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GABA Systems, Benzodiazepines, and Substance Dependence

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GABA Systems, Benzodiazepines, and Substance Dependence Robert J. Malcolm GABA Systems, Benzodiazepines, and Substance Dependence Robert J. Malcolm, M.D. Alterations in the γ-aminobutyric acid (GABA) receptor complex and GABA neurotransmission influence the reinforcing and intoxicating effects of alcohol and benzodiazepines. Chronic modulation of the GABAA-benzodiazepine receptor complex plays a major role in central nervous system dysregulation during alcohol abstinence. Withdrawal symptoms stem in part from a decreased GABAergic inhibitory function and an increase in glutamatergic excitatory function. GABAA recep- tors play a role in both reward and withdrawal phenomena from alcohol and sedative-hypnotics. Although less well understood, GABAB receptor complexes appear to play a role in inhibition of moti- vation and diminish relapse potential to reinforcing drugs. Evidence suggests that long-term alcohol use and concomitant serial withdrawals permanently alter GABAergic function, down-regulate ben- zodiazepine binding sites, and in preclinical models lead to cell death. Benzodiazepines have substan- tial drawbacks in the treatment of substance use–related disorders that include interactions with alco- hol, rebound effects, alcohol priming, and the risk of supplanting alcohol dependency with addiction to both alcohol and benzodiazepines. Polysubstance-dependent individuals frequently self-medicate with benzodiazepines. Selective GABA agents with novel mechanisms of action have anxiolytic, anticonvulsant, and reward inhibition profiles that have potential in treating substance use and with- drawal and enhancing relapse prevention with less liability than benzodiazepines. The GABAB receptor agonist baclofen has promise in relapse prevention in a number of substance dependence dis- orders. The GABAA and GABAB pump reuptake inhibitor tiagabine has potential for managing alcohol and sedative-hypnotic withdrawal and also possibly a role in relapse prevention. (J Clin Psychiatry 2003;64[suppl 3]:36–40) lcohol dependence is among the most common psy- the central nervous system (CNS). During continuous Achiatric disorders in the general population. Current exposure to alcohol, neuroadaptive changes occur to prevalence of alcohol dependence is fairly stable in the compensate for alcohol’s destabilizing effects.3 When United States at approximately 6% of men and 2% alcohol use is discontinued, the maladaptive nature of of women,1 although 14% of Americans may be alcohol these changes becomes evident. Gamma-aminobutyric dependent at some point during their lives.2 According to acid (GABA)—the main inhibitory neurotransmitter in the DSM-IV, a diagnostic criterion of physiologic alcohol the mammalian CNS—is implicated in multiple aspects dependence is the presence of an alcohol withdrawal syn- of alcohol intoxication, dependency, and withdrawal. drome during acute reduction in or cessation of drinking GABA systems are sensitive to both the initial and the (Table 1). chronic effects of alcohol exposure. The neuropathology of withdrawal is opposite to that MECHANISMS OF ALCOHOL WITHDRAWAL of intoxication. Alcohol intoxication enhances the func- tion of the GABAergic system, resulting in enhanced The alcohol withdrawal syndrome is the result of the inhibitory neurotransmission and, thus, depression of the brain’s adaptation to the long-term presence of alcohol in CNS. Conversely, withdrawal is marked by increased glu- tamatergic action and reduced GABA activity, resulting in heightened excitatory neurotransmission and brain hyper- excitability. In untreated alcohol withdrawal, the neuronal From the Medical University of South Carolina, Center for Drug and Alcohol Programs, Charleston. firing rate and recruitment of neighboring neurons in- This article is derived from the teleconference “The Role crease while CNS levels of oxidative free radicals, peroxi- of GABA in Neuropsychiatric Disorders: A Review of GABA dases, and intracellular calcium rise.4 Cell damage or cell Agents,” which was held April 3, 2002, and supported by an unrestricted educational grant from Cephalon, Inc. death is possible. Cortical, brain stem, and limbic func- Corresponding author and reprints: Robert J. Malcolm, tion are disrupted. At the clinical level, alcohol with- M.D., Medical University of South Carolina, Institute of Psychiatry, Center for Drug and Alcohol Programs, drawal can cause a host of autonomic and CNS effects, 67 President St., P.O. Box 250861, Charleston, SC 29425. including hypertension, tachycardia, excessive sweating, 36 © COPYRIGHT 2003 PHYSICIANS POSTGRADUATE PRESS, INC. © COPYRIGHT 2003 PHYSICIANSJ Clin PsychiatryPOSTGRADUATE 2003;64 PRESS (suppl, INC 3). Benzodiazepines and Substance Abuse Table 1. Diagnostic Criteria for Alcohol Withdrawala Figure 1. Cycle of Alcohol Dependencea Decrease in (or cessation of) prolonged and heavy alcohol use 2 or more of the following symptoms developing within several hours Chronic Alcohol Use/Abuse to a few days of the above Autonomic hyperactivity (eg, elevated pulse rate or diaphoresis) Tremor Psychomotor agitation Repeated Withdrawal Episodes Insomnia Transient hallucinations or illusions Anxiety Altered Brain Function Nausea or vomiting Seizures Decreased GABAergic Function Increased Glutamatergic Function The above symptoms cause considerable distress or impairment and Alcohol are not better accounted for by another mental disorder or medical Drinking condition Relapse aAdapted with permission from DSM-IV.2 Kindled Withdrawal Symptoms and Consequences Increased Dysphoria Increased Anxiety Increased Sleep Disturbance hypothermia, tremor and other motor incoordination, Increased Seizure Susceptibility cognitive disruption, dysphoria, anxiety, insomnia, hallu- Increased Excitotoxicity Risk cinations, delirium, seizures, and—in about 1% of inad- equately treated cases—death. Potential Neurologic Damage Potential Cognitive Impairment Chronic alcohol use renders GABAA receptors dys- functional, permanently dampening GABAergic function. Autopsies of histologically normal brains of human al- aAdapted with permission from Becker.3 coholics found benzodiazepine receptor sites, which are located on the GABAA receptor complex, reduced by 30% in the hippocampus and by 25% in the frontal cortex.5 Di- prognosis and relatively high mortality rate.10 Patients with minished inhibition via GABAA receptors may contribute withdrawal-related seizures are more likely to have under- to the worsening of withdrawals over time. Also, repeated gone numerous previous detoxifications than patients withdrawals may increase the number of glutamatergic re- without seizures.6,11,12 ceptors, making the brain more vulnerable to neural excit- ability and excitotoxic damage.3 TREATMENT OF ALCOHOL WITHDRAWAL In a process of sensitization, sometimes clinically re- ferred to as neuronal “kindling,” withdrawal symptoms For more than 4 decades, benzodiazepines have been intensify as withdrawal episodes grow in number.6 Prior first-line treatment for patients with alcohol withdrawal. withdrawal experience is associated with more severe and Their anxiolytic and anticonvulsant properties appear to medically complicated later withdrawal episodes. This address both psychological and physiologic symptoms. progression is not solely attributable to a worsening of al- More recently, research suggests that benzodiazepines may coholic drinking over the course of alcoholism. Rather, have substantial drawbacks in the treatment of alcohol- having a previous withdrawal episode reduces the duration related disorders. Benzodiazepines combined with alcohol and extent of intoxication necessary to provoke subse- in the outpatient setting can lead to death, even with rela- quent withdrawal episodes.3 For example, mice exposed tively low levels of blood alcohol.13 Benzodiazepines also to alcohol for 3 cycles of 16 hours showed more severe interact with alcohol to produce motor impairment that withdrawal symptoms than mice exposed to alcohol for patients may not recognize. Additionally, some patients 48 hours straight.7 Further, chronic intermittent alcohol treated with benzodiazepines experience rebound (a rever- exposure led to hippocampal cell loss in rats, but continu- sal of the medication’s effects and return of symptoms) ous alcohol exposure did not.8,9 In mammals, cycles of upon discontinuation of treatment. Benzodiazepines ame- binge-drinking followed by abstinence initially provoke liorate withdrawal symptoms at any one episode of with- no withdrawal symptoms, then mild withdrawal symp- drawal, but they do not appear to interrupt the kindling toms, then moderate and finally severe withdrawal symp- process.11,14,15 Because benzodiazepines are potentially toms. Through “kindling,” the alcoholic brain ultimately habit-forming, there may be a risk of substituting one de- becomes hyperexcitable (Figure 1). pendence (or abuse) for another when benzodiazepines are Kindling is a term originally used in the study of used chronically to treat patients with alcoholism. epilepsy to describe the augmentation process by which My colleagues and I conducted a series of studies16,17 in low level, intermittent, subconvulsant stimulus eventually which we compared the anticonvulsant carbamazepine— provokes seizure.3 Seizure can be a symptom of severe al- which has a long history of use in the detoxification of cohol withdrawal and as such is associated with poor alcohol-dependent patients in Europe—to the benzodiaze- J© Clin COPYRIGHT Psychiatry 2003 2003;64 PHYSICIANS (suppl P 3)OSTGRADUATE PRESS, INC. © COPYRIGHT 2003 PHYSICIANS
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