Alternative Therapies in Treating Alcohol and Drug Abuse

國際中醫藥香港高峰論壇 Hong Kong

August 05, 2018

David Y-W. Lee, PhD

Harvard Medical School/McLean Hospital 115 Mill Street, Belmont, MA 02478

Emerging Epidemics of Drug Abuse in the United States Economic costs of alcohol and drug abuse tops $1 trillion in 2017

• Opioid use disorders-involving prescription opioids, heroin, fentanyl caused an ongoing rise in opioid overdose deaths (42,000 in 2016) and continue to challenge the health system in the US and “there is no good treatment”

Treatments for drug addiction

Detoxification -Methadone programs -Buprenorphine and other medications -Naloxone, naltroxone (Vivitrol) -Acamprosate

Recovery -Behavioral therapies -psychological therapies Treatments for pain and drug addiction

What are the neurobiological mechanisms that dampen the pain circuitry without arousing or stimulating the reward circuitry? Neuronal Circuitries for Addiction

THE MESOLIMBIC DOPAMINERGIC REWARD PATHWAY

PFC Hip

dopamine

NAc glutamate

GABA

Amy VTA Comparative circuitry of reward and pain systems in human

HUMAN—Project 3 PAIN NETWORK REWARD NETWORK thalamus1° somatosensory cortex thalamus dorsal anterior dorsal cingulate cortex 2° somatosensory cortex striatum insula prefrontal cortex

nucleus accumbens prefrontal amygdala cortex amygdala periaqueductal gray Pathways nucleus ventral tegmental parabrachial nucleus PAIN-subjective accumbens PAIN-sensory area REWARD Treatment of Drug Abuse

• There are currently no uniformly effective pharmacotherapies for alcohol and drug abuse

• Four prescription medicines are available, but all have side effects

• Traditional Chinese remedies developed during opium war era could be a rich source for discovering new drug candidates Poppy (罂粟)-Morphine-Heroin

Morphine

Heroin

The poppy is the natural source for morphine and other opioid alkaloids

Encyclopedia of Treatment of Opium Smoking

Formula of NPI-025

1. Ligusticum wallichii Franch (NPI-025-1) 川芎 2. 2. Corydalis yanhusuo W. T. Wang (NPI-025-2) 元胡 3. Uncaria rhynchophylla (Miq.) Jacks (NPI-025-3) 钩藤 4. Aconitum carmichaeli Dex. (NPI-025-4) 乌头 5. Notopterygium incisun (NPI-025-5) 羌活

1 3

4 5 Clinical Report of NPI-025

NPI-025 was used to treat 300 drug addicts in Hong Kong over a 10-year period. In 1985, Yang et al. reported the clinical results of 100 cases for which there were comparatively complete records. In summary, NPI-025 significantly reduced the withdrawal symptoms (-48%). Follow-up visits of many “cured” patients one to three years after treatment revealed that NPI-025 was helpful in overcoming their craving for drugs.

Fingerprint of NPI-025

HPLC instrument: Pump: Waters 1525 Binary HPLC pump Detector: Waters 2487 Dual λ absorbance detector Operation system: Breeze Time Flow rate A B Column: YMC ODS-A S-5 120Å , 4.6 x 150mm (Min.) (mL/min) (%) (%) Temperature: Room temperature Wavelength: 254 nm 0 1.0 5.0 95.0 Solvent A: MeOH; Solvent B: 0.5% HAc 60 1.0 50.0 50.0 Flow rate: 1 mL/min 90 1.0 100.0 0.0 Sample preparation: NPI-025 250mg/ml (50% MeOH) 100 1.0 5.0 95.0 Eluting method: Gradient as following table NPI-025-4

Chinese Name: Wutou, Chuanwu, Caowu, Fuzi (Fupian) Medical Name: Radix Aconiti (root of Common Monkshood) Latin Name: Aconitum carmichaeli Debx Origin: The radix or root undergoes a special process to detoxify it Family: Ranunculaceae Major traditional use: The root is anaesthetic, analgesic, anti-inflammatory, antirheumatic, cardiotonic, stimulant and vasodilator. It is used in the treatment of shock and collapse, chronic diseases with symptoms of cold, gastralgia and rheumatic arthralgia, oedema and diarrhoea due to hypofunction of the spleen and kidney Caution! Unprocessed material is very toxic OH OH OCH3 OCH3

OCH3 OCH3 OCOC6H5 OCOC6H5 o H2O, 100 C C2H5 N C H N OH 2 5 OH OCOCH3 OH HO HO

CH OCH 2 3 OCH3 CH2OCH3 OCH3

Aconitine Benzoylaconine

LD50: 1 mg/kg (human) o H2O, 170 C - or OH /H2O

OH OCH3

OCH 3 OH

C H N 2 5 OH OH HO

CH2OCH3 OCH3

Aconine Nontoxic

Principle of Detoxification of Wutou through processing Chronic Administration of Candidate Medications and Cocaine “Choice”

Technique 2 - Cocaine Self-Administration in Rats Cocaine Discrimination in Rats: NPI-025

NPI-025 Cocaine + NPI-025

100 100 N = 6

75 75 Percent cocaine-like responding 50 50

25 25

0 0

1.5 1.5

1 1

Responses per second 0.5 0.5

0 0 0 100 0 100 180 300 Dose NPI-025 (mg/kg) Dose NPI-025 (mg/kg) Opioid Receptor Assay

The data is shown as mean ± S.E.M. (n=2-3). The numbers in red mean significant binding to the receptors at indicated concentrations. OFQ data is one to three times results. Sample I.D. Conc. [3H]DIP rMOR [3H]DIP [3H]DIP [3H]OFQ (µM) (% of Control) mDOR hKOR hOFQR (% of Control) (% of Control) (% of Control) NPI-025-1-1 Hexane 100 21±8.9 -4±14 52±13 142,112 NPI-025-1-2 AcOEt 100 36±6 49±8.5 40±7 209, 153 NPI-025-1-3 BuOH 100 63±5.5 54±9.2 73±7.4 123,118 NPI-025-1-4 MeOH 100 76±3.5 62±7.5 87±4 109,74 NPI-025-1-5 Water 100 93±3 79±3.5 96±0.5 133,116 NPI-025-2-1 100 11±3 19±1 14±7 107,112 NPI-025-2-2 100 41±5 36±4 32±2 128,126 NPI-025-2-3 100 28±2 35±6 26±6 110,81 NPI-025-2-4 100 47±1 50±6 56±11 102,91 NPI-025-2-5 100 89±7 90±4 94±3 94,96 NPI-025-3-1 100 0±4 -8±5 15±23 146,150 NPI-025-3-2 100 30±15 4±8 48±20 164,157 NPI-025-3-3 100 75±5 40±8 67±11 109,112 NPI-025-3-4 100 86±6 64±5 80±9 132,104 NPI-025-3-5 100 94±4 81±2 91±0 116,116

Compounds Isolated from NPI-025-2

MeO MeO MeO

N N MeO N MeO HO OMe OMe OMe Me COOH HOOC OMe OMe OMe NPI 025-2 BuOH-1 NPI 025-2 BuOH-2 NPI 025-2 BuOH-3 NPI 025-2 BuOH-4 (=13-Methylpalmatine) (=Succinic acid) (=Tetrahydropalmatine) (=Isocorypalmine)

O MeO O N O N N H HO O N O O OMe O NH O O NPI 025-2 BuOH-5 OMe O NPI 025-2 BuOH-6 (=Coptisin) NPI 025-2 BuOH-7 NPI 025-2 BuOH-9 (=Columbamine) (=Stylopine) (=Uracil) HO MeO

N MeO N MeO O OMe H OMe Me Me COOH N N OH OMe OMe O O NPI 025-2 BuOH-8 NPI 025-2 BuOH-10 NPI 025-2 BuOH-11 NPI 025-2 BuOH-12 (=Dehydrocorybulbine) (=Corydaline) (=N-Acetylproline) (=N-acetyl GABA) l-THP and isocorypalmine - purified from Corydalis yanhusuo

Tetrahydroprotoberberine backbone

CH 3

O HO N NH2 HO HO O CH 3

dopamine O

CH 3

NPI025-2 BuOH-4 (Isocorypalmine) Structure of l-THP and major Metabolites compared with dopamine. Dopamine Receptor Binding Assay

ID D1 D2 D3 D4 D5

NPI 025-2 BuOH 1 71.3 - - - - NPI 025-2 BuOH 3 93.2 62.4 57.8 - 87.2 NPI 025-2 BuOH 4 99.4 97.5 81.0 95.2 97.3 NPI 025-2 BuOH 5 - - - - - NPI 025-2 BuOH 6 67.6 - - - - NPI 025-2 BuOH 7 91.4 84.7 74.2 58.2 73.1 NPI 025-5 BuOH 10 67.2 - - 59.5 - MeO MeO MeO O H N N N N O MeO MeO RO H OMe OMe OMe Me O

OMe OMe OMe O THP NPI 025-2 BuOH-1 NPI 025-2 BuOH-5 MeO O R=H: NPI 025-2 BuOH-3 MeO R=Me: NPI 025-2 BuOH-4 N N O N HO MeO

OMe OMe O Me

OMe O OMe

NPI 025-2 BuOH-6 NPI 025-2 BuOH-7 NPI 025-2 BuOH-10

Receptor Binding Study

ID 5ht1a 5ht2b 5ht2c 5ht7

- NPI 025-2 BuOH 1 - - 52.7

NPI 025-2 BuOH 3 64.6 65.2 - 71.8

NPI 025-2 BuOH 4 48.8 74.4 - 66.8 NPI 025-2 BuOH 5 - - 52.3 - NPI 025-2 BuOH 6 - - 79.7 103.5 NPI 025-2 BuOH 7 - - - - NPI 025-2 BuOH 10 - - - 81.8 MeO MeO MeO O H N N N N O MeO MeO RO H OMe OMe OMe O Me

O OMe OMe OMe THP NPI 025-2 BuOH-1 R=H: NPI 025-2 BuOH-3 NPI 025-2 BuOH-5 HO MeO O R=Me: NPI 025-2 BuOH-4 N N N MeO HO O OMe OMe Me O

OMe OMe O NPI 025-2 BuOH-10 NPI 025-2 BuOH-6 NPI 025-2 BuOH-7 Dopamine Receptor Binding Study

D1 dopamine receptor D5 dopamine receptor

Ki EC50 Emax Ki EC50 Emax (nM) (nM) (% of dopamine) (nM) (nM) (% of dopamine)

Dopamine 34.4 100 4.2 ± 0.74 100 ± 4.12

L-THP 94± 9 NA* 321± 50 NA*

L- 83± 5 5.5 ± 4.61 28± 2 27± 3 1.9 ± 0.37 32± 4.8 isocorypalmine

MeO MeO

N N MeO HO H OMe OMe

OMe OMe L-THP L-Isocorypalmine Dopamine Receptor Functional Assay

Figure 1: cAMP accumulation in HEK 293 cells transfected with the human D1 or D5 receptor after stimulation for 15 min in the presence of 0.75 mM IBMX. Each data point was tested in duplicate. Shown is three times mean results

D1 35

30 DA D1 25

[cAMP] / nM #2931 D1 L-THP: #2336 10 5 #2336 D1 L-Isocorypalmine: #2931 0 -11 -10 -9 -8 -7 -6 -5 log c

D5 35

30 DA D5

20 #2931 D5

15 [cAMP] / nM 10 #2336 D5

0 -11 -10 -9 -8 -7 -6 -5 log c L-THP Targets at D1 and D2 * L-THP only has low affinities (153-305 nM) to

D1 and D5 receptors and has much low affinities (>1,000 nM) to D2, D3 and D4 receptor * L-ICP the metabolite of L-THP has high

affinities (3-12 nM) to D1 and D5 receptors * L-THP is undergoing clinical study in the US

L-THP Clinical Studies

• L-THP is effective in treating heroine addiction in China. • L-THP Phase I clinical study completed in 2015 and showed good efficacy and no adverse effects in cocaine use disorder patients. * A P01 Program Project is submitted to investigate the mechanism of action of L-THP for treating Pain and drug abuse Mechanism of Action of L-THP what are the mechanisms that dampen the pain circuitry without arousing or stimulating the reward circuitry?

We hypothesize that a target compound that has a unique profile of DA and µ opioid activity will affect both circuits to produce this highly desired outcome and thus have a major impact on combating the opioid crisis. Animal Drinking Model: Two- Bottle Choice Study

Technique 2 - Cocaine Self-Administration in Rats NPI-025 Reduces Bar-Pressing for Alcohol Drinking

1 6 0 1 0

1 4 0

1 2 0

1 0 0 6

8 0

4 6 0

* 4 0 * 2

2 0 *

0 0

0 1 0 2 5 5 0 1 0 0 0 1 0 2 5 5 0 1 0 0

N P I - 0 2 5 D o s e ( m g / k g , I P ) N P I - 0 2 5 D o s e ( m g / k g , I P ) Effects of 5 components of NPI-025 on Alcohol Drinking in Rats

Fig. 1 - Component 1 of NPI-025 is Most Potent and Component 5 is Least in Reducing 6 Hr Alcohol Intake at Dose of 50 mg/kg

-10

-20

-30

-40

-50

-60 Alcohol Intake Alcohol

-70 %Change in Baseline in %Change -80

-90 Comp 1 Comp 2 Comp 3 Comp 4 Comp 5 Component of NPI-025 Comparison of several treatments on alcohol intake: NPI-025 (100 mg/kg)

10 300 450 100 100 150 Acamp Acamp NPI-31G NPI-025 NPI-025 0

-10

-20

-30

-40 Food Intake Alcohol Intake

%Change in Alcohol Intake Alcohol in %Change -50

-60 300 450 100 100 150 NPI-028 Reduces Alcohol Intake in Rats Pueraria Lobota (Kudzu): the major component in NPI-028 Bioactive Compounds Isolated from Kudzu Extract Chart A

Chemical Structures of Purified Kudzu Extract Components HO HO HO OH HO OH

HO O O HO O HO O O O HO HO OH HO O HO HO O O O OCH OH OH 3 O O OH OH Puerarin (NPI-031G) Daidzin (NPI-031D) 3'-Methoxy-puerarin (NPI-031F) Daidzein (NPI-031C)

HO HO HO HO OH OR

O O HO O HO O HO HO

HO O HO O OH O OH O OH OH OH OCH3

O O OH OH Genistein (NPI-031L) Biochanin A (NPI-031M) 3'-Hydroxy-puerarin (NPI-031H) Mirificin (NPI-031K) R= apiosyl (1-6) Chronic Administration of NPI-031G Kudzu Extract & Binge Drinking “Natural” Setting Laboratory Kudzu Extract & Binge Drinking

Customized End Table/Drinking Monitor Kudzu Extract & Binge Drinking

Digital scale hidden in end table Digital scale readout Filename: KSA 016-1927v3 Rear of ohaus Beverage: Heineken table Pretreatment: unknown Units: grams

yr mo dy hr mn sc weight 03 11 25 17 11 23 START 03 11 25 17 11 24 0 03 11 25 17 13 28 BBBQ 03 11 25 17 13 29 0 03 11 25 17 13 55 908 03 11 25 17 14 11 0 03 11 25 17 14 41 830 03 11 25 17 15 40 0 03 11 25 17 15 46 762 03 11 25 17 18 02 0 03 11 25 17 18 12 736 03 11 25 17 19 08 0 03 11 25 17 19 14 687 03 11 25 17 20 43 0 03 11 25 17 20 52 646 03 11 25 17 21 50 0 03 11 25 17 21 58 549 03 11 25 17 22 33 0 03 11 25 17 22 42 BBBQ 03 11 25 17 22 43 0 03 11 25 17 23 00 905 03 11 25 17 23 12 0 Digital scale reader 03 11 25 17 23 23 823 ActiWatch-Score device

Wrist actigraphy/data recorder Kudzu Extract & Binge Drinking

Results: Results: Number of Beers Total Volume Consumed Consumed per Session per Session (g) 1400 4 1200

3 1000

800 2

Consumed * * 600

400 1

# of Beers 200 Amount Consumed (g)

0 0 Kudzu Placebo Kudzu Placebo Treatment Treatment Summary： Clinical Studies

• Kudzu extract (NPI-031, Alkontrol-herbal) Completed Phase II Study in Heavy Drinking Alcoholics and showed promising results with no adverse effects • Our Kudzu extract (Alkontrol-herbal) STTR grant will be funded in 2016 for a Phase II study with Treatment Seeking Alcoholics • Puerarin (NPI-031G) completed a Phase II Study and showed very good results with no side effects • An independent third party study conducted by BBC showed efficacy. The TEAS device is operated by a 9V battery. Its current is delivered via electroconductive patches. TEAS Stimulation Points • Hegu point (LI 4) and the Laogong point (on the palmar

side opposite to Hegu) LI 4 of the hand.

• Neiguan and Waiguan points (PC6) on the opposite forearm.

PC 6 EA accelerates the release of endogenous opioids EA suppression of morphine cpp The best frequency to suppress craving VAS (visual analogue scale)

Pre-TEAS Post-TEAS 5 TEAS treatment

30 min / d 2 Hz > 100 Hz

4 (VAS) 3 100 Hz

mock 2 100 Hz

2 Hz 1 2 Hz 2/100 Hz

Degree of craving craving of Degree 0 0 10 20 30 Observation days n = 29 － 30 /group 06 fMRI: Experiment Design

Subjective VAS inquiry

2 Hz-E.A. fMRI （n = 34） fMRI Session 1 Session 2

Pure heroin BOLD BOLD 100 Hz-E.A. Pre-experiment Addicts Scanning* Scanning （n = 27） (Food craving ) ( n = 93 )

+ +

Video Cue Video Cue 0 Hz-E.A. inducing inducing （n = 32）

08 The Top Eight ROIs Relative to Heroin Craving

1 AMY_1(Right) 2 ACC 3 AMY_2(Right) 4 Insula 5 OFC 6 CERE.P.L. 7 Unnamed region* 8 AMY_3(Left)

n =93 (detail, p = e-8),

12 Heroin-cue induced brain activation Changes in ROIs before and after TEAS Stimulations

AMY NAc Paired-t-test_2_Hz (EP1-2)

n= 34 n= 34 Suppressed Voxels of ROIs in 3 groups P < 0.0001 P < 0.0001

ACC Hippo 100 90 80 70 60 50 AMY 40 Nac 30

20 ACC Suppressed Voxels(%) Suppressed 10 HIPPO 0

2 ACC n= 34 100 HIPPO n= 34 0 Nac

P < 0.0001 P < 0.0001 Frequency(Hz) AMY ROIs A C

Footnote: (A) Heroin-Cue can also induce brain activation in AMY [(21,0,18),(-24,-3,-15) ] , NAc [(12,6,-6), (-9,9,-6)],ACC [(12,33,24)] and Hippo.[(-30,-27,-12)]. (B) The results of paired t test (EP1-EP2) show significant BOLD signal changes in these ROIs shown in the glass brain view. (C)The bar plot shows the BOLD signal changes( Voxel volume ) EA stimulation at 0, 2, and 100 Hz respectively. Only 2Hz-EA significantly decreased activities in the amygdala (-91.58% ) and nucleus accumbens (-76.32%).

16 Summary

Heroin related cue can induce craving with the activation of regions of interests (ROI) involved in the reward pathway that is common to cocaine craving

The purity of drug addicts (heroin only) and the sample size ( n = 93) make this fMRI study more reliable than those with smaller sample size;

From this result, we concluded that AMY is significantly associated with the craving emotion.

There are 8 most intensive regions related to heroin craving.

Cue-induced Heroin Craving Can Be Suppressed by TEAS (2Hz) Treatment as Evidenced by fMRI Study 32 Reduction of opioids use for the detoxification of heroine addicts

Adopted from:

«substance abuse » Lowinson et al. Eds,

Buprenorphin Buprenorphin dose 4th edition, Chapter 49, 2005

Methadone Methadone dose

7 TEAS--Alcohol

Results-Number of Drinks and Craving

2.75

2.50 10

2.25 9

2.00 8 1.75 7 1.50 6 1.25 5 1.00 4 0.75 3

0.50 2 Number of Drinks/Day of Number

0.25 Alcohol for Craving 1 0 0 TENS Sham TENS Sham Treatment Treatment Summary

* Multi-components and multi-targeted approach is far better than a single chemical entity approach in terms of treating human diseases

* There are many bioactive natural products with slightly different chemical structures which could enhance clinical efficacy by synergism or at least combinatory activity

* Many of these natural products have been tested in humans for hundreds of years. The safety of TCM is better than Western drugs

Acknowledgements

University of Maryland Temple University Dr. Brian Berman Dr. Lee-Yuan Liu-Chen Dr. Kamal Moudgil Dr. Lao Lixing

Harvard Medical School Dr. David Y-W. Lee Dr. Scott Lukas (Clinical Study) Dr. Ma Zhongze Dr. Liu Yanze Dr. Jing Liu

NIH/NCCAM: P01-AT-002065