Chronology of illness in dual diagnosis heroin addicts: The role of mood disorders

Addressing Dual Disorders in a Medium-Term Admission Unit

Due to the significant functional repercussions suffered by patients with dual disorder, we must evaluate which ones can benefit from intensive rehabilitative therapies in medium-stay psychiatric units. This was a retrospective study of patient medical records which intended to analyze sociodemographic and clinical variables and parameters related to the hospitalization and discharge of patients admitted to the Medium-Stay Unit (MSU) at the Castellón Provincial Hospital Consortium over 2 years (2017 and 2018), according to the presence or absence of dual disorders in these patients. Patients with a dual disorder represented 55.2% of the hospitalized patients. A higher proportion of them were male, were relatively younger, and had an earlier onset of mental illness, fewer associated medical pathologies, and shorter hospital admission times to the Short-Term Hospitalization Unit than those who did not present a dual disorder. A diagnosis on the schizophrenia spectrum with cannabis use or polyconsumption was the most common diagnosis; 98.2% of all the patients responded adequately to admission to the MSU. This work highlighted the need for higher doses of depot paliperidone in patients with dual disorders.

Developmental trajectories in psychiatric disorders: does substance/alcohol use moderate the effects of affective temperaments as moderators of age at onset? A study in post-acute, hospitalized patients with psychotic or DSM-5 bipolar or major depressive disorders

BACKGROUND

Age-at-onset (AAO) affects psychiatric disorder outcome; substance (SUDs) or alcohol use disorders (AUDs) may influence their onset. Affective temperaments may affect early AAO and drug-use proneness. Objectives: To investigate whether SUD/AUD moderated temperamental effects in determining AAO of mental disorders. Methods: We included 300 post-acute inpatients with schizophrenia-spectrum and other psychotic (SSOPDs), major depressive (MDD) or bipolar (BD) disorders (168 men; mean age, 40.63 years ± 11.82 men, 43.21 years ± 12.69 women) with (N = 110) or without (N = 190) SUD/AUD. Patients completed cross-sectionally TEMPS-A. We carried moderation analysis with each regression-significant TEMPS temperament as independent variable, SUD/AUD presence/absence as dichotomous moderator, and AAO as dependent variable. Significance was set at p < 0.05. Results: AAO was lower in patients with SUD/AUD diagnosis than in patients without (23.74 ± 10.09 vs. 27.73 ± 10.35, respectively, p = 0.001, η2 = 0.034). SUD/AUD patients scored higher on the hyperthymic (10.22 ± 4.08, p < 0.001, η2 = 0.069) and irritable (8.26 ± 4.69, p < 0.01, η2 = 0.026) temperaments than nonSUD/AUD patients. Moderation analysis showed only direct effects of irritable (β = -0.55, p < 0.005) and hyperthymic (β = -0.95, p < 0.001) temperaments on AAO and no significant SUD/AUD and interaction effects. Limitations. Cross-sectional design. Conclusions: When irritable and hyperthymic traits prevail over other temperaments, AAO is earlier in SSOPDs, MDD, and BD. SUD/AUD presence/absence does not moderate the relationship between temperament and AAO.

Factors associated with sedative use and misuse among heroin users

BACKGROUND

Rates of both opioid and sedative use and misuse are rising. Comorbid opioid and sedative use is associated with especially severe consequences (e.g., overdose and poor health outcomes). Heroin users report multiple motivations for sedative use, including self-medication. We aimed to understand differences in lifetime substance use characteristics between heroin users with different sedative use histories.

METHODS

Substance use data were collected from 385 non-treatment seeking heroin users. Subjects were divided into four lifetime sedative-use groups: no use, medical use only, non-medical use only, and mixed medical and non-medical use. We examined patterns of use of various substances of abuse (tobacco, alcohol, marijuana, cocaine, heroin, and sedatives) and individual characteristics associated with each.

RESULTS

Non-medical sedative use (alone or in addition to medical use) was associated with more negative consequences from using all substances. Medical sedative use alone was not related to increased overdose or emergency room visits associated with heroin use. Non-medical sedative use was associated with increases in 15 of the 21 measured heroin consequences and only one of those - health problems - was also associated with medical sedative use.

CONCLUSIONS

Concomitant non-medical sedative use and heroin use is associated with significantly greater negative outcomes than those experienced by heroin users who report use of sedatives only as prescribed. Understanding these differences offers insight into risks related to using both substances and may help treatment providers create targeted harm reduction interventions for this population.

The long-term outcome of patients with heroin use disorder/dual disorder (chronic psychosis) after admission to enhanced methadone maintenance

BACKGROUND

Over-standard methadone doses are generally needed in the treatment of heroin use disorder (HUD) patients that display concomitant high-severity psychopathological symptomatology. A flexible dosing regimen may lead to higher retention rates in dual disorder (DD), as we demonstrated in bipolar 1 HUD patients, leading to outcomes that are as satisfactory as those of HUD patients without high-severity psychopathological symptomatology.

OBJECTIVE

This study aimed to compare the long-term outcomes of treatment-resistant chronic psychosis HUD patients (PSY-HUD) with those of peers without dual disorder (HUD).

METHODS

85 HUD patients who also met the criteria for treatment resistance-25 of them affected by chronic psychosis and 60 without DD-were monitored prospectively for up to 8 years while continuing to receive enhanced methadone maintenance treatment.

RESULTS

The rates of endurance in the treatment of PSY-HUD patients were 36%, compared with 34% for HUD patients (p = 0.872). After 3 years of treatment, these rates tended to become progressively more stable. PSY-HUD patients showed better outcome results than HUD patients regarding CGI severity (p < 0.001) and DSM-IV-GAF (p < 0.001). No differences were found regarding good toxicological outcomes or the methadone dosages used to achieve stabilization. The time required to stabilize PSY-HUD patients was shorter (p = 0.034).

CONCLUSIONS

An enhanced methadone maintenance treatment seems to be equally effective in patients with PSY-HUD and those with HUD.

Medications for substance use disorders (SUD): emerging approaches

INTRODUCTION

Substance use disorders are a group of chronic relapsing disorders of the brain, which have massive public health and societal impact. In some disorders (e.g., heroin/prescription opioid addictions) approved medications have a major long-term benefit. For other substances (e.g., cocaine, amphetamines and cannabis) there are no approved medications, and for alcohol there are approved treatments, which are not in wide usage. Approved treatments for tobacco use disorders are available, and novel medications are also under study. Areas covered: Medication-based approaches which are in advanced preclinical stages, or which have reached proof-of concept clinical laboratory studies, as well as clinical trials. Expert opinion: Current challenges involve optimizing translation between preclinical and clinical development, and between clinical laboratory studies to therapeutic clinical trials. Comorbidities including depression or anxiety are challenges for study design and analysis. Improved pharmacogenomics, biomarker and phenotyping approaches are areas of interest. Pharmacological mechanisms currently under investigation include modulation of glutamatergic, GABA, vasopressin and κ-receptor function, as well as inhibition of monoamine re-uptake. Other factors that affect potential market size for emerging medications include stigma, availability of treatment settings, adoption by clinicians, and the prevalence of persons with SUD who are not actively treatment-seeking.

Can a rapid measure of self-exposure to drugs of abuse provide dimensional information on depression comorbidity?

BACKGROUND AND OBJECTIVES

Addictions to heroin or to cocaine are associated with substantial psychiatric comorbidity, including depression. Poly-drug self-exposure (eg, to heroin, cocaine, cannabis, or alcohol) is also common, and may further affect depression comorbidity.

METHODS

This case-control study examined the relationship of exposure to the above drugs and depression comorbidity. Participants were recruited from methadone maintenance clinics, and from the community. Adult male and female participants (n = 1,201) were ascertained consecutively by experienced licensed clinicians. The instruments used were the SCID-I, and Kreek-McHugh-Schluger-Kellogg (KMSK) scales, which provide a rapid dimensional measure of maximal lifetime self-exposure to each of the above drugs. This measure ranges from no exposure to high unit dose, high frequency, and long duration of exposure.

RESULTS

A multiple logistic regression with stepwise variable selection revealed that increasing exposure to heroin or to cocaine was associated greater odds of depression, with all cases and controls combined. In cases with an opioid dependence diagnosis, increasing cocaine exposure was associated with a further increase in odds of depression. However, in cases with a cocaine dependence diagnosis, increasing exposure to either cannabis or alcohol, as well as heroin, was associated with a further increase in odds of depression.

DISCUSSION AND CONCLUSIONS

This dimensional analysis of exposure to specific drugs provides insights on depression comorbidity with addictive diseases, and the impact of poly-drug exposure.

SCIENTIFIC SIGNIFICANCE

A rapid analysis of exposure to drugs of abuse reveals how specific patterns of drug and poly-drug exposure are associated with increasing odds of depression. This approach detected quantitatively how different patterns of poly-drug exposure can result in increased odds of depression comorbidity, in cases diagnosed with opioid versus cocaine dependence. (Am J Addict 2017;26:632-639).

Adult Attachment, Social Adjustment, and Well-Being in Drug-Addicted Inpatients

In recent years, attachment studies have gathered overwhelming evidence for a relation between insecure attachment and drug addiction. The existing literature predominantly addresses attachment styles and little attention is given to attachment-pattern-oriented studies. The current study explored how attachment, social adjustment, and well-being interact in 40 (28 men, 12 women; ages 20-52 years, M = 32.3, SD = 9.4) inpatients with drug addiction. The Adult Attachment Projective Picture System (AAP), the Social Adjustment Scale-Self-report (SAS-SR), and the General Health Questionnaire-28 (GHQ-28) were administered. Descriptive statistics were computed as well as differences between patterns of attachment in all variables were measured. None of the inpatients showed a secure attachment pattern: 7 scored as dismissing (18%), 5 preoccupied (12%) and 28 unresolved (70%). AAP stories were mainly connected with themes of danger, lack of protection, and helplessness. Inpatients classified as unresolved reported significantly higher maladjustment on the SAS-SR and GHQ-28 than those with resolved attachment patterns. Implications for clinicians and researchers are presented.