Can the migration process influence the clinical expression of heroin use disorder in migrants to Italy?

BACKGROUND: For some time now, there has been a strong consensus that the migration process can influence the onset, course, development, outcome, and clinical aspects of psychiatric pathologies. METHODS: In this study, we have analyzed the influence of the migration process on the clinical expression of heroin use disorder (HUD). In a naturalistic case-control study, we compared, both at univariate and multivariate level, 30 migrant HUD (M-HUD) patients with 30 age/gender-matched Italian HUD (IT-HUD) patients. We also analyzed demographic data, drug addiction history, psychopathological symptoms, addictive behavior, and emotional reactivity to life events. RESULTS: Compared with IT-HUD pairs, at HUD Agonist Opioid Treatment, M-HUD patients were characterized by inadequate income and the presence of legal problems. They were more frequently at stage 3 of heroin addiction, with a concomitantly less frequent use of stimulants. Their age at the onset of heroin use was greater than that of subjects in the IT-HUD group. HUD post-traumatic stress disorder spectrum was present and was more severe in all M-HUD patients, but grief reactions and maladaptive behavior were the most discriminant traits. No differences were found in terms of addictive behaviors related to heroin craving or with respect to the severity/typology of psychopathology specific to HUD. CONCLUSIONS: The migratory process does not seem to be correlated with addictive behaviors or with psychopathology specific to HUD. It partly affects HUD history, and specifically correlates with emotional reactivity to loss and traumatic life events, so suggesting that in M-HUD individuals, the link between the migratory syndrome and HUD is very close.

Towards a psychopathology specific to Substance Use Disorder: Should emotional responses to life events be included?

INTRODUCTION: The severity of emotional responses to life events (PTSD spectrum) as part of Post Traumatic Stress Disorder (PTSD) in Substance Use Disorder (SUD) patients has often been considered from a unitary perspective. Light has also been shed on the possible definition of a specific psychopathology of SUD patients. This psychopathology has been proved to be independent of treatment choice, of being active in using substances, of lifetime psychiatric comorbidity and primary substance of abuse (heroin, alcohol, cocaine). METHODS: To further support this unitary perspective, in this study we have compared the severity and typology of the five psychopathological dimensions found in SUD patients, by dividing 93 HUD patients (77.4% males and 22.6% females), characterized by the lifetime absence of exposure to actual or threatened death, serious injury, or sexual violence, on the basis of the severity of their PTSD spectrum. We used the cut-off that differentiated people developing (High PTSD spectrum; H-PTSD/S) or not developing (Low PTSD spectrum; L-PTSD/S) a PTSD after the earthquake that hit L'Aquila, Italy, in April 2009. RESULTS: Using a canonical correlation analysis, the significant (p<0.001) canonical variate set-one (psychopathology) is saturated negatively by "panic anxiety" and positively by the "worthlessness-being trapped" and "violence-suicide" dimensions. Set-two (PTSD spectrum) is saturated negatively by "emotional, physical and cognitive responses to loss and traumas", and positively by "grief reactions", "re-experiencing numbing", "arousal symptoms" and "personality traits". When comparing the two groups, all five psychopathological dimensions were significantly more severe in H-PTSD/S patients, who were distinguished by higher values of worthlessness-being trapped, sensitivity-psychoticism and violence-suicide symptomatology. No differences were observed regarding the typology of psychopathology. CONCLUSIONS: This study further supports the SUD-PTSD spectrum unitary perspective and argues in favor of the inclusion of the PTSD spectrum in the psychopathology of SUD.

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.

Psychopathology of addiction: Can the SCL90-based five-dimensional structure differentiate Heroin Use Disorder from a non-substance-related addictive disorder such as Gambling Disorder?

BACKGROUND: In the Gambling Disorder (GD), there is no exogenous drug administration that acts as the central core of the traditional meaning of addiction. A specific psychopathology of Substance Use Disorders has been proposed recently. In a sample of Heroin Use Disorder (HUD) patients entering opioid agonist treatment, it became possible to identify a group of 5 mutually exclusive psychiatric dimensions: Worthlessness-Being trapped (W-BT), Somatic Symptoms (SS), Sensitivity-Psychoticism (SP), Panic Anxiety (PA) and Violence-Suicide (VS). The specificity of these dimensions was suggested by the absence of their correlations with treatment choice, active substance use, psychiatric comorbidity and the principal substance of abuse and by the opportunity, through their use, of fully discriminating HUD from Major Depression patients and, partially, from obese non-psychiatric patients. To further support this specificity in the present study, we tested the feasibility of discriminating HUD patients from those affected by a non-substance-related addictive behaviour, such as GD. In this way, we also investigated the psychopathological peculiarities of GD patients. METHODS: We compared the severity and frequency of each of the five aspects found by us, in 972 (83.5% males; mean age 30.12 ± 6.6) HUD and 110 (50% males; average age 30.12 ± 6.6) GD patients at univariate (T test; Chi square) and multivariate (discriminant analysis and logistic regression) level. RESULTS: HUD patients showed higher general psychopathology indexes than GD patients. The severity of all five psychopathological dimensions was significantly greater in HUD patients. Discriminant analysis revealed that SS and VS severity were able to discriminate between HUD (higher severity) and GD patients (lower severity), whereas PA and SP could not. W-BT severity was negatively correlated with SS and VS; GD patients were distinguished by low scores for SS and VS low scores associated with high ones for W-BT. Psychopathological subtypes characterized by SS and VS symptomatology were better represented in HUD patients, whereas PA symptomatology was more frequent in GD individuals. No differences were observed regarding the W-BT and SP dimensions. At multivariate level, the one prominent characteristic of HUD patients was the presence of SS (OR = 5.43) as a prominent qualification for psychopathological status. CONCLUSIONS: Apart from the lower severity of all psychopathological dimensions, only the lower frequency of SS typology seems to be the prominent factor in GD patients. The SCL90-defined structure of opioid addiction seems to be useful even in non-substance-related addictive disorders, as in the case of GD patients, further supporting the possible existence of a psychopathology specific to addiction.

Substance Use Among Homeless Individuals With Schizophrenia and Bipolar Disorder.

Mental illness and substance use are overrepresented within urban homeless populations. This paper compared substance use patterns between homeless individuals diagnosed with schizophrenia spectrum (SS) and bipolar disorders (BD) using the Mini-International Neuropsychiatric Interview. From a sample of 497 subjects drawn from Vancouver, Canada who participated in the At Home/Chez Soi study, 146 and 94 homeless individuals were identified as BD and SS, respectively. In the previous 12 months, a greater proportion of BD homeless reported greater use of cocaine (χ = 20.0, p = 0.000), amphetamines (χ = 13,8, p = 0.000), opiates (χ = 24.6, p = 0.000), hallucinogens (χ = 11.7, p = 0.000), cannabinoids (χ = 5.05, p = 0.034), and tranquilizers (χ = 7.95, p = 0.004) compared to SS. Cocaine and opiates were significantly associated with BD homeless (χ = 39.06, df = 2, p < 0.000). The present study illustrates the relationship between substance use and BD in a vulnerable urban population of homeless, affected by adverse psychosocial factors and severe psychiatric conditions.

Psychopathology of addiction: May a SCL-90-based five dimensions structure be applied irrespectively of the involved drug?

BACKGROUND: We previously found a five cluster of psychological symptoms in heroin use disorder (HUD) patients: 'worthlessness-being trapped', 'somatic-symptoms', 'sensitivity-psychoticism', 'panic-anxiety', and 'violence-suicide'. We demonstrated that this aggregation is independent of the chosen treatment, of intoxication status and of the presence of psychiatric problems. METHODS: 2314 Subjects, with alcohol, heroin or cocaine dependence were assigned to one of the five clusters. Differences between patients dependent on alcohol, heroin and cocaine in the frequency of the five clusters and in their severity were analysed. The association between the secondary abuse of alcohol and cocaine and the five clusters was also considered in the subsample of HUD patients. RESULTS: We confirmed a positive association of the 'somatic symptoms' dimension with the condition of heroin versus cocaine dependence and of the 'sensitivity-psychoticism' dimension with the condition of alcohol versus heroin dependence. 'Somatic symptoms' and 'panic anxiety' successfully discriminated between patients as being alcohol, heroin or cocaine dependents. Looking at the subsample of heroin dependents, no significant differences were observed. CONCLUSIONS: The available evidence coming from our results, taken as a whole, seems to support the extension of the psychopathological structure previously observed in opioid addicts to the population of alcohol and cocaine dependents.

The impact of psychopathological subtypes on retention rate of patients with substance use disorder entering residential therapeutic community treatment.

BACKGROUND: A specific psychopathology of addiction has been proposed and described using the self-report symptom inventory (SCL-90), leading to a 5-factor aggregation of psychological/psychiatric symptoms: 'worthlessness and being trapped', 'somatic symptoms', 'sensitivity-psychoticism', 'panic-anxiety' and 'violence-suicide' in various populations of patients with heroin use disorder (HUD) and other substance use disorders (SUDs). These clusters of symptoms, according to studies that have highlighted the role of possible confounding factors (such as demographic and clinical characteristics, active heroin use, lifetime psychiatric problems and kind of treatment received by the patients), seem to constitute a trait rather than a state of the psychological structure of addiction. These five psychopathological dimensions defined on the basis of SCL-90 categories have also been shown to be correlated with the outcomes of a variety of agonist opioid treatments. The present study aims to test whether the 5-factor psychopathological model of addiction correlates with the outcome (retention rate) of patients with SUDs entering a therapeutic community (TC) treatment. METHODS: 2016 subjects with alcohol, heroin or cocaine dependence were assigned to one of the five clusters on the basis of the highest SCL-90 factor score shown. Retention in treatment was analysed by means of the survival analysis and Wilcoxon statistics for comparison between the survival curves. The associations between the psychopathological subtypes defined by SCL-90 categories and length of retention in treatment, after taking into account substance of abuse and other sociodemographic and clinical variables, were summarized using Cox regression. RESULTS: Patients with cocaine use disorder (CUD) showed poorer outcomes than those with heroin dependence (HUD). Prominent symptoms of "worthlessness-being trapped" lead to a longer retention in treatment than in the case of the other four prominent psychopathological groups. At the multivariate level, age, detoxified status and total number of psychopathological symptoms proved to influence outcome negatively, especially in CUD. Somatic symptoms and violence-suicide symptoms turned out to correlate with dropout from residential treatment. CONCLUSIONS: The SCL-90 5-factor dimensions can be appropriately used as a prognostic tool for drug-dependent subjects entering a residential treatment.

Challenges of Treating ADHD with Comorbid Substance Use Disorder: Considerations for the Clinician.

Adults with attention deficit/hyperactivity disorder (ADHD) often present psychiatric comorbidities and, in particular, substance use disorder (SUD). ADHD-SUD comorbidity is characterized by greater severity of both disorders, earlier age of onset, higher likelihood of polydrug-abuse and suicidal behaviors, more hospitalizations, and lower treatment adherence. At the present stage, research focused on the pharmacological management of ADHD with comorbid SUD in both adolescents and adults is still lacking. Furthermore, while the short-term effects of stimulants are well studied, less is known about the chronic effects of these drugs on dopamine signaling. Current available evidence is consistent in reporting that high doses of stimulant medications in ADHD-SUD subjects have a mild to moderate efficacy on ADHD symptoms. Some data suggest that pharmacological treatment with stimulants may be beneficial for both ADHD symptoms and comorbid cocaine or amphetamine use. However, in the long run, stimulant medications may have a potential risk for misuse. For the absence of potential misuse, atomoxetine is often recommended for ADHD with comorbid cocaine or amphetamine use disorder. However, its efficacy in reducing addictive behavior is not demonstrated. In subjects with other subtypes of SUD, both atomoxetine and stimulant drugs seem to have scarce impact on addictive behavior, despite the improvement in ADHD symptomatology. In this population, ADHD treatment should be combined with SUD-specific strategies.

Characteristics of Stress Sensitivity in Heroin Use Disorder Patients during Their Opioid Agonist Treatment.

In the present study, performed on a sample of Heroin Use Disorder (HUD) patients undergoing Opioid Agonist Treatment (OAT), we attempted to explore the relationships between stress sensitivity and heroin addiction-related clinical aspects. HUD patients' stress sensitivity was evaluated with the Heroin/PTSD-Spectrum questionnaire (H/PSTD-S). The Drug Addiction History Questionnaire (DAH-Q), the Symptomatological Check List-90 (SCL-90), and The Behavioural Covariate of Heroin Craving inventory (CRAV-HERO) were all used, as were the Deltito Subjective Wellness Scale (D-SWS), a self-report scale evaluating subjective well-being; the Cocaine Problem Severity Index (CPSI), a questionnaire determining the extent of a cocaine problem; and the Marijuana Craving Questionnaire (MC-Q), an instrument assessing craving for cannabinoids. We checked correlations between stress sensitivity and the extent of HUD clinical features and compared patients with and without problematic stress sensitivity. H/PTSD-S was positively correlated with patients' income, altered mental status, legal problems, the lifetime different treatments index, the current treatment load index, and all SCL-90 indexes and factors. Regarding subjective well-being, stress sensitivity negatively correlated with the contrast best week (last five years) index. Patients with high-stress sensitivity were females with a low income. They exhibited a more severe mental status at treatment entry, greater difficulty in working adaptation, and legal problems during treatment. Additionally, these patients showed a higher level of psychopathology, more impairment in well-being, and more risky behaviours during treatment. Stress sensitivity, as H/PTSD-S, must be considered an outcome of HUD. HUD's addiction history and clinical features are significant risk factors for H/PTSD-S. Therefore, social and behavioural impairment in HUD patients could be considered the clinical expression of the H/PTSD spectrum. In summary, the long-term outcome of HUD is not represented by drug-taking behaviours. Rather, the inability to cope with the contingent environmental conditions is the key feature of such a disorder. H/PTSD-S, therefore, should be seen as a syndrome caused by an acquired inability (increased salience) concerning regular (daily) life events.

Adult Attention-Deficit Hyperactivity Disorder/Substance Use Disorder Dual Disorder Patients: A Dual Disorder Unit Point of View.

Substance Use Disorders (SUDs) are often associated with Attention-Deficit Hyperactivity Disorder (ADHD) in adult populations due to multiple neurobiological, genetic, and psychosocial risk factors. This chapter provides a picture of the clinical aspects of adults with both ADHD and SUDs at treatment entry into a Dual Disorder Unit introducing the concept of different types of craving that may lead to substance use and abuse. At treatment entry, the presence of different comorbid SUD clusters, characterized by either stimulants/alcohol or by the use of cannabinoids, has not been shown to influence ADHD-specific symptomatology or severity, despite being crucial for the identification of a specific type of craving. We identified four clinical presentations of adult ADHD: Emotional Dysregulation, Substance Use, Core-ADHD Symptoms, and Positive Emotionality variants, that offer a practical guide in diagnosing and managing adult ADHD patients. Although the evidence of an effective medical treatment for Cocaine Use Disorder is insufficient, in our experience, toxicomanic behavior during stimulant treatment is sharply reduced in ADHD patients with cocaine addiction. Moreover, caffeinated compounds in military soldiers with ADHD may help reduce ADHD symptoms, making caffeine a potential pharmacological tool worth further investigation. Finally, substance use comorbidity does not influence treatment retention rate.