[Clinical aspects and therapeutic positioning in addictology]. / Aspects cliniques et positionnement thérapeutique en addictologie.

The concept of addiction emerged subsequent to the moral approaches of the end ofthe 19th century as a pathological behaviour. The manuals which classify mental disorders, together with the notion of substance-related disorders, enable them to be approached with a medical vision. The subject of numerous, often heated or divisive debates, addictology requires a clinical approach. The treatment of addiction must involve professionals from the medical, nursing, psychological and social fields. This multi-disciplinarity encourages each player to consider their own nursing identity while taking into account that of each other.

[Alcoholic disease in women, what specificities?] / Maladie alcoolique chez la femme, quelles spécificités ?

Alcoholic disease in women, what specificities? Alcoholic disease in women has long been neglected. Taboo, culturally, it has also probably been so in the field of research and on clinical practice. But this has changed since the recent publication of some very relevant studies that attracted particular attention from a part of the public opinion who came in support of professionals alarmed by the inaction on this subject. Based on a specific clinical experience and from epidemiological studies, clinical data and the complications due to alcohol misuse by women, this article demonstrates the need to focus more on this pathology as it is serious for the patients as well as for their entourage. Indeed, complications seem to be able to develop from the first drink: they are somatic, psychiatric, but also social. There are specificities of this disease in women both through the factors of vulnerability but also by the clinical presentation or by its consequences. Women are more vulnerable than men to alcohol. The lack of knowledge from which this disease suffers leads to longer delays before consultation of patients and insidiously installs complications that are heavier than those of men. In fact, care requires a specific approach in relation to a request and a still particular status attributed to women. It is important to increase the information work in order to encourage patients to consult but also to better legislate on the promotion that mainly targets women and young people, and this in the framework of a more rigorous and efficient prevention.

Maladie alcoolique chez la femme, quelles spécificités ? La maladie alcoolique chez les femmes est restée longtemps négligée. Taboue sur le plan culturel, elle l'était probablement aussi encore dans le domaine de la recherche et de la clinique. Mais cela change depuis certaines études récentes très éloquentes qui ont éveillé l'intérêt d'une partie de l'opinion publique venue en soutien aux professionnels qui s'alarmaient de l'immobilisme à ce sujet. Sur la base d'une expérience clinique particulière et à partir d'études consacrées à l'épidémiologie, la clinique et les complications du mésusage d'alcool chez les femmes, cet article montre la nécessité de se pencher davantage sur cette pathologie tant elle est grave pour les patientes ainsi que pour leur entourage. En effet, les complications semblent pouvoir se développer dès le premier verre : elles sont somatiques, psychiatriques mais aussi sociales. Il existe des spécificités de cette maladie chez les femmes à la fois à travers les facteurs de vulnérabilité mais aussi par le tableau clinique ou encore par ses conséquences. Les femmes sont plus fragiles que les hommes face à l'alcool. Le manque de connaissance dont pâtit cette maladie rallonge le délai de consultation des patientes et installe insidieusement les complications qui sont plus lourdes que chez les hommes. De fait, la prise en charge nécessite une approche spécifique en lien avec une demande et un statut encore particulier attribué aux femmes. Il est important d'accentuer le travail d'information afin d'inciter les patientes à consulter mais aussi de mieux légiférer sur la promotion qui vise principalement la cible des femmes et les jeunes, et cela dans le cadre d'une prévention plus rigoureuse et plus efficace.

[General principles of treatment in addictology]. / Principes généraux de la prise en charge en addictologie.

General principles of treatment in addictology. Among all mental disorders, addictive pathologies are serious disorders. Their prognosis is severe. Their management is complex. It requires the evaluation of the addictive disorder, the psychiatric pathologies and the motivation. The follow-up must be adapted to the patient's motivation. By medications, it is traditional to oppose substitution and withdrawal strategies and risk reduction. Psychiatric comorbidities, frequent, are factors of aggravation of the dependency. They need parallel and integrated cares between addiction and mental health care systems. The place of hospitalization is reduced, support for families is essential.

Principes généraux de la prise en charge en addictologie. Parmi l'ensemble des troubles mentaux, les pathologies addictives sont des troubles graves. Leur pronostic est sévère. Leur prise en charge est complexe et nécessite l'évaluation du trouble addictif, des troubles psychiatriques associés et de la motivation. Le suivi au long cours doit s'adapter à la motivation du patient. Sur le plan médicamenteux, il est classique d'opposer les stratégies de substitution et de sevrage et la réduction des risques. Les comorbidités psychiatriques, habituellement résistantes, sont des facteurs de gravité. Elles nécessitent une prise en charge parallèle et intégrée entre les systèmes de soins en addictologie et en santé mentale. La place de l'hospitalisation est réduite, le soutien aux familles indispensable.

Naltrexone in the Treatment of Broadly Defined Behavioral Addictions: A Review and Meta-Analysis of Randomized Controlled Trials.

INTRODUCTION: Broadly defined behavioral addiction is a conceptual framework including behaviors characterized by loss of control and continuation despite significant negative consequences. Broadly defined behavioral addictions share many similarities with substance use disorders. As naltrexone is one of the most studied treatment for substance use disorders, we conducted a meta-analysis of randomized placebo-controlled trials (RCT) assessing the effectiveness of naltrexone in the treatment of broadly defined behavioral addictions. METHOD: We conducted a literature search and selection, up to January 1, 2017, according to previously set inclusion criteria. The selected trials underwent a quality assessment before data extraction and statistical analysis, which used fixed and random effects models. Standardized mean differences (SMD) were calculated using Hedge's adjusted g. RESULTS: A total of 6 RCTs (n = 356) were included. Of these, 3 assessed naltrexone effectiveness in the treatment of pathological gambling, and 3 tested its benefits in broadly defined behavioral addictions other than pathological gambling (kleptomania, trichotillomania, and impulsive compulsive disorders). The meta-analysis of the whole sample resulted in a statistically significant score improvement under naltrexone versus placebo (fixed effect model: SMD = -0.27, 95% CI [-0.51 to -0.03], z = 2.23; p = 0.025). CONCLUSION: The results of our meta-analysis suggest a beneficial effect of naltrexone in the treatment of broadly defined behavioral addictions.

[Cannabis-induced cognitive and psychiatric disorders]. / Les troubles cognitifs et psychiatriques liés à la consommation de cannabis.

Several studies have shown that Δ-9-THC the main psychoactive constituent of cannabis, can impair cognitive functions, especially attention, episodic memory, working memory and executive functions. These impairments have been related to the duration, frequency, dose and age at onset of cannabis use. Cognitive deficits may disappear with abstinence, but abnormalities may be long-lasting in subjects who began smoking cannabis before age 15. The lifetime prevalence of cannabis use disorders is about 1% in the general population. The main characteristics of cannabis use disorders are craving, persistent desire or unsuccessful efforts to cut down or control cannabis use, and persistent avoidance of familial, social occupational or recreational activities because of cannabis use. Nine prospective longitudinal studies in the generalpopulation have shown that cannabis use is associated with a two-fold increase in the risk of psychotic disorders, particularly schizophrenia, compared to controls. The risk of psychosis increases in a dose-related fashion. A higher risk of schizophrenia is predicted by earlier onset of cannabis use. The effects of cannabis are exerted primarily through THC interaction with cannabinoid (CB) 1 receptors in the brain. Cannabis exposure may disrupt the last steps of brain maturation, through the endocannabinoid system, thereby increasing the risk of psychosis during adolescence.

Creating a psychosocial intervention combining growth mindset and implementation intentions (GMII) to reduce alcohol consumption: A mixed method approach.

This work aimed at creating a psychosocial intervention based on growth mindset theory and implementation intention strategies, in order to reduce alcohol consumption among users in the general population, and the clinical population of individuals with alcohol use disorder. A mixed method approach was used, combining qualitative and quantitative research methods among both populations. Four focus groups were first conducted to extract arguments in favor of a malleable view of alcohol consumption (study 1A), situations that trigger the desire to drink alcohol, as well as strategies used by people to counteract this need (study 1B). Data were analyzed using reflective thematic analysis in line with the scientific literature on alcohol consumption. The results were used to create a questionnaire scoring the relevance of each argument, situation and strategy (study 2). The 20 best scored arguments, situations and strategies were selected to create the intervention. The created intervention consisted in a popularized scientific article describing alcohol consumption as malleable, including the selected arguments and followed by two internalization exercises. Then, a volitional help sheet included the selected situations and solutions was presented, allowing forming up to three plans. The discussion focused on the added value of the created material compared to pre-existing tools in the literature, and presents plans to test the intervention in a future study.

Neurological soft signs in non-psychotic patients with cannabis dependence.

Psychomotor performance has consistently been found to be altered in chronic cannabis users. Neurological soft signs (NSS) reflect neurological dysfunction involving integrative networks, especially those involving the cerebellum, where cannabinoid receptors are particularly concentrated. Our objective was to study, for the first time, NSS in a group of patients with cannabis dependence compared with a of healthy control subjects, matched for age, gender and level of education. All outpatients seeking treatment for chronic cannabis use in the substance abuse department of Sainte-Anne Hospital in Paris between June 2007 and May 2009 and meeting the cannabis dependence DSM-IV criteria were included in the study (n = 45). Patients with psychotic disorders, bipolar 1 disorder and current alcohol, opioid or cocaine dependence were excluded. All patients and controls were assessed using the Diagnostic Interview for Genetic Studies, which screens for lifetime DSM-IV diagnoses, and the Standardized Neurological Examination of Neurological Soft Signs. NSS scores were significantly higher in patients with cannabis dependence compared with healthy subjects (8.90 ± 4.85 versus 6.71 ± 2.73, respectively, Mann-Whitney: U = 775.0, P = 0.05). Patients had particularly high scores on motor coordination and sensory integration NSS factors. Cannabis dependence is associated with more NSS and especially motor coordination and sensory integration signs. These results suggest that cannabinoids interact with the brain networks underlying NSS, known to be altered in schizophrenia.

Variable individual sensitivity to cannabis in patients with schizophrenia.

There is now compelling evidence that cannabis consumption might precipitate psychosis onset. The objective of the present study was to assess the role of individual sensitivity to the psychotogenic effect of cannabis in male patients with schizophrenia. The lifetime diagnosis, disease and substance-use history were determined using a standardized interview in 190 patients with schizophrenia. Of patients with lifetime cannabis use (n=121), 44 were characterized as Cannabis-sensitive (CS) patients if the onset of psychotic symptoms occurred within 1 month following the initiation of cannabis consumption, or following a marked rise of cannabis consumption, or marked aggravation of psychotic symptoms each time the subject used cannabis. Age at onset of psychosis was not different in patients with lifetime cannabis use compared to non-users. By contrast, the first psychotic episode occurred 2.6 yr earlier in CS compared to Non-cannabis-sensitive (NCS) patients (p=0.006). Moreover, a specific excess of family history of psychotic disorder was found in CS patients, but not of any other psychiatric disorder, as well as an earlier age at exposure to cannabis (16.7+/-2.5 yr, p=0.03). Sensitivity to psychotogenic effects of cannabis in schizophrenia patients could be related to both genetic vulnerability to schizophrenia and the influence of cannabis on brain maturation and could modulate the influence of cannabis on the onset of schizophrenia.

[How to manage adult attention deficit hyperactivity disorder in patients with substance use disorders?] / Comment prendre en charge le trouble déficit de l'attention/ hyperactivité de l'adulte en addictologie ?

How to manage adult attention deficit hyperactivity disorder in patients with substance use disorders? Adult attention deficit hyperactivity disorder (ADHD) frequently occurs with anxiety disorders, mood disorders and above all addictive comorbidities. Its evaluation must be systematic during an addictology consultation. ADHD is a neurodevelopmental disorder characterized by a complex clinical picture combining cognitive, affective and behavioral dimensions that frequently underlies addictive disorder. Substance misuse frequently begins as an over-the-counter medication. The multidimensional diagnostic approach makes it possible to detect these complex interactions. The motivational therapeutic approach involving the comorbidity issue is crucial to support the patient in his change towards a control of his addictions.

Comment prendre en charge le trouble déficit de l'attention/ hyperactivité de l'adulte en addictologie ? Le trouble déficit de l'attention/hyperactivité de l'adulte se présente fréquemment a vec des comorbidités anxieuses, thymiques et surtout addictives. Qu'il soit connu dès l'enfance ou non, traité ou non, son exploration doit être systématique en consultation d'addictologie. Pathologie développementale à l'expression clinique complexe mêlant les dimensions cognitive, affective et comportementale, ce trouble constitue un facteur de risque significatif pour les troubles addictifs. La prise de substances correspond fréquemment à des stratégies d'automédication. L'approche diagnostique multidimensionnelle permet de détecter ces interactions parfois complexes. L'approche thérapeutique motivationnelle et la prise en compte de cette comorbidité permettent d'accompagner le patient dans son changement vers un contrôle de ses addictions.

Toward a better understanding of the influence of repetitive negative thinking in alcohol use disorder: An examination of moderation effect of metacognitive beliefs and gender.

Repetitive negative thinking (RNT), the most studied forms of which are depressive ruminations and anxious worry, is a unique transdiagnostic process responsible for the development and maintenance of many mental disorders. Over the past decade, studies have shown that RNT could be involved in the development and maintenance of alcohol use disorder (AUD). However, to date, little is known about the factors that can influence this relationship, even though some theoretical and empirical arguments suggest that variables such as gender or metacognitive beliefs may determine the role of RNT in the onset of symptoms. The aim of the present study was to test the moderation effect of metacognitive beliefs and gender in the relationship between RNT and AUD. Eighty-one AUD patients were administered measures of AUD severity, RNT, metacognitive beliefs about thinking and alcohol use, anxiety, and depression. Results indicated that the 'capture mental resources' factor of RNT is a significant predictor of AUD severity, independent from anxiety and depression, and that this effect is moderated by metacognitive beliefs and gender. RNT is a significant predictor of AUD severity only for people with high negative beliefs about thoughts regarding uncontrollability and danger. Furthermore, RNT was found to predict AUD severity only for men with high beliefs about the need to control thoughts and for men with high positive beliefs about emotional self-regulation. Treatments that reduce attentional impairments caused by RNT and modify dysfunctional metacognitive beliefs could be promising for some patients with AUD.