[Weighing the benefits and harms of psychotropic and analgesic substances - A perspective of German addiction medicine experts]. / Abwägung von Nutzen und Schädlichkeit von berauschenden und schmerzlindernden Substanzen aus der Perspektive von deutschen Suchtmedizinern.

BACKGROUND: In Europe, there have been several addiction-expert rankings of harms related to the use of psychotropic substances in the last 15 years. Among them, only one expert ranking took into account the potential benefits of these drugs. Non-Opioidergic Analgesics (NOAs), such as gabapentinoids and NSAIDs, which have been increasingly the subject of abuse / misuse reports, have not been considered in such expert rankings. Likewise, there is currently no multi-substance comparison as to whether the valuation rank of the harmfulness of an illegal drug may change along with an imagined change in legal status in Germany. OBJECTIVES AND METHODS: Using a questionnaire, 101 experienced addiction physicians (first cohort) evaluated 33 psychoactive substances including analgesics with regard to their health and social harms as well as potential usefulness for the consumer and their environment / society ('others'). In addition, this cohort investigated whether the harmfulness assessment of an illegal substance changes if it would be legalized. In order to obtain the average overall harmfulness (overall risk) of a substance, the percentage contribution of each dimension to the overall harmfulness was determined in a second survey (second cohort, 36 experienced addiction medicine experts). Finally, the average benefit and overall risk ratings of each substance were related to each other. RESULTS: Prescription psychoactive substances such as analgesics, NOAs (including gabapentinoids) and opioidergic maintenance medications to treat opiate dependence were judged to have a favorable benefit-harm profile. Cannabis and ketamine were placed in the midfield of both, the harm and benefit rankings. Together with most illicit narcotic drugs, alcohol and nicotine, have been ranked among the most harmful and least useful substances, whereby alcohol was judged on average to be more harmful but also more useful than nicotine. In the event of potential legalization, the overall harm of the traditional illegal drugs methamphetamine, heroin, cocaine and cannabis was estimated to be reduced. This was mainly due to a more favorable valuation of the harm to others under these virtual conditions. CONCLUSION: Prescription substances including opioidergic and non-opioidergic analgesics as well as opioid maintenance therapy medications (methadone and buprenorphine) were assigned a favorable benefit-harm profile. Alcohol, nicotine and traditional illicit drugs (with the exception of cannabis and ketamine) were determined to have an unfavorable profile. The overall harm of traditional illicit drugs was assessed to decrease along with legalization, mainly by decreasing the harm to others in this virtual event.

Ranking the Harm of Psychoactive Drugs Including Prescription Analgesics to Users and Others-A Perspective of German Addiction Medicine Experts.

Background: Over the past 15 years, comparative assessments of psychoactive substance harms to both users and others have been compiled by addiction experts. None of these rankings however have included synthetic cannabinoids or non-opioid prescription analgesics (NOAs, e.g., gabapentinoids) despite evidence of increasing recreational use. We present here an updated assessment by German addiction medicine experts, considering changing Western consumption trends-including those of NOAs. Methods: In an initial survey, 101 German addiction medicine physicians evaluated both physical and psychosocial harms (in 5 dimensions) of 33 psychoactive substances including opioids and NOAs, to both users and others. In a second survey, 36 addiction medicine physicians estimated the relative weight of each health and social harm dimension to determine the overall harm rank of an individual substance. We compared our ranking with the most recent European assessment from 2014. Results: Illicit drugs such as methamphetamine, heroin, cocaine and also alcohol were judged particularly harmful, and new psychoactive drugs (cathinones, synthetic cannabinoids) were ranked among the most harmful substances. Cannabis was ranked in the midrange, on par with benzodiazepines and ketamine-somewhat more favorable compared to the last European survey. Prescribed drugs including opioids (in contrast to the USA, Canada, and Australia) were judged less harmful. NOAs were at the bottom end of the ranking. Conclusion: In Germany, alcohol and illicit drugs (including new psychoactive substances) continue to rank among the most harmful addictive substances in contrast to prescribed agents including opioid analgesics and NOAs. Current laws are incongruent with these harm rankings. This study is the first of its kind to include comparative harm rankings of several novel abused substances, both licit/prescribed and illicit.

Differential relationships of PTSD and childhood trauma with the course of substance use disorders.

A large body of research documents the link between Posttraumatic Stress Disorder (PTSD) and the course of Substance Use Disorders (SUD). Similar relationships have been reported between Childhood Trauma (CT) and the course of illness in patients with SUD even in the absence of PTSD, but few studies have examined differential effects of PTSD and CT (independent of PTSD) in this population. We used the International Diagnostic Checklist (IDCL) and the Posttraumatic Diagnostic Scale (PDS) to diagnose PTSD in a sample of patients with SUD (N = 459). The Childhood Trauma Questionnaire (CTQ) and the European Addiction Severity Index (EuropASI) were administered to assess childhood trauma and addiction related problems including comorbid psychopathological symptoms. The sample was divided into three groups: patients with experiences of CT and PTSD (CT-PTSD), experiences of CT without PTSD (CT-only), and neither experiences of CT nor PTSD (No trauma) to examine their differential associations with the course and severity of SUD. Patients of both the CT-PTSD (n = 95) and the CT-only group (n = 134) reported significantly higher levels of anxiety and depression as well as more suicidal thoughts and suicide attempts during their lifetime than the No trauma group (n = 209). Regarding most variables a graded association became apparent, with the highest level of symptoms in the CT-PTSD group, an intermediate level in the CT-only group and the lowest level in the No trauma group. The CT-PTSD group also differed in almost all substance use variables significantly from the No trauma group, including a younger age at first use of alcohol and cannabis, more cannabis use in the last month, and more lifetime drug overdoses. Our results confirm the relationships of both CT and PTSD with psychiatric symptoms in patients with SUD. Thus, it seems important to include both domains into the routine assessment of SUD patients. Specific treatments for comorbid PTSD but also for other consequences of childhood trauma should be integrated into SUD treatment programs.

Relationships between a Dissociative Subtype of PTSD and Clinical Characteristics in Patients with Substance Use Disorders.

The increasing support for a dissociative subtype of post-traumatic stress disorder (PTSD-D) has led to its inclusion in DSM-5. We examined relationships between PTSD-D and relevant variables in patients with substance use disorders (SUD). The sample comprised N = 459 patients with SUD. The International Diagnostic Checklist and the Posttraumatic Diagnostic Scale were used to diagnose PTSD. In addition, participants completed the Childhood Trauma Questionnaire and the Dissociative Experiences Scale. The course of SUD was assessed by means of the European Addiction Severity Index. One-fourth of participants fulfilled a diagnosis of PTSD (25.3%). Patients with PTSD-D (N = 32, 27.6% of all patients with PTSD) reported significantly more current depressive symptoms, more current suicidal thoughts, more lifetime anxiety/tension, and more suicide attempts. The PTSD-D group also showed a significantly higher need for treatment due to drug problems, higher current use of opiates/analgesics, and a higher number of lifetime drug overdoses. In a regression model, symptoms of depression in the last month and lifetime suicide attempts significantly predicted PTSD-D. These findings suggest that PTSD-D is related to additional psychopathology and to a more severe course of substance-related problems in patients with SUD, indicating that this group also has additional treatment needs.