Letters to the Editor
Aripiprazole Reduces Alcohol Use
Dear Editor:
Few pharmacotherapy options exist for the treatment of alcohol dependence. Recent reports suggest that newer atypical antipsychotic medications may reduce alcohol craving and use when prescribed to patients with alcohol abuse or dependence (1).
Aripiprazole, a new atypical antipsychotic, has partial dopamine agonist and antagonist effects (2). Since dopamine stimulation in the nucleus accumbens has been suggested to cause addictive behaviour, aripiprazole’s partial dopamine agonist effects in this area of the brain may reduce this behaviour (3). We present a case wherein aripiprazole reduced alcohol craving and use.
Case Report
Mr S is white, aged 39 years, and diagnosed with schizophrenia, paranoid type, according to DSM-IV criteria. He received outpatient psychiatric treatment with psychotherapy and pharmacotherapy (olanzapine 20 mg daily). He continued to experience delusions of reference and periodic auditory hallucinations. His Brief Psychiatric Rating Scale (BPRS) score was 31.
Mr S also met the DSM-IV diagnostic criteria for alcohol dependence, which started at age 18 years with an occasional beer and progressed to his drinking a 12-pack daily. He denied any medical problems, but admitted to problems with employment and relationships caused by his alcohol use. Despite several attempts to quit, including treatment in 2 substance use treatment programs, he relapsed repeatedly. His current use amounted to 6 cans of beer daily. He refused to attend any addiction program, including Alcoholics Anonymous.
He also suffered from glaucoma. During treatment, he discovered through the Internet that olanzapine might exacerbate glaucoma, which led him to stop olanzapine on his own. At his next meeting, his psychiatrist discussed several options, including the newer atypical antipsychotic, aripiprazole. Mr S finally agreed to try this medication, which has limited anticholinergic effects and therefore might not worsen glaucoma. Aripiprazole was started at 10 mg initially and increased to 20 mg daily over 2 months.
During follow-up, Mr S reported reduced psychotic symptoms (his BPRS score decreased to 23). He stopped daily drinking and reported decreased alcohol craving (his Pennsylvania Craving Scale score decreased from 27 to 5; his Self-Report Likert Craving Scale score decreased from 7 to 3; and his Addiction Severity Index score for alcohol decreased from 6 to 2). His only reported side effect was increased anxiety, which resolved within a week.
Discussion
Approximately 50% of patients with schizophrenia abuse alcohol and (or) drugs. The older typical antipsychotic medications reportedly did not affect substance use when prescribed in such patients and might have worsened it (4–6)—probably because of their strong antagonist effect at the dopamine D2 receptors in the nucleus accumbens. When stimulated by drugs of abuse or by alcohol, these cause sensations of reward or the experience of a “high” (7). Aripiprazole is unique in that it has partial dopamine agonist and antagonist properties. The dopamine agonistic effects may stimulate the dopamine receptors in the nucleus accumbens and decrease the desire for further stimulation from alcohol. While other mechanisms may be involved, Mr S’s sequential reduction in alcohol use after starting aripiprazole suggests causality.
This is the first report of aripiprazole’s effect on alcohol use. More research is needed to establish the benefits of aripiprazole in regard to alcohol and other substance use disorders. Until then, some dual diagnosis patients may benefit from aripiprazole, which may reduce craving for and use of alcohol.
References
1. Sattar SP, Grant K, Bhatia SC, Petty F. Potential use of quetiapine in treatment of substance dependence disorders. J Psychiatry Neurosci 2004;29:452–7.
2. Argo TR, Carnahan RM, Perry PJ. Aripiprazole, a novel atypical antipsychotic drug. Pharmacotherapy 2004;24:212–28.
3. Pilla M, Pearchon S, Sautel F, Garrido F, Mann A, Wermuth CG, and others. Selective inhibition of cocaine-seeking behavior by a partial dopamine D-3 receptor agonist. Nature 1999;400:371–5.
4. Bowers MB Jr, Mazure CM, Nelson JC, Jatlow DI. Pyschogenic drug use and neuroleptic response. Schizophr Bull 1990;16:81–5.
5. Sirrius SG. Pharmacologic treatment of substance abusing Schizophrenia patients. Schizophr Bul.1990;16:111–22.
6. McEvoy JP, Freudenreich O, Levin ED, Rose JE. Haloperidal increases smoking in patients with schizophrenia. Psychopharmacol 1995;119:124–6.
7. Green AI, Zimmet SV, Strous RD, Schildkraut JJ. Clozapine for co-morbid substance use disorder and schizophrenia: do patients with schizophrenia have a higher reward deficiency syndrome that can be ameliorated by clozapine. Harv Rev Psychiatry 1999;6: 287–96.
Mustafa Warsi, MD
S Pirzada Sattar, MD
Subhash C Bhatia, MD
Frederick Petty, PhD, MD
Omaha, Nebraska
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