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A Double-Blind Randomized Controlled Trial of Daridorexant for Alcohol Use Disorder
Project Summary/Abstract This R01 application proposes integrating a randomized, double-blinded, placebo-controlled clinical trial into a real-world treatment setting to test whether the dual orexin receptor antagonist (DORA) daridorexant reduces alcohol craving and use and improves total sleep time among patients with alcohol use disorder (AUD) and co-occurring sleep disturbance. DORAs have shown promise in modulating reward and reducing alcohol self- administration in preclinical models. Further, DORAs are FDA-approved for insomnia, are highly efficacious for treatment of sleep disturbance, have a favorable safety profile, and demonstrate low abuse liability. Thus, DORAs are a highly promising treatment for AUD, particularly among persons that have co-occurring sleep disturbance. To this end, the proposed study will recruit individuals from a residential treatment facility, following completion of medically managed withdrawal and stabilization. Eligible participants will be randomized to daridorexant to placebo, and will complete measures of alcohol craving, total sleep time (assessed through both wireless electroencephalography and biometric data collection), and adverse events. Following discharge from residential treatment, participants will continue taking the study medication for two weeks while submitting daily reports of alcohol use, alcohol craving, sleep diaries, and biometric sleep data. Participants will also be prompted to submit three-times weekly random breath alcohol level using a portable BACtrack S80 breathalyzer, and will attend weekly check-in visits to assess adverse events and to confirm daily alcohol reports. A one-month follow-up assessment will be conducted to collect long-term data on alcohol use, AUD symptoms, and sleep. Ultimately, this study has the potential to identify a novel treatment for co- occurring AUD and sleep disturbance, and will address the following specific aims: (1) Test whether daridorexant reduces alcohol craving and post-treatment alcohol use relative to placebo. (2) Test whether daridorexant improves objectively measured total sleep time relative to placebo. (3) Examine the frequency of adverse events in persons assigned to daridorexant relative to placebo. If these aims are supported, then we will also explore whether effects are moderated by insomnia severity. We will also examine if the effects replicate across residential environments (with structured sleep/wake times and close monitoring of medication adherence) and outpatient environments (with self-imposed sleep/wake times and self-dosing). Currently, there are no FDA approved medications indicated for both AUD and insomnia. This innovative strategy aims to address a critical gap by investigating the effectiveness of daridorexant in modulating alcohol craving and alcohol use. This study will contribute to a growing literature on the role of the orexin system in reward and alcohol use.
Gut food cravings? How gut signals control appetite and metabolism
Gut-derived signals regulate metabolism, appetite, and behaviors important for mental health. We have performed a large-scale multidimensional screen to identify gut hormones and nutrient-sensing mechanisms in the intestine that regulate metabolism and behavior in the fruit fly Drosophila. We identified several gut hormones that affect fecundity, stress responses, metabolism, feeding, and sleep behaviors, many of which seem to act sex-specifically. We show that in response to nutrient intake, the enteroendocrine cells (EECs) of the adult Drosophila midgut release hormones that act via inter-organ relays to coordinate metabolism and feeding decisions. These findings suggest that crosstalk between the gut and other tissues regulates food choice according to metabolic needs, providing insight into how that intestine processes nutritional inputs and into the gut-derived signals that relay information regulating nutrient-specific hungers to maintain metabolic homeostasis.
The anterior insular cortex in the rat exerts an inhibitory influence over the loss of control of heroin intake and subsequent propensity to relapse
The anterior insular cortex (AIC) has been implicated in addictive behaviour, including the loss of control over drug intake, craving and the propensity to relapse. Evidence suggests that the influence of the AIC on drug-related behaviours is complex as in rats exposed to extended access to cocaine self-administration, the AIC was shown to exert a state-dependent, bidirectional influence on the development and expression of loss of control over drug intake, facilitating the latter but impairing the former. However, it is unclear whether this influence of the AIC is confined to stimulant drugs that have marked peripheral sympathomimetic and anxiogenic effects or whether it extends to other addictive drugs, such as opiates, that lack overt acute aversive peripheral effects. We investigated in outbred rats the effects of bilateral excitotoxic lesions of AIC induced both prior to or after long-term exposure to extended access heroin self-administration, on the development and maintenance of escalated heroin intake and the subsequent vulnerability to relapse following abstinence. Compared to sham surgeries, pre-exposure AIC lesions had no effect on the development of loss of control over heroin intake, but lesions made after a history of escalated heroin intake potentiated escalation and also enhanced responding at relapse. These data show that the AIC inhibits or limits the loss of control over heroin intake and propensity to relapse, in marked contrast to its influence on the loss of control over cocaine intake.
Neuroimaging in human drug addiction: an eye towards intervention development
Drug addiction is a chronically relapsing disorder characterized by compulsive drug use despite catastrophic personal consequences (e.g., loss of family, job) and even when the substance is no longer perceived as pleasurable. In this talk, I will present results of human neuroimaging studies, utilizing a multimodal approach (neuropsychology, functional magnetic resonance imaging, event-related potentials recordings), to explore the neurobiology underlying the core psychological impairments in drug addiction (impulsivity, drive/motivation, insight/awareness) as associated with its clinical symptomatology (intoxication, craving, bingeing, withdrawal). The focus of this talk is on understanding the role of the dopaminergic mesocorticolimbic circuit, and especially the prefrontal cortex, in higher-order executive dysfunction (e.g., disadvantageous decision-making such as trading a car for a couple of cocaine hits) in drug addicted individuals. The theoretical model that guides the presented research is called iRISA (Impaired Response Inhibition and Salience Attribution), postulating that abnormalities in the orbitofrontal cortex and anterior cingulate cortex, as related to dopaminergic dysfunction, contribute to the core clinical symptoms in drug addiction. Specifically, our multi-modality program of research is guided by the underlying working hypothesis that drug addicted individuals disproportionately attribute reward value to their drug of choice at the expense of other potentially but no-longer-rewarding stimuli, with a concomitant decrease in the ability to inhibit maladaptive drug use. In this talk I will also explore whether treatment (as usual) and 6-month abstinence enhance recovery in these brain-behavior compromises in treatment seeking cocaine addicted individuals. Promising neuroimaging studies, which combine pharmacological (i.e., oral methylphenidate, or RitalinTM) and salient cognitive tasks or functional connectivity during resting-state, will be discussed as examples for using neuroimaging for empirically guiding the development of effective neurorehabilitation strategies (encompassing cognitive reappraisal and transcranial direct current stimulation) in drug addiction.
Effect of social choice-induced voluntary abstinence on incubation of methamphetamine craving and AMPA receptor expression in nucleus accumbens core
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