical Association; all rights reserved).
EVALUATING AND TREATING ALCOHOLISM
Taking an alcohol history
The National Institute on Alcohol Abuse and Alcoholism Clinician's Guide (49) recommends that a first step in identifying at-risk drinking, alcohol abuse, or alcohol dependence is for the practitioner to screen patients effectively in general health settings, including in emergency departments, during hospital visits, and in outpatient or community clinics. All patients presenting for medical care should be asked the screening question “Do you sometimes drink beer, wine, or other alcoholic beverages?” If the answer to that question is “yes,” a 5-minute screening questionnaire, the Alcohol Use Disorders Identification Test (AUDIT) (50), should be administered. An AUDIT score <8 for men and <4 for women should be used as an opportunity for practitioners to reinforce drinking habits within “safe” limits, which are ≤4 standard drinks per day and ≤14 standard drinks/week for men under age 65 and ≤3 standard drinks per day and ≤7 standard drinks per week for women under age 65. For those over age 65, the “safe” limit for both men and women is ≤3 standard drinks per day and ≤7 standard drinks per week. One standard drink is 0.5 oz of absolute alcohol, equivalent to 10 oz of beer, 4 oz of wine, or 1 oz of 100-proof liquor (51). An AUDIT score ≥8 for men or ≥4 for women—suggestive of excessive drinking—should prompt even more detailed questions about the patient's drinking.
Detailed questions about drinking should start with the first time the patient took a drink; drank regularly; recognized that drinking was a problem (i.e., by causing physical harm or accidents, discordant relationships with family or friends, failure to perform obligations at school or work, and legal problems, such as driving under the influence); had to drink more to get a “buzz” or a “high”; experienced insomnia, sweating, tremors, or nausea several hours after cessation of drinking; and noticed spending most of the day thinking about or actually drinking, irrespective of the consequences. Each of these questions about first drinking-related behaviors should be followed up by establishing the behavior's severity and course. Based on the patient's responses, especially those pertaining to the preceding 12-month period, a diagnosis of alcohol abuse or dependence can be made according to DSM-IV-TR criteria. Finally, the practitioner should help the patient quantify carefully the amount of alcohol consumed each week in standard drinks. A useful method for demonstrating this graphically would be to ask patients to pour into a clean measuring jug the amount of their preferred beverage that they consume, on average, each day. If the patient binges on weekends or at other times, the practitioner should ask him or her to pour an amount of water into the measuring jug equivalent to how much alcohol he or she consumed during the heaviest drinking day. The practitioner must establish whether the patient is still actively drinking, has recently stopped, or has been abstinent for a verifiable amount of time. Information pertaining to current drinking level, especially in the preceding month, should be compared with drinking levels after the initiation of treatment to chart progress.
DIAGNOSIS AND PHARMACOTHERAPEUTIC OPTIONS
The patient in case 1 is a middle-aged schoolteacher who meets DSM-IV-TR criteria for alcohol dependence. The age at onset of problem drinking could not be ascertained. The patient has a possible family history of alcohol dependence in his father and antisocial traits, as well as medical complications that include high blood pressure, high cholesterol, and liver impairment. This patient has a severe form of alcohol dependence with a chronic and pervasive course. The first step in treatment should be to negotiate a drinking goal with the patient. While the gold standard for a positive treatment outcome is complete abstinence, some patients need to be helped toward this goal by setting increasingly lower levels of heavy drinking.
Given the severe nature of the patient's alcohol dependence and the fact that he is still drinking heavily and has important medical complications, my choice of pharmacotherapy would be topiramate. An additional advantage of topiramate in this patient is that because it is excreted mostly unchanged by the kidneys in the urine (52), there would be a reduced risk of the medication worsening his developing liver impairment. Topiramate, a sulfamate-substituted fructopyranose derivative, has been shown in two large-scale randomized, placebo-controlled clinical trials to improve all drinking outcomes, including a reduction of heavy drinking and a promotion of abstinence (53, 54). Topiramate is presumed to exert its antidrinking effects by cortico-mesolimbic dopamine system modulation through the facilitation of GABA function via a non-benzodiazepine site on the GABAA receptor (55) and the antagonism of glutamate activity at α-amino-3-hydroxy-5-methylisoxazole-4-propionate and kainate receptors (56). Topiramate also has been shown to decrease the medical consequences of alcohol dependence, including obesity, hypertension, liver abnormality, and high cholesterol; however, it is unknown whether this effect is independent of its antidrinking properties (57). Topiramate is generally well tolerated, and the more common adverse events associated with its use include paresthesia, taste perversion, anorexia, and difficulty with concentration.
Topiramate treatment should be initiated at a dosage of 25 mg/day and titrated over 8 weeks up to 300 mg/day (Table 1) while a brief intervention, such as brief behavioral compliance enhancement treatment, is provided on a weekly basis (5). Care should be taken to titrate the dose of topiramate slowly, and longer dose-escalation schedules should be considered if necessary. The practitioner should be aware that topiramate's efficacy appears to be evident at dosages as low as 100 mg/day. Thus, stopping topiramate titration at this dosage may be considered if tolerability is a problem. Although the clinical trials for alcohol dependence in the United States typically report shorter-term outcomes (i.e., 3–6 months), prudent clinical practice would suggest that most patients need to be treated for 6 months to 1 year to increase the likelihood of a remission.
a
Reprinted from Johnson et al. (53), with permission from Elsevier.
An alternative medication treatment for this patient would be baclofen—an agonist at presynaptic GABAB (bicuculline-insensitive) receptors that appears to act by modulation of G-protein-gated inwardly rectifying potassium channels (GIRK, Kir3) to suppress cortico-mesolimbic dopamine system neurons (58). Baclofen might be useful for this patient, as it has shown promise in treating alcohol dependence, particularly in patients with liver impairment (59). Baclofen is excreted primarily through the kidneys. It is recommended that baclofen be titrated from a starting dosage of 5 mg three times daily in the first 3 days, and then to the ceiling dosage of 10 mg three times daily. Unlike topiramate, baclofen is administered to patients who have already become abstinent, possibly by the use of a reducing dosage of the benzodiazepine chlordiazepoxide on an outpatient basis. While baclofen might itself aid in reducing alcohol withdrawal symptoms (60), its cessation should be gradual to avoid the emergence of withdrawal symptoms of its own, which may include confusion, hallucinations, anxiety, perceptual disturbance, and extreme muscle rigidity with or without spasticity. Common adverse events associated with baclofen administration include headaches, insomnia, nausea, hypotension, urinary frequency, and, rarely, excitement and visual abnormalities (61).
The patient in case 2 is an elderly woman who meets DSM-IV-TR criteria for alcohol dependence. Alcohol dependence among the elderly is often underdiagnosed, and every practitioner should be diligent in inquiring about drinking habits in this age group (62). The first step in treatment should be to negotiate a drinking goal with the patient. Because of the high association of alcohol dependence with morbidity and mortality in elderly patients, the practitioner should negotiate a goal, or a sequence of targets, that culminate in abstinence.
Given the patient's age, which may make her prone to forgetfulness, and her relative isolation, my choice of pharmacotherapy would be an injectable extended-release formulation of naltrexone (Vivitrol). After a period of abstinence (3–5 days), which might require supportive benzodiazepine treatment (e.g., a reducing dosage of chlordiazepoxide), the patient can be scheduled to receive injectable extended-release naltrexone at 380 mg/month for 4 months. The efficacy and adverse-event profile of this formulation, administered on a monthly basis, are similar to those of oral naltrexone. Pharmacotherapy should be accompanied by a brief intervention (e.g., brief behavioral compliance enhancement treatment or medical management).
Notably, while consideration would be given to adding an antidepressant such as a selective serotonin reuptake inhibitor (SSRI) to the medication regimen, it would not be appropriate to do so at present with this patient, for three reasons. First, the patient does not meet DSM-IV-TR criteria for major depression, and the reported “gloominess” is likely to lift as her drinking outcomes improve, particularly if there are fewer episodes of heavy drinking or increasing periods of abstinence. Second, SSRIs have shown added benefit in comorbid alcohol-dependent and depressed patients mainly when the symptoms of dysphoric mood are marked and accompanied by suicidal ideation (63). Third, the patient's age at onset of problem drinking would have to be determined more accurately because SSRIs can trigger an increase (rather than a decrease) in alcohol consumption among late-onset alcoholics.
The patient in case 3 is an emerging adult who meets DSM-IV-TR criteria for alcohol dependence. The first step in treatment should be to educate the patient about the health risks associated with his dependence on alcohol and sensitize him to the risky behaviors in which he engages. In this age group, a motivation-based approach appears to be most useful in setting treatment goals that typically focus on reducing binge and heavy drinking episodes.
Given that the patient has a moderate severity of alcohol dependence, is still drinking, had an early onset of problem drinking, and has a strong family history, the optimal treatment option would be ondansetron, a 5-HT3 antagonist that exerts its antidrinking effects through corticomesolimbic dopamine system modulation. Ondansetron has been shown to improve drinking outcomes in patients with early-onset alcoholism. Adverse events are mild (usually constipation, headaches, and sedation), and the starting dosage of 4 μg/kg twice daily should be maintained throughout treatment. Unfortunately, however, ondansetron is not currently available commercially at the therapeutic dose for alcohol dependence, so it is not a practical alternative outside research treatment settings.
An alternative pharmacotherapeutic option would be the μ-opioid antagonist naltrexone, accompanied by a brief intervention provided on a weekly basis (such as medical management, which was shown to be effective in the Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence [COMBINE] study [7]). Naltrexone was approved by the Food and Drug Administration (FDA) in 1994 for the treatment of alcohol dependence, and its antidrinking properties have been attributed to cortico-mesolimbic dopamine system modulation (47). Furthermore, therapeutic response to naltrexone appears to be enhanced among those with a family history of alcoholism (64). Naltrexone should be provided at a dose that escalates up to 100 mg/day after the patient has been abstinent for 3 to 5 days. A reducing dosage of a benzodiazepine (e.g., chlordiazepoxide) can be prescribed on an outpatient basis according to a standardized schedule (65) to facilitate the achievement of the brief period of abstinence needed before pharmacotherapy is started. Common adverse events associated with naltrexone treatment include nausea and somnolence. Treatment should be continued for as long as possible (at least 2 months).
To date, no published study has examined exclusively the utility of pharmacotherapy coupled with a brief intervention for the treatment of alcohol dependence in emerging adults. Hence, this recommendation is an extrapolation from adult studies with overlapping populations. Notably, among emerging adults, the mainstay of treatment has been brief intervention alone. However, the severity of established alcohol dependence in this patient, rather than just alcohol abuse, suggests that additional pharmacotherapy would be needed to obtain a favorable treatment outcome.
Nevertheless, a brief motivational intervention that has been used frequently to treat college students who binge drink, the Brief Alcohol Screening and Intervention for College Students (BASICS) program (66), may be used as the adjunct to the pharmacotherapy. The BASICS program provides personal feedback, motivation, and strategies that enhance normative drinking patterns (67). It is typically given as a low-intensity intervention, every 2 weeks, over about 8 weeks. The BASICS program is the most well-validated motivation-based brief intervention that has been employed in treating emerging adults with alcohol-related disorders.
Clinical monitoring
An important aspect of clinical monitoring is continuing to quantify drinking behavior and setting appropriate target goals for the reduction or cessation of alcohol consumption. Brief interventions such as medical management or brief behavioral compliance enhancement treatment offer a convenient method for setting treatment goals while providing motivation and reinforcing medication compliance. Current clinical evidence points to the use of these brief interventions with medications rather than to intensive or more formal psychotherapies as adjuncts to pharmacotherapy. Moreover, because brief interventions are more generalizable to general practice, their use with efficacious pharmacotherapies should broaden access to care.
In sum, despite the apparent disparity of presentation of the three patients described here, they all can be managed successfully by nonspecialist practitioners in an office-based practice. Any assistance needed with detoxification can be done on an outpatient basis, and hospital admission for detoxification should be considered only in extreme cases (66), such as in patients with a previous history of seizures or delirium tremens or serious medical complications such as uncontrolled diabetes or fulminant heart disease.
Other pharmacotherapeutic options
Other pharmacotherapeutic choices are available that could have been provided for the patients presented here. From the list of other FDA-approved medications, disulfiram (an inhibitor of aldehyde dehydrogenase) could have been considered. However, disulfiram treatment was not proposed because its efficacy appears to be dependent on having a partner ensure compliance with the medication regimen (68), rendering it a “psychological pill.” Its effects thus derive from the agreement of the patient to take a medication that is part of a daily pledge of abstinence. Furthermore, disulfiram has no effect in reducing the urge or propensity to drink, which newer medications, such as naltrexone, ondansetron, and topiramate, have been reported to do (47). Acamprosate (a modulator of glutamate neurotransmission at metabotropic-5 glutamate receptors) (69) also has received FDA approval for the treatment of alcohol dependence, principally on the basis of European studies, but the failure of two large double-blind U.S. studies has cast doubt on its efficacy (47).
Several new molecular targets are being investigated for the treatment of alcohol dependence (see Figure 1) (46). Apart from those already mentioned, research is being done to evaluate the efficacy of promising agents such as the neurokinin-1 receptor antagonist LY686017 (70) and gabapentin (a modulator of voltage-gated N-type calcium channels) (71). Because recent double-blind trials have not found efficacy for aripiprazole (72) or rimonabant (a cannabinoid receptor-1 antagonist) in the treatment of alcohol dependence, there is less optimism in the pursuit of these targets.
Medication combinations, by being able to target several neurotransmitters simultaneously, also hold the promise of greater efficacy in the treatment of alcohol dependence. However, this research is in its infancy, and the early promise of combining naltrexone and acamprosate (73) appears unlikely to pan out (7). Other medication combinations are currently being tested, and the results of these studies are expected soon (47).
FUTURE PHARMACOGENETIC APPROACHES
Personalized medicine promises to optimize treatment response to ensure that patients with a given disease receive the medication that will benefit them the most. Although examination of the pharmacogenetic effects on treatment response has aroused the most clinical interest, other fields, such as metabolomics, are equally important to our understanding of the biological factors that govern sensitivity to drug effects.
In a retrospective analysis of a double-blind clinical trial of alcohol-dependent individuals of European descent who received naltrexone, Oslin et al. (74) reported that those with one or two copies of the opioid receptor μ 1 (OPRM1) Asp40 allele, compared with their homozygous counterparts, were less likely to return to heavy drinking and had a longer time to return to heavy drinking. A similar pattern of results was reported in the COMBINE study (75), but the size of the effect was small, and the results are contradicted by other clinical studies that have examined the role of the OPRM1 Asp40 allele in predicting treatment response to naltrexone (76) and the μ-opioid receptor antagonist nalmefene (77). Hence, the role of the OPRM1 Asp40 allele in predicting response to naltrexone in the treatment of alcohol dependence remains to be established firmly.
Serotonergic function is an important mediator of mood, impulsivity, and appetitive behaviors, including alcohol consumption. Of the mechanisms controlling synaptic 5-HT concentration, perhaps the most compelling is related to the functional state of the presynaptic 5-HT transporter (5-HTT). The 5-HTT is responsible for removing 5-HT from the synaptic cleft (78). Indeed, up to 60% of neuronal 5-HT function is gated by the 5-HTT. The 5-HTT gene is found at the SLC6A4 locus on chromosome 17q11.1–q12, and its 5′-regulatory promoter region contains a functional polymorphism known as the 5-HTT-linked polymorphic region (79, 80). The polymorphism is an insertion/deletion mutation in which the long (L) variant has 44 base pairs that are absent in the short (S) variant. Because of the differential transcription rates between LL allelic variants compared with their SS counterparts, variation at the 5-HTT gene is an interesting candidate for examining sensitivity to alcohol and treatment response to ondansetron in alcohol-dependent individuals. It is therefore of interest that alcohol-dependent individuals who are L-allelic variants, compared with their SS counterparts, may have greater craving for alcohol (81). Furthermore, a recent pilot study in the human laboratory has suggested that individuals with the LL genotype might be particularly responsive to ondansetron (82). Results of the first large-scale prospective pharmacogenetic study in the alcoholism field to test whether 5-HTT gene allelic variation predicts therapeutic response to ondansetron are eagerly awaited. If the results of this study are positive, it has the potential to make a personalized approach to the treatment of alcohol dependence a reality, whereby potential responders are identified through specific genetic markers and treated with ondansetron.
SUMMARY
Alcohol dependence is a heterogeneous chronic, relapsing brain disorder. All practitioners should be familiar with its early detection. Alcohol dependence is treatable, and the use of efficacious pharmacotherapies has opened up the potential of office-based treatment by nonspecialists. Appropriate pharmacotherapy, along with a brief psychosocial intervention, constitutes optimal treatment. Choice of therapy can be guided by the patient's history of alcoholism and stage of life and, in the future, perhaps by pharmacogenetics.
REFERENCES
1.
US Department of Health and Human Services: 10th Special Report to the US Congress on Alcohol and Health. Bethesda, Md, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, 2000
2.
McLellan AT, Lewis DC, O'Brien CP, Kleber HD: Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA 2000; 284:1689–1695
3.
Swift RM: Drug therapy for alcohol dependence. N Engl J Med 1999; 340:1482–1490
4.
Finney JW, Hahn AC, Moos RH: The effectiveness of inpatient and outpatient treatment for alcohol abuse: the need to focus on mediators and moderators of setting effects. Addiction 1996; 91:1773–1796
5.
Johnson BA, DiClemente CC, Ait-Daoud N, Stoks SM: Brief Behavioral Compliance Enhancement Treatment (BBCET) manual, in Handbook of Clinical Alcoholism Treatment. Edited by Johnson BA, Ruiz P, Galanter M. Baltimore, Lippincott Williams & Wilkins, 2003, pp 282–301
6.
Pettinati HM, Weiss RD, Miller WR, Donovan D, Ernst DB, Rounsaville BJ: Medical Management Treatment Manual: A Clinical Research Guide for Medically Trained Clinicians Providing Pharmacotherapy as Part of the Treatment for Alcohol Dependence. COMBINE Monograph Series, vol 2 (DHHS Publication No. 04-5289). Bethesda, Md, National Institute on Alcohol Abuse and Alcoholism, 2004
7.
Anton RF, O'Malley SS, Ciraulo DA, Cisler RA, Couper D, Donovan DM, Gastfriend DR, Hosking JD, Johnson BA, LoCastro JS, Longabaugh R, Mason BJ, Mattson ME, Miller WR, Pettinati HM, Randall CL, Swift R, Weiss RD, Williams LD, Zweben A (COMBINE Study Research Group): Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA 2006; 295:2003–2017
8.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision. Washington, DC, American Psychiatric Association, 2000
9.
Cloninger CR: Neurogenetic adaptive mechanisms in alcoholism. Science 1987; 236:410–416
10.
Babor TF, Dolinsky ZS, Meyer RE, Hesselbrock M, Hofmann M, Tennen H: Types of alcoholics: concurrent and predictive validity of some common classification schemes. Br J Addict 1992; 87:1415–1431
11.
Babor TF, Hofmann M, DelBoca FK, Hesselbrock V, Meyer RE, Dolinsky ZS, Rounsaville B: Types of alcoholics, I. evidence for an empirically derived typology based on indicators of vulnerability and severity. Arch Gen Psychiatry 1992; 49:599–608
12.
Schuckit MA, Tipp JE, Smith TL, Shapiro E, Hesselbrock VM, Bucholz KK, Reich T, Nurnberger JI Jr: An evaluation of type A and B alcoholics. Addiction 1995; 90:1189–1203
13.
Miller WR, Marlatt GA: Manual for the Comprehensive Drinker Profile. Odessa, Fla, Psychological Assessment Resources, 1984
14.
Johnson BA: Serotonergic agents and alcoholism treatment: rebirth of the subtype concept: an hypothesis. Alcohol Clin Exp Res 2000; 24:1597–1601
15.
Lesch OM, Dietzel M, Musalek M, Walter H, Zeiler K: The course of alcoholism: long-term prognosis in different types. Forensic Sci Int 1988; 36:121–138
16.
Lesch OM, Walter H: Subtypes of alcoholism and their role in therapy. Alcohol Alcohol Suppl 1996; 1:63–67
17.
Johnston LD, O'Malley PM, Bachman JG: Monitoring the Future National Survey Results on Drug Use, 1975–2002, vol 2, College Students and Adults Ages 19–40. Bethesda, Md, National Institute on Drug Abuse, 2003
18.
Clapp JD, Lange JE, Russell C, Shillington A, Voas RB: A failed norms social marketing campaign. J Stud Alcohol 2003; 64:409–414
19.
Wechsler H, Lee JE, Kuo M, Seibring M, Nelson TF, Lee H: Trends in college binge drinking during a period of increased prevention efforts: findings from 4 Harvard School of Public Health College Alcohol Study surveys: 1993–2001. J Am Coll Health 2002; 50:203–217
20.
Hingson RW, Heeren T, Zakocs RC, Kopstein A, Wechsler H: Magnitude of alcohol-related mortality and morbidity among U.S. college students ages 18–24. J Stud Alcohol 2002; 63:136–144
21.
Hingson R, Heeren T, Winter M, Wechsler H: Magnitude of alcohol-related mortality and morbidity among U.S. college students ages 18–24: changes from 1998 to 2001. Annu Rev Public Health 2005; 26:259–279
22.
Fleming MF, Barry KL, MacDonald R: The Alcohol Use Disorders Identification Test (AUDIT) in a college sample. Int J Addict 1991; 26:1173–1185
23.
Kypri K, Langley JD, McGee R, Saunders JB, Williams S: High prevalence, persistent hazardous drinking among New Zealand tertiary students. Alcohol Alcohol 2002; 37:457–464
24.
Bruner AB, Fishman M: Adolescents and illicit drug use. JAMA 1998; 280:597–598
25.
Apostolopoulos Y, Sönmez S, Yu CH: HIV-risk behaviours of American spring break vacationers: a case of situational disinhibition? Int J STD AIDS 2002; 13:733–743
26.
Engs RC, Diebold BA, Hanson DJ: The drinking patterns and problems of a national sample of college students, 1994. J Alcohol Drug Educ 1996; 41:13–33
27.
Presley CA, Meilman PW, Cashin JR: Alcohol and Drugs on American College Campuses: Use, Consequences, and Perceptions of the Campus Environment, vol 4, 1992–1994. Carbondale, Southern Illinois University, Core Institute, 1996
28.
Presley CA, Pimentel ER: The introduction of the heavy and frequent drinker: a proposed classification to increase accuracy of alcohol assessments in postsecondary educational settings. J Stud Alcohol 2006; 67:324–331
29.
Muthén B, Shedden K: Finite mixture modeling with mixture outcomes using the EM algorithm. Biometrics 1999; 55:463–469
30.
Hill KG, White HR, Chung IJ, Hawkins JD, Catalano RF: Early adult outcomes of adolescent binge drinking: person- and variable-centered analyses of binge drinking trajectories. Alcohol Clin Exp Res 2000; 24:892–901
31.
Dawson DA, Grant BF, Stinson FS, Chou PS: Another look at heavy episodic drinking and alcohol use disorders among college and noncollege youth. J Stud Alcohol 2004; 65:477–488
32.
Slutske WS: Alcohol use disorders among US college students and their non-college-attending peers. Arch Gen Psychiatry 2005; 62:321–327
33.
Knight JR, Wechsler H, Kuo M, Seibring M, Weitzman ER, Schuckit MA: Alcohol abuse and dependence among U.S. college students. J Stud Alcohol 2002; 63:263–270
34.
Martin CS, Kaczynski NA, Maisto SA, Bukstein OM, Moss HB: Patterns of DSM-IV alcohol abuse and dependence symptoms in adolescent drinkers. J Stud Alcohol 1995; 56:672–680
35.
Jennison KM: The short-term effects and unintended long-term consequences of binge drinking in college: a 10-year follow-up study. Am J Drug Alcohol Abuse 2004; 30:659–684
36.
O'Neill SE, Parra GR, Sher KJ: Clinical relevance of heavy drinking during the college years: cross-sectional and prospective perspectives. Psychol Addict Behav 2001; 15:350–359
37.
Grant BF, Kaplan K, Shepard J, Moore T: Source and Accuracy Statement for Wave 1 of the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions. Bethesda, Md, National Institute on Alcohol Abuse and Alcoholism, 2003
38.
Hasin DS, Goodwin RD, Stinson FS, Grant BF: Epidemiology of major depressive disorder: results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Arch Gen Psychiatry 2005; 62:1097–1106
39.
Lynskey MT: The comorbidity of alcohol dependence and affective disorders: treatment implications. Drug Alcohol Depend 1998; 52:201–209
40.
Wang J, El-Guebaly N: Sociodemographic factors associated with comorbid major depressive episodes and alcohol dependence in the general population. Can J Psychiatry 2004; 49:37–44
41.
McEachin RC, Keller BJ, Saunders EF, McInnis MG: Modeling gene-by-environment interaction in comorbid depression with alcohol use disorders via an integrated bioinformatics approach. BioData Min 2008; 1:2
42.
Blow FC, Barry KL: Use and misuse of alcohol among older women. Alcohol Res Health 2002; 26:308–315
43.
Merikangas KR, Gelernter CS: Comorbidity for alcoholism and depression. Psychiatr Clin North Am 1990; 13:613–632
44.
Thase ME, Salloum IM, Cornelius JD: Comorbid alcoholism and depression: treatment issues. J Clin Psychiatry 2001; 62(suppl 20):32–41
45.
Hemby SE, Johnson BA, Dworkin SI: Neurobiological basis of drug reinforcement, in Drug Addiction and Its Treatment: Nexus of Neuroscience and Behavior. Edited by Johnson BA, Roache JD. Philadelphia, Lippincott-Raven, 1997, pp 137–169
46.
Johnson BA: New weapon to curb smoking: no more excuses to delay treatment. Arch Intern Med 2006; 166:1547–1550
47.
Johnson BA: Update on neuropharmacological treatments for alcoholism: scientific basis and clinical findings. Biochem Pharmacol 2008; 75:34–56
48.
Koob GF, Le Moal M: Plasticity of reward neurocircuitry and the “dark side”of drug addiction. Nat Neurosci 2005; 8:1442–1444
49.
National Institute on Alcohol Abuse and Alcoholism: Helping Patients Who Drink Too Much: A Clinician's Guide: Updated 2005 Edition (NIH Publication No. 07-3769). Bethesda, Md, US Department of Health and Human Services, 2005
50.
Reinert DF, Allen JP: The Alcohol Use Disorders Identification Test (AUDIT): a review of recent research. Alcohol Clin Exp Res 2002; 26:272–279
51.
Miller WR, Heather N, Hall W: Calculating standard drink units: international comparisons. Br J Addict 1991; 86:43–47
52.
Shank RP, Gardocki JF, Streeter AJ, Maryanoff BE: An overview of the preclinical aspects of topiramate: pharmacology, pharmacokinetics, and mechanism of action. Epilepsia 2000; 41(suppl 1):S3–S9
53.
Johnson BA, Ait-Daoud N, Bowden CL, DiClemente CC, Roache JD, Lawson K, Javors MA, Ma JZ: Oral topiramate for treatment of alcohol dependence: a randomised controlled trial. Lancet 2003; 361:1677–1685
54.
Johnson BA, Rosenthal N, Capece JA, Wiegand F, Mao L, Beyers K, McKay A, Ait-Daoud N, Anton RF, Ciraulo DA, Kranzler HR, Mann K, O'Malley SS, Swift RM (Topiramate for Alcoholism Advisory Board, Topiramate for Alcoholism Study Group): Topiramate for treating alcohol dependence: a randomized controlled trial. JAMA 2007; 298:1641–1651
55.
White HS, Brown SD, Woodhead JH, Skeen GA, Wolf HH: Topiramate modulates GABA-evoked currents in murine cortical neurons by a nonbenzodiazepine mechanism. Epilepsia 2000; 41(suppl 1):S17–S20
56.
Johnson BA: Recent advances in the development of treatments for alcohol and cocaine dependence: focus on topiramate and other modulators of GABA or glutamate function. CNS Drugs 2005; 19:873–896
57.
Johnson BA, Rosenthal N, Capece JA, Wiegand F, Mao L, Beyers K, McKay A, Ait-Daoud N, Addolorato G, Anton RF, Ciraulo DA, Kranzler HR, Mann K, O'Malley SS, Swift RM (Topiramate for Alcoholism Advisory Board, Topiramate for Alcoholism Study Group): Improvement of physical health and quality of life of alcohol-dependent individuals with topiramate treatment. Arch Intern Med 2008; 168:1188–1199
58.
Cruz HG, Ivanova T, Lunn ML, Stoffel M, Slesinger PA, Lüscher C: Bi-directional effects of GABA(B) receptor agonists on the mesolimbic dopamine system. Nat Neurosci 2004; 7:153–159
59.
Addolorato G, Leggio L, Ferrulli A, Cardone S, Vonghia L, Mirijello A, Abenavoli L, D'Angelo C, Caputo F, Zambon A, Haber PS, Gasbarrini G: Effectiveness and safety of baclofen for maintenance of alcohol abstinence in alcohol-dependent patients with liver cirrhosis: randomised, double-blind controlled study. Lancet 2007; 370:1915–1922
60.
Addolorato G, Leggio L, Abenavoli L, Agabio R, Caputo F, Capristo E, Colombo G, Gessa GL, Gasbarrini G: Baclofen in the treatment of alcohol withdrawal syndrome: a comparative study vs diazepam. Am J Med 2006; 119:276.e13–276.e18
61.
Alpha Pharmaceuticals: Alpha-baclofen: data sheet. http://www.medsafe.govt.nz/profs/datasheet/a/alphabaclofentab.htm
62.
Blazer DG, Wu L-T: The epidemiology of at-risk and binge drinking among middle-aged and elderly community adults: National Survey on Drug Use and Health. Am J Psychiatry 2009; 166:1162–1169
63.
Cornelius JR, Salloum IM, Ehler JG, Jarrett PJ, Cornelius MD, Perel JM, Thase ME, Black A: Fluoxetine in depressed alcoholics: a double-blind, placebo-controlled trial. Arch Gen Psychiatry 1997; 54:700–705
64.
Krishnan-Sarin S, Krystal JH, Shi J, Pittman B, O'Malley SS: Family history of alcoholism influences naltrexone-induced reduction in alcohol drinking. Biol Psychiatry 2007; 62:694–697
65.
Ait-Daoud N, Malcolm RJ Jr, Johnson BA: An overview of medications for the treatment of alcohol withdrawal and alcohol dependence with an emphasis on the use of older and newer anticonvulsants. Addict Behav 2006; 31:1628–1649
66.
Dimeff LA, Baer JS, Kivlahan DR, Marlatt GA: Brief Alcohol Screening and Intervention for College Students (BASICS): A Harm Reduction Approach. New York, Guilford, 1999
67.
Baer JS, Kivlahan DR, Blume AW, McKnight P, Marlatt GA: Brief intervention for heavy-drinking college students: a 4-year follow-up and natural history. Am J Public Health 2001; 91:1310–1316
68.
Ait-Daoud N, Johnson BA: Medications for the treatment of alcoholism, in Handbook of Clinical Alcoholism Treatment. Edited by Johnson BA, Ruiz P, Galanter M. Baltimore, Lippincott Williams & Wilkins, 2003, pp 119–130
69.
Harris BR, Prendergast MA, Gibson DA, Rogers DT, Blanchard JA, Holley RC, Fu MC, Hart SR, Pedigo NW, Littleton JM: Acamprosate inhibits the binding and neurotoxic effects of trans-ACPD, suggesting a novel site of action at metabotropic glutamate receptors. Alcohol Clin Exp Res 2002; 26:1779–1793
70.
George DT, Gilman J, Hersh J, Thorsell A, Herion D, Geyer C, Peng X, Kielbasa W, Rawlings R, Brandt JE, Gehlert DR, Tauscher JT, Hunt SP, Hommer D, Heilig M: Neurokinin 1 receptor antagonism as a possible therapy for alcoholism. Science 2008; 319:1536–1539
71.
Brower KJ, Myra Kim H, Strobbe S, Karam-Hage MA, Consens F, Zucker RA: A randomized double-blind pilot trial of gabapentin versus placebo to treat alcohol dependence and comorbid insomnia. Alcohol Clin Exp Res 2008; 32:1429–1438
72.
Anton RF, Kranzler H, Breder C, Marcus RN, Carson WH, Han J: A randomized, multicenter, double-blind, placebo-controlled study of the efficacy and safety of aripiprazole for the treatment of alcohol dependence. J Clin Psychopharmacol 2008; 28:5–12
73.
Kiefer F, Jahn H, Tarnaske T, Helwig H, Briken P, Holzbach R, Kampf P, Stracke R, Baehr M, Naber D, Wiedemann K: Comparing and combining naltrexone and acamprosate in relapse prevention of alcoholism: a double-blind, placebo-controlled study. Arch Gen Psychiatry 2003; 60:92–99
74.
Oslin DW, Berrettini W, Kranzler HR, Pettinati H, Gelernter J, Volpicelli JR, O'Brien CP: A functional polymorphism of the mu-opioid receptor gene is associated with naltrexone response in alcohol-dependent patients. Neuropsychopharmacology 2003; 28:1546–1552
75.
Anton RF, Oroszi G, O'Malley S, Couper D, Swift R, Pettinati H, Goldman D: An evaluation of mu-opioid receptor (OPRM1) as a predictor of naltrexone response in the treatment of alcohol dependence: results from the Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence (COMBINE) study. Arch Gen Psychiatry 2008; 65:135–144
76.
Gelernter J, Gueorguieva R, Kranzler HR, Zhang H, Cramer J, Rosenheck R, Krystal JH (VA Cooperative Study #425 Study Group): Opioid receptor gene (OPRM1, OPRK1, and OPRD1) variants and response to naltrexone treatment for alcohol dependence: results from the VA Cooperative Study. Alcohol Clin Exp Res 2007; 31:555–563
77.
Arias AJ, Armeli S, Gelernter J, Covault J, Kallio A, Karhuvaara S, Koivisto T, Mäkelä R, Kranzler HR: Effects of opioid receptor gene variation on targeted nalmefene treatment in heavy drinkers. Alcohol Clin Exp Res 2008; 32:1159–1166
78.
Lesch KP, Greenberg BD, Higley JD: Serotonin transporter, personality, and behavior: toward dissection of gene-gene and gene-environment interaction, in Molecular Genetics and the Human Personality. Edited by Benjamin J, Ebstein RP, Belmaker RH. Washington, DC, American Psychiatric Publishing, Inc, 2002, pp 109–136
79.
Heils A, Teufel A, Petri S, Stober G, Riederer P, Bengel D, Lesch KP: Allelic variation of human serotonin transporter gene expression. J Neurochem 1996; 66:2621–2624
80.
Heils A, Mossner R, Lesch KP: The human serotonin transporter gene polymorphism: basic research and clinical implications. J Neural Transm 1997; 104:1005–1014
81.
Ait-Daoud N, Roache JD, Dawes MA, Liu L, Wang X-Q, Javors MA, Seneviratne C, Johnson BA: Can serotonin transporter genotype predict craving in alcoholism? Alcohol Clin Exp Res 2009; 33:1329–1335
82.
Kenna GA, Zywiak WH, McGeary JE, Leggio L, McGeary C, Wang S, Grenga A, Swift RM: A within-group design of nontreatment seeking 5-HTTLPR genotyped alcohol-dependent subjects receiving ondansetron and sertraline. Alcohol Clin Exp Res 2009; 33:315–323
Information & Authors
Information
Published In
History
Published online: 1 January 2011
Published in print: Winter 2011
Authors
Metrics & Citations
Metrics
Citations
Export Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
View Options
View options
PDF/EPUB
View PDF/EPUBGet Access
Login options
Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.
Personal login Institutional Login Open Athens loginNot a subscriber?
PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).