and antipsychotic agents in the treatment of acute agitation or violence in the emergency department. J Emerg Med. 2006;31:317–324. 16. Geoffroy PA, Rolland B, Cottencin O. Catatonia and alcohol withdrawal: a complex and underestimated syndrome. Alcohol Alcohol. 2012;47:288–290. 17. Soyka M. Alcohol use disorders in opioid maintenance therapy: prevalence, clinical correlates and treatment. Eur Addict Res. 2015;21:78–87. 18. Arias AJ, Kranzler HR. Treatment of co-occurring alcohol and other drug use disorders. Alcohol Res Health. 2008;31: 155–167. Effectiveness of Nalmefene in Binge Eating Disorder A Case Report To the Editors: B inge eating disorder (BED) is a com- mon eating disorder (ED), affecting between 1.5% and 3.0% of women, char- acterized by binge eating without purg- ing that often, but not necessarily, is associated with obesity (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition). Although no guidelines for the treat- ment of BED are available, the litera- ture supports the use of antidepressants, anticonvulsants, antiobesity agents, and cognitive-behavioral therapy, all with a modest efficacy. 1,2 Therefore, other drugs, specifically sibutramine and topiramate, have been recently shown to significantly reduce binge eating behavior and body weight in obese patients with BED. 3,4 Fur- ther, the pharmacotherapy of BED is now focusing on other compounds, such as opiate blockers and modulators of pep- tide hormones. 5 The present study re- ports the positive response of a patient with BED treated with nalmefene, an opi- oid receptor modulator recently approved by the European Medicine Agency for the treatment of alcoholism in adults with high drinking risk. 6 The patient was a 40-year-old lawyer, married with 2 children, with no personality disorders nor a positive family history for psychiatric disorders. She had been suffer- ing from BED since her adolescence but had hidden the disorder until the marriage, when she revealed the problem to her hus- band. He convinced her to consult a psy- chiatrist who prescribed fluoxetine (up to 60 mg/d) that was effective but was stopped after 6 months. Because she soon re- lapsed, she consulted other psychiatrists who prescribed sertraline and valproate as well as different psychotherapies, all in- effective, so that she was admitted to a psychiatric ward for a depressive episode characterized by depressed mood, loss of energy, drowsiness, decreased interest in daily activities, reduced concentration, and feelings of hopelessness and treated with clomipramine (75 mg/d). After a short pe- riod of relative well-being, she suffered from another similar depressive episode and consulted us 3 years ago. On that occa- sion, she showed a normal body mass in- dex, a score of 33 on the Binge Eating Scale, and of 25 on the Hamilton Rating Scale for Depression. She referred to hav- ing 3 binge episodes a day, especially after dinner, and was strongly convinced that she could not recover any more. She was given bupropion (300 mg/d) and topiramate (up to 400 mg/d), which led to a significant improvement in 5 weeks so that she could resume work full time. However, 1 year later, when her father had a severe medical problem, she relapsed. We then added trazo- done (300 md/d) and agomelatine (25 md/d) with a subsequent improvement lasting another year. Unfortunately, she stopped the treatment against our advice and soon relapsed. The previous treatment was no more effective, and therefore, we prescribed nalmefene (18 mg/d) after obtaining her in- formed consent. After 2 weeks, the binge episodes had totally disappeared, and she indicated that for the first time since the onset of the disorder, she felt no urge to eat. After 1 year, the patient is still well, with no significant side effect (just a mild nausea at the beginning of the treatment that had disappeared after 1 month). This case report highlights the poten- tial use of nalmefene in the treatment of BED. Nalmefene is a new compound com- bining μ and δ receptor (MOR and DOR) antagonism and κ receptor (KOR) partial agonism. The direct involvement of the opioid system in the rewarding effect of alcohol and the indirect modulation of do- paminergic transmission in the mesolimbic areas are considered the main mechanisms of action of nalmefene to reduce alcohol intake. 7 In animal models, nalmefene re- sulted in being more effective than naltrex- one, another opioid modulator shown to be effective in BED. 8 However, naltrexone, despite showing a similar affinity for MOR, behaves as an antagonist of MOR, DOR, and KOR. 9 Available evidence suggests that such mechanisms may be involved also in food craving. 10 Therefore, we would suggest with caution that a MOR/DOR antagonism coupled with KOR partial agonism, typ- ical of nalmefene, might be particularly useful in food craving, such as that typ- ical of BED. In conclusion, our case report under- lines that nalmefene might represent a new pharmacological paradigm in terms of therapeutic target (reduction of food consumption) in BED and other food crav- ing conditions. Further, it suggests that nalmefene may be prescribed also daily and not only when needed, to improve food addiction. Future studies should explore the possibility that nalmefene should be useful not only to reduce alcohol consump- tion, 11 but also to treat specifically different types of addictions. AUTHOR DISCLOSURE INFORMATION All authors have reviewed and ap- proved the manuscript before submission and accepted the responsibility for the in- formation contained in the submission. The authors declare no conflicts of interest. Donatella Marazziti, MD Dipartimento di Medicina Clinica e Sperimentale Sezione di Psichiatria University of Pisa Pisa, Italy dmarazzi@psico.med.unipi.it Armando Piccinni, MD Stefano Baroni, Dr BiolSci Liliana Dell'Osso, MD Dipartimento di Medicina Clinica e Sperimentale Section of Psychiatry University of Pisa Pisa, Italy REFERENCES 1. Appolinario JC, McElroy SL. Pharmacological approaches in the treatment of binge eating disorder. Curr Drug Targets. 2004;3:301–307. 2. Brambilla F, Samek L, Company M, et al. Multivariate therapeutic approach to binge-eating disorder: combined nutritional, psychological and pharmacological treatment. Int Clin Psychopharmacol. 2009;6:312–317. 3. McElroy SL, Guerdjikova AI, Mori N, et al. Pharmacological management of binge eating disorder: current and emerging treatment options. Ther Clin Risk Manag. 2012;8: 219–241. 4. Tata AL, Kockler DR. Topiramate for binge-eating disorder associated with obesity. Ann Pharmacother . 2006;11:1993–1997. 5. Marazziti D, Rossi L, Baroni S, et al. Novel treatment options of binge eating disorder. Curr Med Chem. 2011;18:5159–5164. Journal of Clinical Psychopharmacology • Volume 36, Number 1, February 2016 Letters to the Editors © 2015 Wolters Kluwer Health, Inc. All rights reserved. www.psychopharmacology.com 103 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.