Topiramate to Reduce Heavy Drinking in HIV-Positive Heavy Drinkers

A. General Design: This study will employ an 11-week, parallel-groups design (TOP vs. placebo) to test the effects of topiramate (TOP) on HD by HIV+ individuals with a current alcohol use disorder. We will gradually increase the dosage of TOP from 25 mg/day to 150 mg/day over a 6-week period to minimize adverse events. Random assignment to treatment group and double-blind conditions will be maintained throughout the study.

B. Recruiting: HIV+ men and women will be recruited through advertisements and by collaboration with physicians in the University of Pennsylvania Health System (UPHS) who will be invited to refer patients for whom heavy drinking in their HIV+ patients has created medical concerns. Patients will be recruited using the following methods: through referrals to the research center at the University of Pennsylvania (UPenn); by posting/distributing recruitment materials in community settings with public posting areas or other means of providing community access to materials (such as hospitals, town halls, public libraries, YMCA, health fairs/organizations); and through advertisements in local media (including text ads in newspapers, magazines; radio ads on local radio stations; web ads on internet sites and web postings on community message boards and research listings). These methods have been successful for Dr. Kranzler at the University of Pennsylvania and for many investigators at the Treatment Research Center (TRC) at UPenn. The TRC is an active center for clinical investigation and the staff and faculty there are highly experienced and capable in the conduct of clinical trials such as this. We will use institution-approved recruitment materials to advertise for regular or daily drinkers who are HIV+ and want to reduce their drinking. We will obtain permission at selected locations before distributing or posting the approved recruitment materials (to ensure that we comply with other institutions' guidelines). We anticipate that approximately 40% of patients will be women and that minority patients will be represented at least in proportion to the general population in Philadelphia. Based upon the large number of potential patients and our success in recruitment for prior studies, including those involving heavy drinkers, we are confident of our ability to achieve our recruitment goals.

C. Study Visits: At the screening visit, patients will provide informed consent and their reading ability will be evaluated, a medical and psychiatric history obtained. Blood and urine samples will be taken for routine clinical laboratory evaluations (including GGTP), drug screening, and pregnancy testing in females of reproductive potential. Patients will be interviewed with the Structured Clinical Interview for DSM-IV (SCID). Patients who are excluded will be referred to treatment.

The baseline visit will occur 1-14 days after the screening visit. Eligible patients will undergo a research evaluation, complete a packet of questionnaires, complete cognitive testing, and be interviewed by the research assistant. A physical examination will be performed by a study physician or nurse practitioner. Eligible patients will receive their first counseling session and first supply of study medication during a subsequent treatment session the same day. We will use urn randomization, a probabilistic balancing procedure to assign patients to medication group so that groups are balanced on key variables (Wei 1978): sex, race (white or non-white), number of HD days in past month.

During the 11-week treatment period, patients will return to the clinic weekly for five weeks while the dosage of the medication is gradually increased and then biweekly for six weeks. For patient safety during travel, they will be instructed not to drink prior to study visits. At each visit, the patient's breath alcohol level, weight, and vital signs will be measured. They will complete questionnaires and cognitive testing, and be interviewed by the research nurse about their use of concurrent medications, the occurrence of adverse events, and protocol compliance and then receive the medical management intervention. During visit 9 (end of treatment week 11), patients will complete questionnaires and cognitive testing and be interviewed by the research evaluator concerning their alcohol consumption. Patients will be compensated for this end-of-treatment visit. Patients will also be interviewed by the research nurse about their use of concomitant medications, occurrence of adverse events, compliance with the protocol, and their assessment of the effectiveness and acceptability of the treatment procedures (through the Medication Questionnaire; MED-Q). The nurse will dispense 4 days of medication for the taper and instruct the patient on how to take the medication during this period. Blood samples to measure serum GGTP will be obtained to assess the validity of self-reported drinking. A study nurse or research coordinator will call the patient one week after the endpoint visit to confirm that the subject completed the medication taper. Continuing adverse events will be followed by the study nurse and physician to their conclusion, as is feasible. Patients requesting (or clearly needing) additional treatment for alcohol problems will be referred to local treatment centers. All patients (including those who discontinue treatment prematurely) will be asked to complete an end-of-treatment evaluation and to complete all scheduled assessments to facilitate intention-to-treat (ITT) analyses. For patients who withdraw early and do not wish to continue with study visits/procedures, all end-of-treatment procedures will be administered at the time of withdrawal. Such patients will also be asked to undergo in-person or telephone follow-up at end-of-treatment for collection of the remaining treatment-phase Timeline Followback (TLFB) data.