Karpyak, Victor M.

IntroductionAlcohol withdrawal syndrome (AWS) is among the most severe components of alcohol dependence (AD). Severe AWS, especially complicated with seizures and delirium, was a common reason for medical complications and death. The introduction of benzodiazepines decreased but did not eliminate those risks. The definition of AWS evolved in different versions of Diagnostic and Statistical Manual for Mental Disorders (DSM) from having hand tremor plus one or more other symptoms in DSM-III-R to any two or more symptoms in DSM-IV, which was retained in the current version of DSM-5.ObjectivesComparing subgroups of individuals with AUD based on AWS symptoms profile to define phenotypes for investigation of biological underpinnings of AWS phenomenology and treatment response.MethodsTreatment-seeking individuals diagnosed with DSM-IV alcohol dependence (AD; n=473; 35.5% females) were assessed with Psychiatric Research Interview for Substance and Mental Disorders (PRISM), Timeline Follow back (past 90 days) alcohol consumption, Penn Alcohol Craving Scale (PACS), Pittsburgh Sleep Quality Index (PSQI), Patient Health Questionnaire-9 (PHQ9), and General Anxiety Disorder-7 (GAD-7). Latent class analysis was used to classify subjects according to lifetime prevalence of AWS symptoms according to DSM-III-R or DSM-IV/5. Demographic and other clinical variables were compared among clusters by linear model ANOVA and chi-squared test.ResultsFour clusters were identified: subjects with (1) no history of meeting any AWS criteria (n=50); (4) with complete number of AWS symptoms, meeting both DSM definitions (n=259); and two clusters of subjects with smaller number of AWS symptoms: (3) those meeting only DSM-IV/5 criteria (n=94) and (2) those also meeting DSM-III-R criteria (n=70). Compared to cluster 2, the Cluster 3 members had higher frequency of anxiety, insomnia, and restlessness during withdrawal. The clusters also differed in the total number of drinks (p=0.021), average drinks per drinking days (p=0.013), history of anxiety disorder (p=0.006), substance-induced depression (p=0.019), and higher scores of PSQI (p<0.001), PHQ9 (p<0.001), and GAD-7 (p<0.001) with a relative increase in frequency between clusters as follows 1<2<3<4. Group 4 also had the highest percentages of subjects with history of seizure, delirium or hallucinations.ConclusionsDifferent definitions of AWS capture clusters of AD patients with different symptomatology, comorbidity and consumption patterns. Understanding of biological underpinnings behind those differences may guide improvement in personalized treatment selection.Disclosure of InterestNone Declared

Abstract Background Acamprosate is an FDA-approved medication for the treatment of alcohol use disorder (AUD), however, only about 50% of patients will respond to acamprosate. Previously, we conducted an acamprosate trial (n=442), which is one of the largest acamprosate clinical studies ever conducted and currently the only study with multi-omics data. To date, no biological measures are utilized to predict response to acamprosate treatment. Aims & Objectives We set out to apply our established pharmaco-omics informed genomics strategy to identify potential biomarkers associated with acamprosate treatment response. Method Our open-label acamprosate clinical trial recruited 442 patients with AUD, all of whom were treated with acamprosate for three months. The primary outcomes were 1) relapse to alcohol use and 2) relapse to heavy drinking. Alcohol consumption was measured using the self-reported timeline follow back method. Plasma protein levels were measured using Olink proximity extension immunoassays. Results Our established “Pharmaco-Omics-informed genome-wide association study (GWAS)” research strategy identified 12 proteins, including interleukin-17 receptor B (IL17RB), that were associated with acamprosate treatment response. A GWAS for IL17RB concentrations identified several genome-wide significant signals. Specifically, the top hit single nucleotide polymorphism (SNP) rs6801605 with a minor allele frequency of 38% in the European American population mapped 4 kilobase (Kb) upstream of IL17RB, and intron 1 of the choline dehydrogenase (CHDH) gene on chromosome 3 (p: 4.8E-20). The variant genotype (AA) for the SNP rs6801605 was associated with lower IL17RB protein expression. In addition, we identified a series of genetic variants in IL17RB that were associated with acamprosate treatment outcomes. Furthermore, the variant genotypes for all of those IL17RB SNPs were protective against alcohol relapse. Finally, we demonstrated that the basal level of mRNA expression of IL17RB was inversely correlated with those of nuclear factor-κB (NF-κB) subunits, and a significantly higher expression of NF-κB subunits was observed in AUD patients who relapsed to alcohol use. Discussion & Conclusions This study illustrates that IL17RB genetic variants might contribute to acamprosate treatment outcomes. This series of studies represents an important step toward generating functional hypotheses that could be tested to gain insight into mechanisms underlying variation in acamprosate treatment response phenotypes.

AbstractBackground and AimsSex‐related hormones and proteins may underlie sex differences in alcohol use disorder characteristics and consequences. Previous reports suggest steroid sex hormones may influence alcohol consumption behaviors while proteins that regulate their circulation levels are rarely investigated. Following up on our earlier study of individual sex‐related hormones' associations with alcohol dependence (AD), this study measured the associations between the combinations of sex‐related hormones and proteins and AD in a larger sample.DesignSex‐stratified case‐control comparison and clustering of plasma sex‐related hormone and protein levels, plus a genome‐wide association study on the AD‐associated hormone and protein combinations.SettingAddiction treatment programs in the United States.ParticipantsFour hundred treatment‐seeking recently abstained AD patients (median = 24.5 days) and 388 age‐and‐sex‐matched controls from a community biobank (male:female ≈ 2:1).MeasurementsPlasma levels of total testosterone, estrone (E1), estradiol (E2), follicle‐stimulating hormone (FSH), luteinizing hormone (LH), sex hormone binding globulin (SHBG) and albumin.FindingsIn males, we found higher E2 [β = 0.13, Punadjusted < 0.001, false discovery rate (FDR) = 0.005], progesterone (β = 0.01, Punadjusted = 0.025, FDR = 0.054), LH (β = 0.12, Punadjusted = 0.017, FDR = 0.044) and albumin (β = 0.09, Punadjusted < 0.001, FDR = 0.005) in AD patients than controls; in females, we observed lower E1 (β = −0.24, Punadjusted = 0.024, FDR = 0.113) and progesterone (β = −1.86, Punadjusted = 0.026, FDR = 0.113) and higher albumin (β = 0.18, Punadjusted < 0.001, FDR = 0.001) in AD patients than controls. Three principal components (PCs), reflecting hormone signatures, were statistically significantly associated with AD in each sex: PC1 (TT, E2 and SHBG; β = −0.15, P = 0.016), PC3 (E1, progesterone and albumin; β = 0.28, P = 0.007) and PC4 (SHBG and albumin; β = 0.34, P = 0.001) in males; PC3 (progesterone and albumin; β = −0.38, P = 0.009), PC4 (TT and albumin; β = −0.49, P = 0.001) and PC5 (TT and progesterone; β = 0.54, P = 0.004) in females. Statistically significant SNP × group associations were found in females between PC4 and polymorphisms in RP51004I9.1 (top SNP: rs6082693; P = 5.41E‐12) and in males between PC3 and a genomic locus that contained SLC35E4, DUSP18 and OSBP2 (top SNP: rs13053277; P = 1.77E‐07).ConclusionsThree sex‐related hormone and protein signatures appear to be associated with alcohol dependence in each sex. Peripheral levels of sex‐related hormones and proteins, as well as their combinations, could be altered in people with alcohol dependence who have abstained for a few weeks compared with controls, and such differences may be sex‐specific.

AbstractBackgroundWorkforce engagement can provide structure, income, feelings of accomplishment, and personal contacts, growing an individual's recovery capital (RC). Employed individuals are also more likely to complete addiction treatment. We sought to investigate whether changes in employment status from alcohol treatment admission to discharge correlated with changes in alcohol use frequency over those time points.MethodsThe Treatment Episode Dataset—Discharges (2017–2021) provided the data. Employment status (full‐time, part‐time, unemployed, and not in labor force) and alcohol use frequency (daily use, some use, and no use in past month) were assessed at treatment admission and discharge. Changes in alcohol use frequency during treatment were recorded as Reduction or No reduction. Logistic regression using reduced alcohol use frequency as the dependent variable included employment status at admission and discharge separately. A second analysis included employment status at both admission and discharge and their interaction term. An adjusted model included all covariates (race, ethnicity, age, education, and referral source), with its results being used to derive the marginal probabilities of reduced alcohol use frequency.ResultsThere were 856,085 alcohol treatment admissions over the 5 years, with 221,724 (25.9%) first admissions. Transitioning from not in the labor force or unemployed to full‐time saw the largest percentage of encounters decreasing alcohol use frequency: 71.9% (95% CI: 70.0–73.7) and 69.3% (95% CI: 68.1–70.5), respectively. Those remaining unemployed had the lowest reduction at 26.7% (95% CI: 26.3–27.1), with a sample reduction of 42.7% (95% CI: 42.5–42.9) overall. Far more people (60.4%) completed treatment within the Reduction group than in the No reduction group (30.2%).ConclusionsFindings suggest that improving employment status may be relevant for reducing alcohol use frequency. This aligns with past work showing overall improved health outcomes with lower unemployment levels. Incorporating vocational training and workforce engagement activities into outpatient treatment may help augment traditional approaches to improve an individual's RC.

ABSTRACTOpioid use disorder is a persistent epidemic despite several FDA‐approved medications for its treatment. While the pathogenesis of opioid use disorder has been classically attributed to dopamine pathways in the brain, there is emerging evidence and interest surrounding the role of inflammation and inflammatory signaling in its development and treatment. Buprenorphine has become the most prescribed medication for opioid use disorder, largely due to its ease of access and tolerability. This review aimed to better characterize contemporary knowledge of how buprenorphine modulates the human immune system and inflammatory functions in this population. A comprehensive review was conducted using 11 key databases, including Embase, MEDLINE, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. This review captured 8177 records, and 14 studies were ultimately selected for inclusion and discussion in this review. Notably, all 14 clinical studies evaluated buprenorphine's effect on the peripheral immune system, and the majority of the studies supported the notion that initiation and maintenance of buprenorphine restore immune suppression caused by opioid use disorder. In addition, we discuss how recent and ongoing work utilizing advanced imaging and cellular technologies is advancing the understanding of how buprenorphine affects the immune and inflammatory signaling in the brain.

Alcohol use disorder (AUD) is the most prevalent substance use disorder. Excessive alcohol consumption leads to a range of health issues. We set out to identify inflammatory markers linked to alcohol consumption, which might ultimately offer novel insight into genetic underpinnings and have implications for alcohol-associated disease. Alcohol consumption and blood-based multi-omics data were collected by The Mayo Clinic Center for Individualized Treatment of Alcohol Dependence study. Plasma samples from patients with AUD were used for proteomics analysis using the OLINK “Explore Inflammation” panel (n=410). Liver enzymes were also measured. A genome-wide association study (GWAS) was performed to explore the relationship between genetic variants and plasma TREM2 levels. Our findings show thatplasma triggering receptor expressed on myeloid cells 2 (TREM2), a key gene associated with neurodegenerative disease, was the most significant signal correlated with alcohol consumption, and has also been associated with liver enzyme levels in patients with AUD. We identified the rs7232 single nucleotide polymorphism (SNP) in MS4A6A as a key genetic variant associated with plasma TREM2 levels, with the minor allele (A) linked to higher TREM2 levels and increased alcohol consumption, particularly in men. Furthermore, MA4A6A is an ethanol-responsive gene in a SNP-dependent manner, and the variant genotype of the rs7232 SNP was associated with lower expression for MA4A6A due to proteasome-mediated protein degradation. In summary, this study provides insight into the relationship between plasma TREM2 levels, alcohol consumption, and liver function in AUD patients, shedding light on genetic factors underlying alcohol-related diseases.

Abstract Objective Sex-specific differences impact vulnerability to alcohol effects, dependence (AD) and related phenotypes. Previous studies demonstrated that sex-related hormone and protein levels may contribute to those differences in sex-specific manner. However, previous studies were limited by sample size, the depths of phenotyping assessments and/or the number of hormones and proteins measured at the same time. Here, we investigated the association of the sex-related hormone (testosterone, estrogens, and progesterone) and protein (FSH, LH, SHBG, and albumin) levels with AD in males and females treated in community-based programs compared to age and sex-matched controls. We also investigated the associations of AD with the combined plasma sex-related hormone/protein “signatures” in the same groups of study subjects. Methods Sex-related hormone and protein levels were measured in plasma samples collected from 401 male and female subjects meeting DSM-IV-TR criteria for AD and 401 age and sex matched controls. Psychiatric Research Interview for Substance and Mental Disorder (PRISM) was used to capture DSM-IV diagnoses of substance use and other psychiatric disorders. All analyses were stratified by sex. Associations between each plasma sex-related hormone/protein level and AD was assessed with multivariable linear regression adjusted for age and BMI for males and age, BMI, and menopause status for females. Progesterone was defined as a continuous variable and a binary variable based on a lower laboratory detection limit of 0.1 ng/mL. We used principal component analysis to define hormone/protein signatures. Hormones and proteins with factor loadings =/&gt; |0.4| were considered important drivers for the corresponding principal components (PCs). Resulting PCs were entered into a sex-stratified logistic regression model with adjustment of age and BMI to determine which PCs were associated with AD. Results Male AD subjects had higher estradiol and albumin levels (p &lt;0.00625) as well as progesterone and LH levels (p &lt;0.05) compared to controls. Progesterone was detected in a larger proportion of AD subjects than in the controls (62.6% vs. 47.7%; p = 0.017). In females, albumin levels were significantly higher (p &lt;0.00385) while estrone and progesterone levels were lower (p &lt;0.05) in AD subjects than the controls. Total testosterone (TT) levels were relatively higher in AD subjects but differences between groups were not significant (p &gt;0.05). In males, the first PC (PC1) that accounted for the majority of data variance was significantly associated with AD (p=0.016) and was mostly driven by TT, estrone, estradiol and SHBG. PC3 (driven by albumin, progesterone and estradiol) and PC4 (driven by albumin and SHBG) were also associated with AD (p=0.007 and p&lt;0.001, respectively). In females, PC1 (driven by estrone, estradiol, SHBG) was not significantly associated with AD. However, PC3 (driven by Albumin and progesterone), PC4 (driven by TT and Albumin) and PC5 (driven by progesterone and TT), were significantly associated with AD (p=0.009, p=0.001, p=0.004, respectively). Conclusion Our findings indicate that individual hormone/protein levels as well as hormone/protein combination signatures associated with AD are different in male and female alcoholics. Future studies should investigate physiological mechanisms reflected in hormone/protein signatures captured by PC analyses.

Abstract Background Alcohol consumption behaviors and alcohol use disorder risk and presentation differ by sex, and these complex traits are associated with blood concentrations of the steroid sex hormones, testosterone and estradiol, and their regulatory binding proteins, sex hormone binding globulin (SHBG) and albumin. Genetic variation is associated with alcohol consumption and alcohol use disorder, as well as levels of steroid sex hormones and their binding proteins. Methods To assess the contribution of genetic factors to previously described phenotypic associations between alcohol-use traits and sex-hormone levels, we estimated genetic correlations (rg) using summary statistics from prior published, large sample size genome-wide association studies (GWAS) of alcohol consumption, alcohol dependence, testosterone, estradiol, SHBG, and albumin. Results For alcohol consumption, we observed positive genetic correlation (i.e. genetic effects in the same direction) with total testosterone in males (rg = 0.084, p = 0.007) and trends toward positive genetic correlation with bioavailable testosterone (rg = 0.060, p = 0.084) and SHBG in males (rg = 0.056, p = 0.086) and with albumin in a sex-combined cohort (rg = 0.082, p = 0.015); however in females, we observed positive genetic correlation with SHBG (rg = 0.089, p = 0.004) and a trend toward negative genetic correlation (i.e. genetic effects in opposite directions) with bioavailable testosterone (rg = -0.064, p = 0.032). For alcohol dependence, we observed a trend toward negative genetic correlation with total testosterone in females (rg = -0.106, p = 0.024) and positive genetic correlation with BMI-adjusted SHBG in males (rg = 0.119, p = 0.017). Several of these genetic correlations differed between females and males and were not in the same direction as the corresponding phenotypic associations. Conclusions Findings suggest that shared genetic effects may contribute to positive associations of alcohol consumption with albumin in both sexes, as well as positive associations between alcohol consumption and bioavailable testosterone and between alcohol dependence and SHBG in males. However, relative contributions of heritable and environmental factors to associations between alcohol-use traits and sex-hormone levels may differ by sex, with genetic factors contributing more in males and environmental factors contributing more in females.

AbstractBackground and ObjectivesTranscranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) have evidence for their potential in the treatment of substance use disorders (SUD). Medication for addiction treatment (MAT) is underutilized and not always effective. We identified randomized controlled trials (RCTs) and case studies that evaluated the effectiveness of TMS or tDCS used concurrently with MAT in SUD treatment.MethodsA systematic review of published literature following Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines was conducted on 6/1/2023 by a medical librarian. Craving‐related scales were extracted for an effect size calculation. The Physiotherapy Evidence Database (PEDro) scale assessed study quality.ResultsEight studies (7 RCT, 1 case) including 253 individuals were published from 2015 to 2022, 5 of which had available data for meta‐analysis. TMS or tDCS combined with MAT significantly reduced craving‐related measures relative to sham stimulation (Hedges' g = −0.42, confidence interval: −0.73 to −0.11, p < .01). Opioid use disorder, methadone, and the dorsolateral prefrontal cortex were the most commonly studied SUD, MAT, and target region.Discussion and ConclusionsOur results show a significant effect; however, is limited by a small number of studies with heterogeneous methodology across intervention methods and SUDs. Additional trials are needed to fully assess the clinical impact and mechanisms of combined brain stimulation and pharmacotherapy. We discuss a possible mechanism for synergism from these treatment combinations.Scientific SignificanceAdds the first systematic review of combination treatment with TMS or tDCS and MAT in SUD patients to the literature and estimates its overall effect size.

AbstractAimsBrain-derived neurotrophic factor (BDNF) levels may be associated with alcohol use disorders (AUD) and alcohol consumption, correlate with sleep disturbance and be influenced by sex differences and sex hormones. These associations have not been examined in a single sample accounting for all these factors.MethodsData from 190 participants (29.4% female) with AUD were utilized. Sleep quality, craving intensity, depression, anxiety and alcohol consumption were assessed using the Pittsburgh Sleep Quality Index (PSQI), Penn Alcohol Craving Scale (PACS), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7) and Timeline Follow Back for 90 days(TLFB 90). Inventory of Drug Taking Situations (IDTS) assessed the tendency to drink in positive/negative emotional states. Serum BDNF (sBDNF) and plasma sex hormones (estrogen, progesterone, testosterone, FSH and SHBG) were measured. Pearson correlation analyses were used to examine the association between sBDNF and these measures in the entire sample and in men and women separately. Higher order interaction effects between these factors were evaluated for their association with sBDNF using a backward selection model.ResultsNo significant correlations between sBDNF levels and sex hormones, PSQI, PHQ-9, PACS, IDTS scores and alcohol consumption were found (all P-values &gt; 0.05). sBDNF levels were negatively correlated with GAD-7 scores in men (r = −0.1841; P = 0.03). When considering all quadratic and two-way interactions among PSQI, PHQ-9, GAD-7, mean and max drinks/day, number of drinking days, heavy drinking days, and sex no higher order moderating effects of sBDNF levels were found.ConclusionOur study revealed no significant associations between sBDNF and alcohol measures, sleep, depression and sex hormones suggesting limited utility as a biomarker.