More Evidence Chantix May Reduce Heavy Drinking(*)

A newly published study suggests varenicline (Chantix) may have role in the treatment of co-occurring alcohol use disorder and smoking.  Results from the Phase 2, randomized placebo-controlled trial, published in last month's JAMA Psychiatry, showed a reduction in the percentage of heavy drinking days among some of its participants.  These results, however, came with a big asterisk: the improvements were only seen among the men enrolled in the study, while the women in the placebo group showed more improvement than those in the medication group.

Chantix has been FDA-approved for smoking cessation since 2006.  As a partial nicotinic acetylcholine receptor agonist, it has been called the "Suboxone of nicotine addiction."  As researchers gained insights into the converging role this receptor system plays in both smoking and alcohol reward, the idea that it could have value in alcohol use disorder (AUD) treatment gained momentum.  Preclinical studies in 2007, 2009, and 2011 showed some promising results, indicating rodents taking the medicine drank less alcohol than those who weren't.  This led to several small human trials of Chantix for heavy drinking, though with mixed results.  The February study was the first to show such divergent results between the two genders, and it is unclear why men fared so much better than the women enrolled in the study.

Nevertheless, these results contribute a little more data to the search for new addiction medications and suggest prescribers may want to consider Chantix for their male patients who both smoke and drink heavily.  Here at Alltyr Clinic, we have seen some of our AUD patients respond quite well to Chantix.  Since our clinicians routinely screen our patients who smoke for their desire to quit, it has been a logical option to consider as a firstline treatment. Despite the less-than-blockbuster results of this study, we are glad to hear about any new research on potential medication options.

See the study here:
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2665215?redirect=true

And the earlier trial can be seen here:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3914416/ 

Researchers: Supervised Methadone and Buprenorphine Dosing Adds Little Therapeutic Benefit

Methadone, the full agonist synthetic opioid, is one of the most tightly regulated medications on the planet - at least, that is, when it's being used to treat opioid addiction.  Here in Minnesota, no fewer than 5 regulatory bodies oversee the clinics that provide methadone maintenance treatment (MMT).  One of the core federal requirements of "opiate treatment programs" is daily supervised dosing, requiring patients to come daily to the clinic to receive their dose, observed by trained nursing staff for at least the first 3 months.  After that, patients earn one additional day of "take-home" doses at a time until they've earned 1 week (after the 8th month of treatment), then 2 weeks (after the first year in treatment), and finally 4 weeks of take-home doses (after 2 years of sustained participation in the program).  The rationale for these highly restrictive federal rules, ostensibly, has been that it will protect patient safety, decrease diversion, and will improve outcomes among MMT patients.

A recent review of the literature throws these assumptions into question.  The review, analyzed and shared by the folks at Drug and Alcohol Findings, found "no evidence that supervising consumption meant patients were better safeguarded or that the treatment more effectively reduced illegal drug use."  Instead, these policies tend to be quite costly to programs and burdensome to patients.  They reinforce negative stereotypes about MMT patients and have prevented people from seeking potentially lifesaving treatment. 

Here at Alltyr Clinic, we routinely hear from patients that the ability to receive a monthly prescription of Suboxone has meant they could keep their job or maintain their role within the family.  With all the national attention being given to the recent spike in overdose statistics, maybe it's time the feds re-visit these burdensome regulations and increase access to the highly effective treatments. 

From the Findings UK article:

Supervised dosing with a long-acting opioid medication in the management of opioid dependence
http://findings.org.uk/PHP/dl.php?file=Saulle_R_1.txt&s=eb&sf=sfnos

Key points
From summary and commentary

Guidelines recommend making opioid-dependent patients take their methadone or other opioid substitutes at the clinic or pharmacy to safeguard the patient and prevent medication being ‘diverted’ to other people.

Randomised trials and studies study which monitored patients in routine treatment afforded no evidence that supervising consumption meant patients were better safeguarded or that the treatment more effectively reduced illegal drug use.

However, introduction of supervision to UK treatment services was associated with fewer methadone-related overdose deaths.

Findings and expert opinion support initial supervised consumption and its relaxation on an individual basis, depending on assessment of the patient.