10/7/16

Sure Cure for Drunkenness

© Volodymyr Baleha | 123rf.com

© Volodymyr Baleha | 123rf.com

Researchers at the University of North Carolina have identified a circuit between two regions of the brain that are thought to control binge drinking. The two areas—the extended amygdala and the ventral tegmental area (VTA)—have been implicated in past studies of alcohol binge drinking.  The results of this study provide the first direct evidence that inhibiting a circuit between two brain regions may protect against binge drinking. Todd Thiele, who directed the research, said: “If you can stop somebody from binge drinking, you might prevent them from ultimately becoming alcoholics. We know that people who binge drink, especially in their teenage years, are much more likely to become alcoholic-dependent later in life.” But so far, the research has only been demonstrated with mice.

Thiele and his team demonstrated that alcohol activates the CRF (corticotropin releasing factor) neurons in the extended amygdala, which in turn act on the ventral tegmental area. Applied to humans, these observations suggest that when someone drinks alcohol, CRF neurons in human brains are activated in a similar manner, promoting continued and excessive drinking. Thiele thought their findings could be relevant for future pharmacological treatments to help curb binge drinking. Although Thiele and his team didn’t connect their research to a particular pharmacological treatment for binge drinking, others did.

Writing for the Telegraph last year, Laura Donnelly connected the dots between the UNC team of researchers and a drug called Selincro (nalmefene).  Selincro was approved by the National Health Service (NHS) in Britain to help individuals cut back on their alcohol intake. It costs £3 ($3.96) and is to be taken as needed to stave off the desire to drink. Writing for the Mirror, Paul Christian’s headline was designed more to catch your attention than communicate truth: “New £3 pill to ‘cure’ alcoholism can stop binge boozing.”

Paul Fuhr was more cautious in his article for After Party Magazine, “Pill Could Cure Alcoholism, Binge Drinking.” His review accurately pointed out that Selincro is recommended for heavy drinkers. “In targeting weekend warriors rather than career alcoholics, the drug becomes less a cure-all than a solid first step toward sobriety.” He thought the implication of using Selincro to treat binge drinking was more intriguing than the reported effectiveness of the pill.

The prospect of a $4 pill that helps binge drinkers from falling down the alcoholic rabbit hole is an intriguing one but, in my opinion, could cause more damage than good. The pill’s very existence would feed the very problem it’s trying to combat, serving as something of a security blanket for people who know they can take a pill. It’s more important that researchers have uncovered the link between brain areas than designing a drug to flip the switch.

I think Fuhr is exactly right in his assessment that uncovering the link between brain areas is more important than a drug designed to “flip the switch.” I also agree that any drug used to turn this neurochemical circuit off and on will likely do more harm than good, aggravating the problem it is supposed to relieve. Its effectiveness is contingent upon the person actually taking the Selincro. And since it will also limit the euphoric effects of the alcohol as well as the cravings, if you don’t want to limit the euphoria, you won’t take it.

It may disrupt cravings and limit the euphoria from drinking, and this could limit how much you drink; but it won’t neutralize the other physiological effects of the alcohol you do drink. Physiological conditions from heavy drinking (anemia, cancer, cardiovascular disease, cirrhosis, gout, high blood pressure, pancreatitis, to name a few) may not improve—and could even progress—with continued drinking. It also won’t limit you blood alcohol level (BAL), so alcohol can still effect your judgment and decision making. Your self-control will still be blunted.

And this isn’t a new drug or a new treatment method, as some of the media seems to imply. The Sinclair Method actually recommends intentionally drinking after taking naltrexone. It conceives alcoholism to be a learned disorder. Limiting the euphoric reward of drinking is alleged to “cure” your alcoholism by systematically extinguishing the high. They should have remembered from behaviorism 101 that intermittent reinforcement (flicking the alcohol euphoria switch off-and-on) makes it more difficult to extinguish a behavior. See “A ‘Cure’ for Alcoholism.”

Another issue lies with the mixed results of research studies done with nalfmefene on humans.

Two French researchers published “Nalmefene: a new approach to the treatment of alcohol dependence” in the journal Substance Abuse and Rehabilitation. They reviewed the recent scientific literature on nalmefene that described its value in reducing alcohol consumption in alcohol-dependent patients. They noted where nalmefene was well tolerated. Its most common side effects were nausea, dizziness, insomnia and headache—which were mild or moderate and of short duration. Now the adverse effects disclaimer:

Selincro® must not be used in people who are hypersensitive (allergic) to nalmefene or any of its other ingredients. It must not be used in patients taking opioid medicines, in patients who have current or recent opioid addiction, patients with acute symptoms of opioid withdrawal, or patients in whom recent use of opioids is suspected. It must also not be used in patients with severe liver or kidney impairment or a recent history of acute alcohol withdrawal syndrome (including hallucinations, seizures, and tremors).

Paille and Martini said the available studies on nalmefene showed it to be more effective than placebo in reducing the number of heavy drinking days and total alcohol consumption. They lamented that the reduction of alcohol consumption in alcohol-dependent patients is not more widely recognized as a treatment objective. They pointed to the February 2013 approval of nalmefene by the European Medicines Agency with the following indications:

Selincro is indicated for the reduction of alcohol consumption in adult patients with alcohol dependence who have a high drinking risk level, without physical withdrawal symptoms and who do not require immediate detoxification.

Selincro should only be prescribed in conjunction with continuous psychosocial support focused on treatment adherence and reducing alcohol consumption.

Selincro should be initiated only in patients who continue to have a high drinking risk level two weeks after initial assessment.

The European Medicines Agency limits the use of Selincro (nalmefene) in patients with a high drinking risk level that continues two weeks after an initial assessment. These patients should not exhibit physical withdrawal symptoms upon decreased alcohol consumption; and should not be in need of detoxification. And it should only be initiated in patients who remained in “continuous psychosocial support” that focused on treatment adherence and reducing alcohol consumption. In others words, use nalmefene as a method to reduce alcohol consumption and not as a method to more effectively control the negative consequences of drinking large amounts of alcohol. Paille and Martini concluded:

Nalmefene appears to be an effective treatment to reduce alcohol consumption in alcohol-dependent patients not wanting to become totally abstinent. It differs from other drug therapies essentially by replacing systematic dosing by “as-needed” dosing adapted to the patient’s clinical situation on a day-to-day basis. Patients therefore take nalmefene when they feel that alcohol consumption is imminent.

This is not the final word in nalmefene as a harm reduction tool with alcohol dependence. Palpacuer et al. published a literature review and meta-analysis of published and unpublished double-blind randomized controlled trials of nalmefene: “Risks and Benefits of Nalmefene in the Treatment of Adult Alcohol Dependence.” Significantly, they used the Cochrane Collaboration tool for assessing the risk of bias in their screening of nalmefene trials for their methodological quality. Five randomized control studies with a total of 2,567 randomized participants were included in the main analysis. So what did the researchers find?

The researchers identified five RCTs that met the criteria for inclusion in their study. All five RCTs (which involved 2,567 participants) compared the effects of nalmefene with a placebo (dummy drug); none was undertaken in the population specified by the European Medicines Agency approval. Among the health outcomes examined in the meta-analysis, there were no differences between participants taking nalmefene and those taking placebo in mortality (death) after six months or one year of treatment, in the quality of life at six months, or in a summary score indicating mental health at six months. The RCTs included in the meta-analysis did not report other health outcomes such as accidents. Participants taking nalmefene had fewer heavy drinking days per month at six months and one year of treatment than participants taking placebo, and their total alcohol consumption was lower. However, more people withdrew from the nalmefene groups than from the placebo groups, often for safety reasons. Thus, attrition bias—selection bias caused by systematic differences between groups in withdrawals from a study that can affect the accuracy of the study’s findings—cannot be excluded. Indeed, when the researchers undertook an analysis in which they allowed for withdrawals, the alcohol consumption outcomes did not differ between the treatment groups.

What do these findings mean?

These findings show that there is no high-grade evidence currently available from RCTs to support the use of nalmefene for harm reduction among people being treated for alcohol dependency. In addition, they provide little evidence to support the use of nalmefene to reduce alcohol consumption among this population. Thus, the value of nalmefene for the treatment of alcohol addiction is not established. Importantly, these findings reveal a lack of information on clinically relevant outcomes in the evidence that led to nalmefene approval by the European Medicines Agency. Thus, these findings also call into question the decisions of this and other regulatory and advisory bodies that have approved nalmefene on the basis of the available evidence from RCTs, and highlight the need for further RCTs of nalmefene compared to placebo and naltrexone for the indication specified in the market approval.

germanPaul Fuhr observed how the idea of miracle cures was as old as time itself, reminiscent of the days of patent medicines, like the German liquor cure sold at one time by Sears Roebuck and company for a buck.

Culturally, we want to believe there is a “cure” for drunkenness in pill form that doesn’t require us to do the hard work of establishing and maintaining abstinence.  My suggestion is to do the hard work.

09/13/16

E-Cigarettes Are Just Unhealthy

© diego_cervo | stockfresh.com

© diego_cervo | stockfresh.com

The pros and cons of e-cigarettes have been trading studies and expert opinions back-and-forth for a number of years. In “Nicotine without smoke: tobacco harm reduction,” The Royal College of Physicians sees e-cigarettes as “an ideal tobacco harm reduction product.” While acknowledging that e-cigarettes are not currently made to medical standards and are probably more hazardous than nicotine replacement therapy (NRT), the report said it was unlikely that the health risks from long-term vapor inhalation would exceed 5% of the harm from smoking tobacco. The report also downplayed concerns that e-cigarettes will increase tobacco smoking and act as a gateway to smoking in younger people. But this strong endorsement is not the last word on the saga of e-cigarettes.

Writing for AfterParty Magazine, Tracy Chabala pointed to a study published in the New England Medical Journal raising the danger of inhaling formaldehyde at concentration levels higher than that of nicotine. If that doesn’t good healthy, you’re correct. Formaldehyde is a known cancer-causing agent, and “How formaldehyde-releasing agents behave in the respiratory tract is unknown.” The study authors calculated the risk from e-cigarettes to be 5 to 15 times as high as the risk of long-term smoking. What’s more, “formaldehyde-releasing agents may deposit more efficiently in the respiratory tract than gaseous formaldehyde, and so they could carry a higher slope factor for cancer.”

In her article,“Can Your E-Cigarette Give You Cancer?,” Tracy Chabala noted there were several strong opinions on the study. A lawyer for the American Vaping Association said the study used the vaping device “in a manner that no one does.” He likened it to leaving a steak on the grill all day—“many cancer-causing substances might be formed but no one would eat such charred works.”  I’m not sure I buy his analogy, that vaping with an e-cigarette is like having a good steak on the grill. But his point seems to be that one limit of the study was that the researchers based their findings on a method of using their devise that no one actually does when vaping.

What the study actually reported was that they used an e-cigarette with a “tank system” and a variable-voltage battery. The aerosolized liquid was collected in an NMR spectroscopy tube over five minutes with each puff of their device taking 3 to 4 seconds. They did not find any formaldehyde-releasing agents at the low voltage setting. However, they did detect agents at the high voltage setting. The lawyer for the American Vaping Association seems to have overplayed his analogy. A biologist from the American Cancer Society said he was reasonably convinced that all the formaldehyde released during the test tube studies would likely break down into formaldehyde in the e-smoker’s lungs. I think I’m going with the opinion of the biologist on this one.

The President of The Cancer Action Network, an advocacy group of the American Cancer Society, urged the federal government to consider the new findings and finalize its proposal to regulate all tobacco products, including e-cigarettes. The findings were just another example of how little is known about these products or the varying levels of exposure to toxic chemicals that can result from using any of the hundreds of different types of e-cigarette devices. He said federal regulation was imperative to help address the health risks of e-cigarettes and others who are exposed to e-cigarette vapor. “Furthermore, until the FDA finalizes its proposal to regulate e-cigarettes and other tobacco products, the industry’s unfettered ability to market these products to kids remains a threat to public health.”

In May of 2016, David Nather reported for STAT News that the FDA issued a set of rules regulating e-cigarettes for the first time, despite strong resistance from the industry. All states would now be required to ban the sale of e-cigarettes to anyone under the age of 18. All devices that went on sale after February 15, 2007 would be subject to FDA review unless the manufacturers can prove their products are ”substantially equivalent” to products being sold or that there is another reason they should be exempt. Dr. Robert Cardiff, the FDA commissioner said: “Today’s rule is a milestone in consumer protection. It marks a new chapter in our efforts to do everything we can under the law to protect Americans from the dangers of tobacco products.”

Manufacturers would have between a year and two years to prepare their applications, depending on whether they are submitting to the reviews or arguing they should be exempt. Then they would have another year to win approval from the FDA. The rule would not ban flavored tobacco products, including e-cigarettes. But the FDA is working on a rule that would restrict cigar companies from using flavors in their marketing just as cigarette makers can’t include flavors in their sales pitches.

The president of the American Vaping Association said it was a big win for American cigarette companies and a giant loss for small businesses.  He predicted that in two or three years, “nearly every vape shop in the country will be closed.” I’m not sure that would be such a bad thing. It seems that the rhetoric pitting Big Tobacco against little vape shops has ignored the real concern over the potential health hazards of vaping instead of smoking tobacco products.

While acknowledging there are anecdotal reports that some people have used e-cigarettes to stop smoking, Mitch Zeller of the FDA said the agency needed more data on how e-cigarettes are being used, including how many people who use e-cigarettes never used tobacco products before. “I hope everyone can agree that kids should not initiate on e-cigarettes simply because of the harm that can come from nicotine.”

Lobbyists for the cigar and e-cigarette industries pushed Congress to create bills that would either exempt them from the new rules or grandfather in products already on the market. Representative Tom Cole of Oklahoma, the chairman of the House subcommittee funding health programs, added a measure to the FDA’s funding bill for next year that would get rid of the February 2007 effective date. Cole said his legislation “provides the same framework for new tobacco products without needlessly subjecting small businesses to unnecessary regulations and without treating law abiding adults like naïve children.”

Mitch Zeller noted that Cole’s measure would eliminate all reviews of e-cigarette products that came on the market after 2007 (the vast majority of them) and clear the way for future products that are similar in design. The proposal “would have an enormously adverse impact on public health and the ability of FDA to do its job.” Beginning on August 8, 2016, the FDA will start regulating e-cigarettes, all cigars, waterpipes (hookahs), tobacco, pipe tobacco, and nicotine gels.

So this leads us to the newest published study of e-cigarettes in the journal Environmental Science & Technology by Sieiman et al., “Emissions from Electronic Cigarettes.” Their study found that all electronic cigarettes emit harmful chemicals. Levels of those toxic compounds are affected by factors in the use of e-cigarettes such as temperature, and the type and age of the device.

A news release from Berkley Lab said the study found that the thermal decomposition of propylene glycol and glycerin leads to the emissions of toxic chemicals such as acrolien and formaldehyde. Propylene glycol and glycerin are found in most e-liquids, the substance vaporized in e-cigarettes. There were 31 different toxic chemicals found at significant levels in e-cigarette vapor. Hugo Destailats, one of the researchers said that while it may be true emissions are much lower from e-cigarettes than conventional ones, that’s only true for certain users, for example, long time smokers who cannot quit. “Regular cigarettes are super unhealthy. E-cigarettes are just unhealthy.”

One of their findings indicated there was a big difference in emissions between the first and last puffs. They found that vapor temperature rose quickly in the first 5 to 10 minutes until it reached a steady state temperature around the twentieth puff.  Emission levels between the first few puffs and the steady state increased by a factor of ten of more. Factors affecting the levels included the device used, the battery voltage and the emitted compound.

In order to test effects due to the device aging, the researchers used a single device over nine consecutive 5-puff cycles without cleaning it. Emissions for formaldehyde, acetaldehyde, and acrolein, which are all irritants or carcinogens, increased. “In some cases we saw formaldehyde levels increase 60 percent between cycles 1 and 9.”

This effect is consistent with the buildup of polymerization byproducts on or near the coil leading to accumulation of the sort of residues that are often referred to in the blogosphere as ‘coil gunk’ or ‘caramelization.’ Heating these residues would provide a secondary source of volatile aldehydes.

Looking at the effect of voltage on emissions, the researchers found that as the voltage increased, both the amount of e-liquid consumed per puff and the vapor temperature were higher. Destailats pointed out this did not mean e-cigarettes were safer to use at lower temperatures. “We found there are emissions of toxic chemicals at any temperature at which you use the device. . . . And the higher the temperature, the more emissions.”

This won’t be the last word in the e-cigarette saga. The back-and-forth conflict is just getting started. You should also keep in mind there is another aspect to the e-cigarette conflict. E-cigarettes are modified or “hacked” to smoke marijuana—dry herb, hash oil or THC liquids. They’re called, ironically, e-joints. See “E-Cigarettes and E-Joints” or do your own Google search.