New Treatment for Alcohol and Nicotine Dependence

• Continuous abstinence rate for smoking [ Time Frame: In the last 4 weeks of treatment ] [ Designated as safety issue: No ]
  This rate is determined by a combination of self-report and CO monitoring after the quit date
• percent heavy drinking days [ Time Frame: In the last 4 weeks of treatment ] [ Designated as safety issue: No ]
  Heavy drinking day is a day where 5 or more alcoholic drinks have been consumed . The timeline follow-back (TLFB) method of measuring alcohol consumption will be used.

• Quality of life [ Time Frame: In the last 4 weeks of treatment ] [ Designated as safety issue: No ]
  Quality of life will be assessed using The Quality of Life Enjoyment and Satisfaction Questionnaire
• Craving for alcohol and nicotine [ Time Frame: During the last 4 weeks of treatment ] [ Designated as safety issue: No ]
  alcohol and nicotine craving scales will be used to monitor craving

This research study aims to test whether topiramate (a drug that is being used for seizure) will help individuals who have problems with both alcohol and nicotine. The investigators believe that individuals taking topiramate will be more successful at abstaining from both alcohol and nicotine than individuals taking placebo.

We propose a novel pharmacological strategy for treating alcohol and nicotine dependence concomitantly.

The reinforcing effects of both alcohol and nicotine are mediated through the cortico-mesolimbic dopamine (CMDA) system, and the concomitant use of both drugs enhances their pharmacological effects. We propose a better approach to control dopamine (DA) effects by contemporaneous indirect modulation of DA release and its functional expression. Both DA release from its cell bodies in the ventral tegmental area and the expression of its reinforcing effects through the cortico-mesolimbic system are modulated by GABA efferents under the tonic control of glutamate-mediated excitatory amino acid pathways. Thus, it is reasonable to hypothesize that a medication that facilitates cortico-mesolimbic GABAergic function and inhibits glutamate action should diminish both nicotine's and alcohol's reinforcing effects by inhibiting the release of midbrain DA and its functional expression through pathways projecting from the nucleus accumbens to the cortex. The promise of this novel approach is exemplified by our recent proof-of-concept demonstration that topiramate compared with placebo significantly improved smoking abstinence rates and decreased serum cotinine levels among alcoholdependent smokers. An important clinical effect of topiramate in alcohol-dependent individuals appears to be that its anti-withdrawal effects promote the gradual tapering of drinking. Hence, due to this unique antiwithdrawal effect of topiramate, we propose to adopt the same methodology for treating alcohol-dependent individuals, as is common practice with smokers, of setting a target quit date (TQD) after which relapse to either drug can be measured. We propose an 18-week, double-blind clinical trial with follow-up visits at 1 month and 3 months, in which alcohol-dependent smokers will receive brief behavioral compliance enhancement treatment (BBCET) plus a smoking self-help manual as their psychosocial treatment, and will be randomized to receive placebo,high-dose topiramate (up to 250 mg/day), or low-dose topiramate (up to 125 mg/day) to prevent relapse to heavy drinking and smoking. Each of the 3 treatment arms shall contain 98 individuals, with a total N of 294.

The TQD will occur at the beginning of the 6th week of treatment. Our primary objective is to determine whether both low- and high-dose topiramate will be more efficacious than placebo at reducing the percentage of heavy drinking days and increasing the continuous abstinence rate for smoking determined by a combination of self-report and CO monitoring after the TQD and in the last 4 weeks of treatment. We also will be able to determine whether a lower dose of topiramate is as efficacious as the higher dose and, therefore, is associated with a lower adverse profile. Our secondary objectives are to test whether topiramate will be more efficacious than placebo at improving quality of life and reducing craving after the TQD and in the last 4 weeks of treatment and whether this improvement will be sustained in the follow-up phase.

• Alcohol Dependence
• Nicotine Dependence

• Drug: Topiramate with brief behavioral enhancement therapy
  high-dose topiramate (up to 250 mg/day), or low-dose topiramate (up to 125 mg/day)
  Other Name: Topamax
• Drug: Placebo with brief behavioral enhancement therapy
  placebo
  Other Name: sugar pill

• Experimental: topiramate
  topiramate with brief behavioral enhancement therapy
  Intervention: Drug: Topiramate with brief behavioral enhancement therapy
• Placebo Comparator: Placebo
  Placebo with brief behavioral enhancement therapy
  Intervention: Drug: Placebo with brief behavioral enhancement therapy

Inclusion Criteria:

• Males and females who have given written informed consent
• Subjects must be above the age of 18
• Good physical health
• DSM-IV diagnosis of alcohol dependence. Subjects who abuse other substances will be included as long as their use patterns would not preclude safe participation or adequate compliance with the protocol.
• Score of ≥3 on the Fagerstrom Test for Nicotine Dependence
• Smoking ≥10 cigarettes/day Subjects must provide evidence of stable residence
• The pregnancy test for females of child-bearing potential at screen and prior to randomization must be negative. Additionally, women of child-bearing potential must be using an acceptable form of contraception.
• Literate in English and able to read, understand, and complete the rating scales and questionnaires accurately, follow instructions, and make use of the behavioral treatments
• Willing to participate in a treatment program for alcohol and nicotine dependence

Exclusion Criteria:

Please contact site for additional information

• National Institute on Alcohol Abuse and Alcoholism (NIAAA)
• M.D. Anderson Cancer Center
• University of California, San Diego