Dual Disorder Heroin Addicts: Clinical and Therapeutical Aspects

Description:

This book provides a comprehensive overview of dual disorders from a clinical and therapeutic point of view, especially for patients with heroin use disorder.

The volume opens with a first part dedicated to the guiding principles for treating dual disorder patients in which terminology, treatment models, use of opioid medications in heroin addiction and future perspectives are reviewed.

A second part is devoted to mood disorders. Anxiety disorders that might affect these patients are discussed in the third part, whereas the fourth part of the book focuses on chronic psychotic patients with heroin use disorder. The conclusive part explores violent heroin-dependent patients with alcohol use disorder and polydrug use.

The book will be a valuable tool for psychiatrists who wish to broaden their knowledge about addictions and a key resource for other clinicians who have practical knowledge of the addictive phenomena but are not familiar with their description in neurobiological or psychopathological terms.

Foreword

Although substance use disorders are defined as mental disorders in international classifications (DSM-5 TR and ICD-11), their consideration as such is not common in the field. The persistent difficulty in conceptualizing the relationship between addictive and other mental disorders stands out among the many challenges faced by the field of Psychiatry.

Icro Maremanni is one of the European and international opinion leaders who quickly understood that substance addictions are inseparable from the presence of other mental disorders, a clinical condition known as Dual Disorders (DDs) [1].

This book contains a comprehensive review of the evidence and draws from Prof. Maremanni’s extensive experience in the field of heroin dual disorders.

Multiple epidemiological studies have established that DDs are an expectation rather than an exception: a substantial fraction of patients suffering from a mental disorder, at some point in their lives, will also experience an addictive disorder, and vice versa. In fact, more than 75% of severe psychiatric disorders occur with other mental disorders, such as substance use disorders and other addictions [2].

From a neuroscience perspective, addiction involves a set of brain interconnected processes, rather than being a disorder defined principally by a single behavior (such as uncontrollable excessive drug use) [3].

For these epidemiological and neuroscientific reasons, people with addictions always present other mental symptoms, pathological personality traits or disorders, that is, Dual Disorders, which are explored in this guide.

An important point to consider when discussing DDs is that only a small proportion of individuals exposed to licit and illicit drugs will ultimately develop addictions. Genetic factors have been strongly implicated in the development of substance use disorders, but the role of this pre-existing vulnerability is still poorly understood and is an area that requires more research [4].

Finally, diagnostics remains a challenge in the field of DDs. Due to the lack of sensitivity and reliability of current diagnostic criteria of psychiatric disorders, clinical scientists seek to identify transdiagnostic processes that may help explain symptom expressions in mental disorders [5]. Dual Disorders, the main topic of this book, is a good example of this approach. Adopting a transdiagnostic perspective to define specific phenotypes can allow the identification of vulnerability or resilience factors to developing different addictions and other mental disorders.

Based on Prof. Maremanni’s research background, this book allows one to consider, in particular, the role of the opioid system in mental disorders. Recent studies have investigated certain mental states/personality traits that are linked to addiction and the opioid system of healthy subjects [6]. As a result of genetic or acquired factors, the opioid system may be disrupted and then produce specific functional deficits or excesses in perception, cognition, emotion, and behavior with overlapping phenotypic expressions across psychiatric domains, including addictions and other mental disorders.

This academic and clinical book is an important step towards integrating mental health care, which, until now, has been separated into different treatment concepts, one for addictions and another for other mental disorders. We are advancing towards a future of personalized and precision psychiatry in the field of Dual Disorders, an important aspiration of clinical neuroscience.

Table of contents :

Foreword
Contents
1: Guiding Principles for the Treatment of Dual Disorder Patients
1.1 Terminology
1.1.1 Habit
1.1.2 Abuse or Non-medical Use
1.1.3 Addiction
1.1.3.1 Dependence Versus Addiction
1.1.3.2 Addictive Ambivalence
1.1.3.3 Addiction and Insight
1.2 Dual Disorders and Its Flaws
1.2.1 Relationship with a Dual Disorder Patient
1.2.2 Dual Disorder Patient Case Management
1.2.3 Dual Disorder Patient and Treatment Systems
1.3 Dual Disorder and Treatment Models
1.3.1 Sequential Model
1.3.2 Parallel Model
1.3.3 Integrated Treatment
1.3.4 Towards a Hierarchical Approach to Dual Disorder Treatment
1.3.5 Criteria to Be Used in Treating Dual Disorders
1.3.5.1 Dead Ends and Start Lines in Dual Disorder
1.3.5.2 Screening and Definition Criteria for Dual Disorder Heroin Addiction
1.3.6 Diversion of Medications Used in the Treatment of Dual Disorder DD/BIP1-HUD Patients
1.3.6.1 Street Opioid Medication Use, Low-Threshold Programmes, and Dual Disorders
1.3.6.2 Impact of MMT in the Natural History of HUD Patients
1.4 Use of Opioid Medications in Heroin Addiction
1.4.1 Agonist Opioid Treatment in DD Patients. The PISA-V. P. Dole Research Group Experience
1.4.2 Pondering Antagonist Opioid Medication Use in DD/BIP1-HUD Patients
1.4.2.1 When Are We Not Allowed to Use Opioid Antagonists in Dual Disorder Patients?
1.5 Future Perspectives
1.5.1 Recruitment
1.5.2 Retention in Treatment Rate
1.5.3 Treatment Globalization
1.5.4 Stages of Treatment
2: Mood Disorders in Dual Disorder Heroin Use Disorder Patients
2.1 Clinical Aspects
2.1.1 Epidemiology
2.1.2 Substance Use and Bipolarity. The Bipolar Spectrum Concept
2.1.3 Hypothesis that Depressive Symptomatology May Be Independent of the Presence of Dual Disorder
2.1.4 Primary or Secondary Nature of Comorbid Mood Disorder in Relation to HUD
2.1.5 Impact of Comorbid Mood Disorders on the Natural History of HUD
2.1.5.1 Most Discriminant Characteristics of Bipolar 1 DD/BIP1-HUD Patients at First Opioid Agonist Treatment
2.1.5.2 Differentiating Between the Course of Illness in Bipolar 1 and Chronic DD/PSY-HUD Patients at Their First Agonist Opioid Treatment
2.1.5.3 Clinical Presentations of Substance Use in Bipolar HUD Patients at Time of Treatment Entry
2.1.6 Addiction and Suicidality
2.1.7 Heroin Addiction and Its Consequences on Mood
2.1.7.1 Exploring the Depressive Syndrome of DD/BIP1-HUD Patients (Dual Depression)
2.1.7.2 Dual Depression and Its Relationship with the Reward Deficiency Syndrome and the Post-Withdrawal Syndrome
2.1.7.3 Addiction Anhedonia: Towards a Depressive Syndrome Specific to Substance Use Disorder Patients (Dual Depression)
2.1.7.4 Therapeutic Implications
2.1.8 Possible Trajectories of Addictions: The Role of Bipolar Spectrum
2.2 Treatment of Mood Disorders in DD/BIP1-HUD Patients
2.2.1 Antidepressants
2.2.2 Mood-Stabilizing Drugs
2.2.3 Opioidergic Agents
2.2.3.1 Agonists
2.2.3.2 Opioid Antagonists in Mood Disorders
2.2.4 The Long-Term Outcomes of DD/BIP1-HUD Patients After Admission to Enhanced MMTP
2.2.5 Proposals
3: Anxiety Disorder in Heroin Use Disorder Patients
3.1 Clinical Aspects
3.1.1 Epidemiology
3.1.2 Panic Disorder and Opioid Use
3.2 Treatment of Anxiety Disorders in Drug Addicts
3.3 Treatment of BDZ Addiction During Methadone Treatment
3.4 Proposal
4: Chronic Psychosis in Dual Disorder Heroin Use Disorder Patients
4.1 Vulnerability, Neurotransmitter Pathway and Clinical Presentations of Psychosis in Substance Use Disorder Patients
4.1.1 Alcohol and Psychosis
4.1.2 Cannabis and Psychosis
4.1.3 Amphetamines and Psychosis
4.1.4 Cocaine and Psychosis
4.1.5 Hallucinogens and Psychosis
4.1.6 Inhalants and Psychosis
4.1.7 Opioids and Psychosis
4.2 Psychotic Chronicity and Schizoaffective Pictures
4.3 Substance Use and the Chronic Course of Psychotic Symptoms
4.4 Proneness to SUD and Proneness to Psychosis: Is There a Bipolar Connection?
4.4.1 Therapeutic Implications
4.5 Substance Use in Psychotic Patients
4.6 Impact of Comorbid Psychosis on the Natural Course of Heroin Use Disorder
4.6.1 Natural History of Addiction in Psychotic Heroin-Addicted Patients at Their First Agonist Opioid Treatment
4.6.2 Primary or Secondary Nature of Comorbid Psychotic Disorders in Relation to HUD
4.6.3 Clinical Aspects of DD/PSY-HUD Patients Compared with Bipolar Ones at Time of AOT Entry
4.7 Negative Symptoms in SUD Patients
4.7.1 Substance Use and Reward-System Acquired Abnormalities
4.7.2 Therapeutic Implications
4.7.3 Final Remarks
4.8 The Therapeutic Aspects of Psychotic Disorders in Addicted Patients, with Special Reference to HUD
4.8.1 Antipsychotic Agents
4.8.2 Methadone and Antipsychotics
4.8.3 Dopaminergic Partial Agonist Medications
4.8.4 Disulfiram
4.8.5 Desimipramine
4.8.6 The Long-Term Outcome of Patients with Heroin Use Disorder/Dual Disorder (Chronic Psychosis) After Admission to Enhanced Methadone Maintenance
4.8.7 Proposal
5: Dual Disorder Special Populations: Violent Heroin Use Disorder Patients
5.1 Introduction
5.2 Assessment
5.2.1 Buss–Durkee Hostility Inventory
5.2.2 SCL90 Anger-Hostility Factor
5.2.3 SCL90 Violence/Suicidality Factor
5.3 Clinical Aspects
5.3.1 Aggressive Behaviour in HUD Patients at Treatment Entry
5.3.2 Aggressive Behaviour of HUD Participants Compared with Substance Non-User Peers
5.3.3 Aggressive Behaviour in Dual Disorder HUD
5.4 Role of V/S Dimension on HUD Patients
5.5 Therapeutic Aspects
5.5.1 Effect of Opioid Medications on Aggression
6: Alcohol Use Disorder and Polytoxicomania in Heroin Use Disorder Patients
6.1 Clinical Aspects
6.2 Treatment of Alcohol Use Disorder in Heroin Use Disorder Patients
6.2.1 Heroin Use Disorder, Alcohol Use Disorder and Self-Help Groups
6.2.2 Agonist Opioid Treatment and Disulfiram Combination
6.2.3 SMO-Treatment for Heroin Use Disorder Patients with Concomitant Alcohol Use Disorder
6.2.3.1 Use of SMO in Alcohol Use Disorder Patients
6.2.3.2 Withdrawal and Non-medical Use Liability
6.2.3.3 SMO in the Treatment of Alcoholic HUD Patients
6.2.3.4 SMO Use in Heroin Use Disorder Poly-User Patients
6.2.3.5 Principles for the Safe and Effective Use of SMO
6.2.3.6 Proposal
References