Beta-Blocker May Prevent Stress-Related Relapse in Addicts

Megan Brooks

June 14, 2011

June 14, 2011 — Psychosocial stress can make it difficult for recovering heroin addicts to make decisions even after a lengthy period of abstinence, potentially contributing to an increased risk for stress-related relapse, a new study suggests.

However, the research also suggests that treatment with the β-blocker propranolol can block stress-induced impairment in decision-making in these individuals, potentially reducing the risk for stress-related relapse.

"The noradrenergic system has become a prime target for pharmacotherapies like propranolol to prevent stress-induced relapse," Thomas R. Kosten, MD, chair and professor of psychiatry, pharmacology, and neuroscience at Baylor College of Medicine, Houston, Texas, and author of a related editorial, told Medscape Medical News.

It's well known that drug abuse is associated with impaired decision-making, which may contribute to relapse in recovering drug addicts, Xiao-li Zhang, MD, from the National Institute on Drug Dependence, Peking University, Beijing, China, and colleagues note in their report.

Yet, little is known about the time course of changes in decision-making ability after abstinence or about the effects of stress on decision-making in recovering addicts.

The study is published in the June issue of the American Journal of Psychiatry.

Stress Is Disruptive

To investigate, the researchers studied 370 male formerly heroin-dependent inpatients who had been abstinent for 3 days to 24 months. They assessed participants' ability to make the standardized decisions embedded in the Iowa Gambling Task.

They found that participants who had been abstinent for only a short period (3, 7, 15, or 30 days) performed worse on this decision-making task than those who had been abstinent for a longer period (3, 6, 12, or 24 months) (P < .05 for all comparisons).

In the absence of stress, decision-making performance in the 24-month abstinent group tended to be similar to that seen in healthy comparison participants, but adding stress to the mix changed that, Dr. Zhang and colleagues found.

They challenged participants who had been off heroin for 15 days to 2 years with acute stress induced by the Trier Social Stress Test, which involves making a public speech, and then administered the decision task.

In the presence of stress, decision-making ability was impaired in all groups of recovering heroin addicts, even in those who had been abstinent the longest (24 months), but not in healthy comparison participants.

It's noteworthy, said Dr. Kosten, that "after even 2 years of opiate abstinence, stress was able to disrupt decision-making, just as it did in more recently detoxified former addicts."

Clinical Implications

Dr. Zhang's team also found that giving 40 mg of the β-adrenergic blocker propranolol blocked the deleterious effect of stress on decision-making in the 30-day, 12-month, and 24-month abstinence groups.

Stress unmasked a latent vulnerability to decisional problems, which was associated with &beta-adrenergic stimulation, the authors note.

Stress is thought to play a major role in relapse to drug abuse. The current findings have "psychotherapeutic implications," Dr. Kosten said, because "former addicts in typical modern therapeutic addiction treatments make decisions in relatively nonstressful situations."

"Thus, getting an accurate assessment of the patient’s ability to make appropriate decisions that will avoid relapse to addiction, when under the stress of the real world, is not simple for either the therapist or the patient while in the therapy session," he said.

Dr. Kosten also made the point that translational studies such as this one "are providing a biological basis for our clinical observations about protracted drug withdrawal and impairments in decision-making. This biological basis has direct pharmacotherapeutic applications in preventing relapse to addiction after the acute withdrawal syndromes have been treated and abated."

The study was supported in part by the National Basic Research Program of China, the National Science Foundation of China, and the National Science Foundation of Beijing Municipality. The study authors have disclosed no relevant financial relationships. Dr. Kosten reports having served as a consultant to Alkermes, Synosia, Reckitt Benkizer, Catalylst, and Titan Pharma.

Am J Psychiatry. 2011;168:610-616. Abstract

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