Bupropion Related Alcohol Cessation

Bupropion hydrochloride, an atypical antidepressant is sometimes used as a pharmacotherapeutic agent in tobacco cessation. Two cases are presented of bupropion related alcohol cessation -  a possibly beneficial side effect not previously described in the literature.

INTRODUCTION:

Bupropion hydrochloride is an antidepressant used as an adjunct in the treatment of smoking cessation (Hughes 1999). By virtue of its dopaminergic and adrenergic actions it is thought to decrease the cravings associated with nicotine dependence (Gastfriend 1998). Two cases are presented in which patients enrolled in a smoking cessation program taking bupropion noted a complete discontinuation of alcohol consumption due to the effects of bupropion.

CASE REPORT:

The first patient is a 24 year-old female diagnosed with nicotine dependence having smoked a pack per day for seven years. She enrolled in smoking cessation for health reasons and at the urging of her family. She had tried to quit several times in the past trying abrupt cessation (cold turkey), or nicotine patch and had never been able to abstain longer than 2 weeks. At the time of enrolment she was taking oral birth control pills and no other prescription medications. She described herself as a social drinker going out one time per week and consuming 1 to 3 beers. She began bupropion hydrochloride sustained release (SR) at 150mg per day for the first three days and then increased it to 150mg b.i.d. after three days. One week later, at the first of four behavioural modification sessions, she described that on about day three of the medication she went out with friends and tried drinking a beer. She stated that there was a "foul" taste associated with the beer and had a friend try it to see if it was the beer. The beer apparently was all right and she tried it again and noted a similar bad taste. The bad taste was also associated with smoking. By week two she had set her quit date and successfully finished the 4-session behavioural modification program tobacco free. She described a similar experience with a bad taste associated with alcohol while on the bupropion but nicotine free and did not return to social drinking until after finishing the 10 week course of medication. The patient finished a course of ten weeks on the bupropion and had no difficulties associated associated with its discontinuation. At a one-month telephonic follow up the patient remained tobacco free and noted the taste of alcohol had returned to its pre-bupropion level.

The second patient is a 22 year-old male with a pack a day habit for 8 years as well as a can of smokeless tobacco every 2-3 days. He had made several attempts to quit his habits and was interested for financial as well as health reasons to quit. He described himself as a moderate drinker consuming 1 to 4 beers on weekend nights. He started on bupropion SR 150mg daily raised to 150mg b.i.d. on day 4 of treatment and noted at that dose a "metallic"taste not only decreasing the pleasure in his cigarettes, his smokeless tobacco but alcohol as well. He felt this poor taste was instrumental in not wanting to smoke or dip and was able to successfully complete the program. After he discontinued bupropion at 9 weeks he also noted a return of the taste of alcohol completely to its pre-bupropion treatment state.

DISCUSSION:

The neurobiology of the alcohol reward system involves several neurotransmitters including the opioid, serotonin, gamma-amino-butyric acid (GABA) and dopamine (Meyer 1998). The effect of alcohol on the dopamine system apparently causes an increase in the synthesis and release of dopamine from the nucleus accumbens (Valenzuela 1997). The particular pathway involved appears to be the mesolimbic which extends to the prefrontal cortex (Valenzuela 1997) the very same pathway proposed by Leshner (Leshner 1996) to be the reward pathway of nicotine, cocaine, amphetamines, marijuana, and alcohol. The clinical observation that the patient's perceived pleasure of alcohol as well as of nicotine diminished while taking bupropion probably is explained by the manipulation of dopamine contributing to a decrease in self-administration. The exact mechanism however is not yet fully defined. There are also dopaminergic projections ascending from the nucleus accumbens into the frontal lobe which may also play a role in the goal directed behaviour of the substances (Pontieri 1996). Along with the dopaminergic influence exerted in the nucleus accumbens the addictive substances may alter the locus coeruleus and noradrenergic balances through out the central nervous system contributing to the addictive properties (Leshner 1996). Although it appears that bupropion may possibly decrease the pleasure associated with alcohol consumption which could be a possible adjunct in alcohol cessation it should be further studied in a more controlled manner. We also advocate that all patients, prior to initiating bupropion for nicotine cessation or any use undergo a thorough assessment of their medical history as to rule out any condition, which would be a contraindication to use of bupropion.

References:

1. Hughes JR, Goldstein MG, Hurt RD, Shiffman S. Recent Advances in the Pharmacotherapy of Smoking. JAMA. 1999; 281: 72-6.
2. Gastfriend DR, Elman I, Solhkhah R. Pharmacotherapy of Substance Abuse and Dependence, in The Psychiatric Clinics of North America Annual of Drug Therapy. Edited by Dunner DL, Rosenbaum JF. Philadelphia, W.B. Saunders Company, 1998, pp. 211-229.
3. Meyer RE, Berger SP. Biology of Psychoactive Substance Dependence Disorders: Cocaine, Opiates, and Ethanol, in The American Psychiatric Press Textbook of Psychopharmacology 2^nd Edition. Edited by Schatzberg AF, Nemeroff CB. Washington, D.C., American Psychiatric Press Inc., 1998, pg. 656.
4. Valenzuela CF, Harris RA. Alcohol: Neurobiology, in Substance Abuse A Comprehensive Textbook 3^rd Edition. Edited by Lowinson JH, Ruiz P, MillmanRB, Langrod JG. Baltimore, Williams and Wilkins, 1997, pg. 130.
5. Leshner AI. Understanding Drug Addiction: Implications for Treatment. Hospital Practice October 1996: 47-59.
6. Pontieri FE, Tanda G, Orzi F, Di Chiari G. Effects of nicotine on the nucleus accumbens and similarity of addictive drugs. Nature July 1996 (382): 255-7.

The conclusions and opinions expressed are those of the authors and do not reflect the policy o position of the US Government, Department of Defense, Department of the Army, the US Army Medical Command, Department of Veteran's Affairs or the 82D Airborne Division.