The newer opioid agonist treatment with lower substitutive opiate doses is associated with better toxicology outcome than the older harm reduction treatment

Background: Charge-free heroin use disorder treatment in Italy follows two main approaches, i.e., harm reduction treatment (HRT) strategy in community low-threshold facilities for drug addiction and opioid agonist treatment (OAT) in high-threshold facilities for opioid addiction, focusing on pharmacological maintenance according to the Dole and Nyswander strategy. We aimed to compare the impact of HRT and OAT on patient outcome, as assessed through negativity for drugs on about 1-year urinalyses. Methods: We examined retrospectively the urinalyses of HRT and OAT patients for which at least four randomly sampled urinalyses per month were available for about 1 year, during which patients were undergoing methadone or buprenorphine maintenance; urinalyses focused on heroin, cocaine, cannabinoids, and their metabolites. Results: Included were 189 HRT and 58 OAT patients. The latter were observed for a significantly longer period. There was a higher proportion of heroin- and cocaine-clean urinalyses in OAT patients, with cocaine-clean urinalyses discriminating best between the two groups. OAT patients were older, with longer dependence duration, more severe addiction history, and received lower methadone doses. Buprenorphine maintenance was more often associated with heroin-clean urinalyses. The higher the methadone doses, the lower were the percentage of heroin-clean urinalyses in HRT patients (negative correlation). Conclusions: The OAT approach was related to higher recovery and polyabuse abstinence rates compared to the HRT approach, despite greater severity of substance use, psychiatric and physical comorbidities. Our results are consistent with the possibility to use lower maintenance opiate doses (after induction and stabilization in methadone treatment according to Dole and Nyswander methodology) in treating heroin addiction. This seemed to be impossible adopting the currently accepted HRT model

Neuropsychological deficits in young drug addicts

Background: Adolescence is a highly vulnerable age for experimenting with drugs; increasing evidence attests that several substances might have detrimental effects on cognitive functioning in this developmental phase, when prefrontal brain areas are still immature and may actually be the main target of the neurotoxic effects of drugs. There are still, in any case, too few studies that specifically address early adulthood. Aim: The present study aims to investigate neuropsychological performance in young drug addicts in residential treatment (aged 18-24). Methods: 41 young drug addicts, after admission to residential treatment, were compared with 27 subjects in the control group. A battery of neuropsychological tests (Brief Neuropsychological Exam-2) was administered to detect possible cognitive impairments. Descriptive and non-parametric statistics (Pearson’s chi square test) were performed. Results and conclusions: Findings suggest that drug dependence in youth is distinguished by neuropsychological deficits, in particular, attention and executive function impairments – issues that now call for tailored and innovative treatment approaches

Do Akiskal & Mallya's affective temperaments belong to the domain of pathology or to that of normality?

BACKGROUND: Kraepelin and Kretschmer hypothesized a continuum between full-blown affective pathology and premorbid temperaments. More recently Akiskal proposed a putative adaptive role for the four fundamental temperaments: the hyperthymic one characterized by emotional intensity, the cyclothymic one by emotional instability, the depressive one by a low energy level, and the irritable one by an excessive response to stimuli. Today it is widely debated whether affective temperaments belong to the domain of pathology or to that of normality. PURPOSE: To make clear, by applying an integrated model, the position of affective temperaments within the continuum between normality and pathology. METHODS: We reviewed several papers that explore the distribution of affective temperaments among the general population, and their involvement both in pathological conditions (somatic and psychiatric) and in human activities (professions and other occupations). RESULTS: Far from being intrinsically pathological conditions, affective temperaments seem to represent adaptive dispositions whose dysregulation can lead to full-blown affective pathology. All the temperamental types display some impact on people's lives by influencing personal skills and professional choices over a wide field of human activities. CONCLUSIONS: Affective temperaments are not problematic when they appear in a mild form, but when they occur in extreme form we have observed a gap between the hyperthymic temperament, which represents the most functional and desirable, and the cyclothymic, depressive, irritable and phobic anxious ones, which are closer to mood, anxiety, and substance use disorders, and imply a component of somatic diseases and life stressors

Clonazepam as Agonist Substitution Treatment for Benzodiazepine Dependence: A Case Report

Nowadays, the misuse of benzodiazepines (BZDs) is a cause for a serious concern among pharmacologically inexperienced patients, whether treated or untreated, that could lead to significant complications, including tolerance, dependence, and addiction. We present a case report in which an Italian patient affected by anxiety disorder and treated with BZDs presented a severe case of dependence on BZDs. We treated him according to an agonist substitution approach, switching from the abused BZD to a slowonset, long-acting, high potency agonist (clonazepam), and looking at the methadone treatment model as paradigm. We decided to use clonazepam for its pharmacokinetic properties. The advantage of choosing a slow-onset, long-lasting BZD for the treatment of our patient was that it led us to a remarkable improvement in the clinical situation, including the cessation of craving, absence of withdrawal symptoms, reduced anxiety, improvements in social functioning, and a better cognition level

Non-medical Cannabis Self-Exposure as a Dimensional Predictor of Opioid Dependence Diagnosis: A Propensity Score Matched Analysis

Background: The impact of increasing non-medical cannabis use on vulnerability to develop opioid use disorders has received considerable attention, with contrasting findings. A dimensional analysis of self-exposure to cannabis and other drugs, in individuals with and without opioid dependence (OD) diagnoses, may clarify this issue.Objective: To examine the age of onset of maximal self-exposure to cannabis, alcohol, cocaine, and heroin, in volunteers diagnosed with OD, using a rapidly administered instrument (the KMSK scales). To then determine whether maximal self-exposure to cannabis, alcohol, and cocaine is a dimensional predictor of odds of OD diagnoses.Methods: This outpatient observational study examined maximal self-exposure to these drugs, in volunteers diagnosed with DSM-IV OD or other drug diagnoses, and normal volunteers. In order to focus more directly on opioid dependence diagnosis as the outcome, volunteers who had cocaine dependence diagnoses were excluded. Male and female adults of diverse ethnicity were consecutively ascertained from the community, and from local drug treatment programs, in 2002–2013 (n = 574, of whom n = 94 had OD diagnoses). The age of onset of maximal self-exposure of these drugs was examined. After propensity score matching for age at ascertainment, gender, and ethnicity, a multiple logistic regression examined how increasing self-exposure to non-medical cannabis, alcohol and cocaine affected odds of OD diagnoses.Results: Volunteers with OD diagnoses had the onset of heaviest use of cannabis in the approximate transition between adolescence and adulthood (mean age = 18.9 years), and onset of heaviest use of alcohol soon thereafter (mean age = 20.1 years). Onset of heaviest use of heroin and cocaine was detected later in the lifespan (mean ages = 24.7 and 25.3 years, respectively). After propensity score matching for demographic variables, we found that the maximal self-exposure to cannabis and cocaine, but not to alcohol, was greater in volunteers with OD diagnoses, than in those without this diagnosis. Also, a multiple logistic regression detected that increasing self-exposure to cannabis and cocaine, but not alcohol, was a positive predictor of OD diagnosis.Conclusions/Importance: Increasing self-exposure to non-medical cannabis, as measured with a rapid dimensional instrument, was a predictor of greater odds of opioid dependence diagnosis, in propensity score-matched samples

Substance Dependence Among Bipolar, Unipolar Depression and Psychotic Homeless: A Canadian National Study

Introduction: Homeless individuals are often mischaracterized as members of a homogeneous population that suffers from a wide mental health and addiction issues, with little consideration of potentially important differences within or between samples. The aim of the present study was to investigate the comorbidy of alcohol and/or substance dependence (ASD) and major psychiatric diagnoses (bipolar disorder, unipolar depression, and psychotic disorder) in a large Canadian sample of homeless individuals, and to examine potential sources of variability including location and ethnicity.Materials and Methods: A sample of 1,585 homeless individuals were assessed for alcohol and/or substance dependence and bipolar disorder, unipolar depression and psychotic disorder with the Mini-International Neuropsychiatric Interview (version 6.0). Regional and ethnic differences in major psychiatric diagnoses between homeless with and without ASD were examined using univariate (i.e., chi-square) and multivariate (i.e., logistic regression) statistics.Results: Members of the sample with ASD were found to be younger, Aboriginal, less well-educated, and born in the Americas. They were more significantly more prevalent in Western Canada and less prevalent in Central and Eastern Canada. The odds of having ASD were higher among people affected by bipolar disorder and (to a less extent) unipolar depression.Limitations: Data collected were self-reported and no urinalyses were performed. We considered diagnosis of ASD according to the previous 12 months only.Conclusions: Homeless people with major mental illness are at high risk for concurrent ASD, however the prevalence of ASD varies significantly between cities, and based on ethnicity and specific psychiatric diagnosis (with greater prevalence in individuals affected by bipolar disorder and, to a less extent, unipolar depression). Clinicians, administrators and policy makers should develop and deliver services based on careful assessment of the local population

Systematic Evaluation of Bipolarity in Parkinson Disease. Rates of comorbidity and clinical implications.

Background: Psychiatric comorbidity is well known in Parkinson Disease (PD), however only apathy, depression and anxiety have been systematically studied. Lifetime prevalence and clinical implications of comorbid of PD and Bipolar Spectrum Disorders are understudied. Aims: The major aims of the present study is the evaluation of psychiatric co-morbidity in a cohort of PD patients and to explore the clinical correlates of PD associated with Bipolar Spectrum Disorders. Methods: 77 PD patients have been screened for psychiatric comorbidities, cognitive profile, motor and non-motor symptoms using validated rating scales. The sample has been divided into three groups: PD-patients with bipolar disorders (BD) comorbidity (N=27), PD-patients with others psychiatric comorbidities (N=27), PD-patients without psychiatric comorbidities (N=23). Clinical aspects of PD were compared among the three groups at univariate and multivariate level. Results: In comparison with the other two groups of PD patients with and without other psychiatric comorbidity, PD patients with BD are younger, showed an an earlier age at onset of PD, reported more involuntary movements, as well as higher rate of first degree familiarity for BD and of ICDs and compulsive behaviors. Moreover BD diagnosis precedes the diagnosis of PD. Conclusion: Bipolar disorder is associated with early onset of PD, involuntary movements and lifetime ICDs. The bipolar diathesis probably identify a particular subtype of PD, that deserves further investigation. Looking at the evolution of this specific subtype could also shed light over some clinical features of bipolar disorder associated with neurodegenerative conditions

Psicosi ed uso di sostanze psicoattive. Storia naturale della tossicodipendenza in eroinomani psicotici al primo trattamento con agonisti oppiacei.

L’analisi della letteratura sui rapporti tra oppiacei e psicosi non è in grado di dirimere il dubbio se l’uso di eroina possa in qualche modo indurre uno stato psicotico,nelle fasi di intossicazione o astinenza,o se giovani psicotici diventino tossicomani nel tentativo di sfruttare le supposte proprietà antipsicotiche degli oppiacei attraverso l’uso di eroina. Scopo primario di questa tesi è il confronto della storia tossicomanica di eroinomani psicotici ed eroinomani senza comorbidità psichiatrica cercando di dirimerne il dubbio. Su un campione costituito da 23 soggetti eroinomani psicotici e 209 eroinomani senza comorbidità psichiatrica, siamo andati a valutare le caratteristiche differenziali della loro storia tossicomanica, all’ingresso in trattamento con agonisti oppioidi. Dall’analisi dei dati abbiamo potuto concludere che la storia tossicomanica degli eroinomani psicotici è meno grave di quella degli eroinomani non psicotici , tuttavia gli eroinomani psicotici sono caratterizzati da un maggior uso concomitante di altre sostanze d’abuso, da una maggiore gravità di sintomi psicopatologici e da prodromi psicopatologici, ciò ad indicare che la psicosi tende ad essere precedente all’uso di eroina e che l’uso di oppiacei negli eroinomani psicotici sia prevalentemente a scopo auto-terapico

Toward the Identification of a Specific Psychopathology of Substance Use Disorders

Addiction is a mental illness in which psychiatric conditions imply a prominent burden. Psychopathological symptoms in substance use disorder (SUD) patients are usually viewed as being assignable to the sphere of a personality trait or of comorbidity, leaving doubts about the presence of a specific psychopathology that could only be related to the toxicomanic process. Our research group at the University of Pisa has shed light on the possible definition of a specific psychopathological dimension in SUDs. In heroin use disorder patients, performing an exploratory principal component factor analysis (PCA) on all the 90 items included in the SCL-90 questionnaire led to a five-factor solution. The first factor accounted for a depressive "worthlessness and being trapped" dimension; the second factor picked out a "somatic symptoms" dimension; the third identified a "sensitivity-psychoticism" dimension; the fourth a "panic-anxiety" dimension; and the fifth a "violence-suicide" dimension. These same results were replicated by applying the PCA to another Italian sample of 1,195 heroin addicts entering a Therapeutic Community Treatment. Further analyses confirmed the clusters of symptoms, independently of demographic and clinical characteristics, active heroin use, lifetime psychiatric problems, kind of treatment received, and, especially, other substances used by the patient such as alcohol or cocaine. Moreover, these clusters were able to discriminate patients affected by addiction from those affected by psychiatric diseases such as major depressive disorder. Our studies seem to suggest the trait-dependent, rather than the state-dependent, nature of the introduced psychopathology dimensions of SUDs

Further evidence of a specific psychopathology of addiction. Differentiation from other psychiatric psychopathological dimensions (such as obesity)

Introduction: In this study, we used a symptomatology checklist (SCL-90) to substantiate the hypothesis that Substance Use Disorder (SUD) has its own five-dimensional psychopathology. The aim of the present study was to test whether this psychopathology can be differentiated from other psychiatric psychopathological dimensions (such as obesity). Methods: The severity and frequency of each of the five dimensions were investigated, at univariate and multivariate levels, by comparing 972 Heroin Use Disorder (HUD) patients (83.5% male, mean age 30.12 ± 6.6, range: 16–59) and 106 obese individuals (50.0% male, mean age 37.59 ± 7.6, range: 24–52). The correlations between the Body Mass Index (BMI) of obese individuals with these psychopathological dimensions were also studied. Results: Obese individuals showed higher SCL-90 total scores, global severity index scores, number of items rated positively, and positive symptoms distress index scores than HUD patients. The severity of all psychopathological dimensions was significantly higher in obese individuals. Discriminant analysis showed that Panic-Anxiety and Violence-Suicide severity were more frequent in obese patients, sufficiently so to allow differentiation between HUD (lower severity) and obese individuals (greater severity). At the reclassification level, 70.8% of obese individuals in the sample were reclassified as HUD patients. Psychopathological subtypes characterized by Panic-Anxiety and Violence-Suicide typology were more frequent in obese patients and sufficiently so as to discriminate between groups. Of obese patients, 47.2% were reclassified as HUD patients. The severity of the Worthlessness-Being Trapped dimension was sufficient to predict the BMI of obese individuals. Conclusions: Our results suggest that the five-factor psychopathology found in HUD can discriminate between HUD and obese patients, but that there is an area of overlap between the forms of psychopathology found in SUD and those found in obese patients