Prevalence and Characteristics of Chronic Pain in Buprenorphine and Methadone-Maintained Patients.

Chronic pain and substance use disorders frequently co-occur. Indeed, chronic pain is highly prevalent, affecting 23-68% of patients receiving opioid agonist treatments (OAT) worldwide. The majority of available estimates come from American studies, but data are still lacking in Europe. We aim to provide European estimates of the prevalence of chronic pain in patients receiving OAT using French data, since France is the first European country in terms of number of patients with OAT. The secondary objectives were to characterize the features and management of chronic pain, as well identify associated risk factors. We conducted a multicenter, cross-sectional study, recruiting patients treated either with buprenorphine or methadone in 19 French addiction centers, from May to July 2016. All participants had to complete a semi-directed questionnaire that collected sociodemographic and medical data, pain characteristics, and licit or illicit drug consumption. In total, 509 patients were included. The prevalence of chronic pain was estimated at 33.2% (95% CI: 29.1-37.3). Compared to non-chronic pain patients, chronic pain patients were older (38.4 vs. 36.1 years, p = 0.006), were more unemployed (66 vs. 52%, p = 0.003), had more psychiatric comorbidities (50 vs. 39%, p = 0.02), and split their OAT for pain management more frequently (24 vs. 7%, p = 0.009). Pain intensity was moderate or severe in 75% of chronic pain patients. Among patients with chronic pain, 15.4% were not prescribed, and did not self-medicate with, any analgesic drugs, 52.1% were prescribed analgesics (non-opioid analgesics, 76.3%; codeine, tramadol, opium, 27.2%; and morphine, fentanyl, oxycodone, 11.8%), and 32.5% exclusively self-medicated with analgesics. Moreover, 20.1% of patients with chronic pain also used illicit drugs for pain relief. On multivariate analysis, variables that remained significantly associated with chronic pain were age [OR = 1.03 (95% CI: 1.00-1.05], p = 0.02], anxiety [OR = 1.52 (1.15-2.02), p = 0.003], and depression [OR = 1.25 (1.00-1.55), p = 0.05]. Chronic pain is a highly prevalent condition in patients receiving OAT, and its appropriate management remains uncertain, since insufficient relief and frequent additional self-medications with analgesics or illicit drugs were reported by these patients. Increased awareness among caregivers is urgently needed regarding a systematic and careful assessment, along with an adequate management of chronic pain in patients receiving OAT.

Analgesic opioid use disorders in patients with chronic non-cancer pain: A holistic approach for tailored management.

Chronic pain is a major public health issue that frequently leads to analgesic opioid prescriptions. These prescriptions could cause addiction issues in high-risk patients with associated comorbidities, especially those of a psychiatric, addictive, and social nature. Pain management in dependent patients is complex and is yet to be established. By combining the views of professionals from various specialties, we conducted an integrative review on this scope. This methodology synthesizes knowledge and results of significant practical studies to provide a narrative overview of the literature. The main results consisted in first proposing definitions that could allow shared vocabulary among health professionals regardless of their specialties. Next, a discussion was conducted around the main strategies for managing prescription opioid dependence, as well as pain in the context of opioid dependence and associated comorbidities. As a conclusion, we proposed to define the contours of holistic management by outlining the main guidelines for creating a multidisciplinary care framework for multi-comorbid patients with chronic pathologies.

[Alcohol use disorder: evolution of the nosography]. / Trouble de l'usage de l'alcool : évolution de la nosographie.

Alcohol use disorder: evolution of the nosography. The arrival of DSM-5 has represented a nosographic break with respect to the DSMIV- TR: by leaving the old biaxial view and its hierarchical gradation between abuse and dependence; by removing the term "dependence" with its stigma and amalgams between psychic and physical dependencies; and by integrating craving, a main therapeutic target, allowing the DSM-5 to join the ICD-10 (and soon the ICD-11). Without being a revolution, the DSM-5 is a real evolution, with a modern dimensional view of addictive behaviors, according to a progressive continuum between use and use disorder (from mild to severe). This approach allows the representation of addictions to change, and to propose various therapeutic strategies adapted to the patient's objectives and inspired by the harm reduction approaches, abstinence being only one of these strategies.

Trouble de l'usage d'alcool : évolution de la nosographie. L'arrivée du DSM-5 a représenté une rupture nosographique vis-à-vis du DSM-IV-TR : en quittant la vision ancienne biaxiale et sa gradation hiérarchisée entre abus et dépendance ; en faisant disparaître le terme dépendance avec sa stigmatisation et ses amalgames entre dépendances psychique et physique ; et en intégrant le craving, une cible thérapeutique majeure, permettant au DSM-5 de rejoindre la CIM-10 (et prochainement la CIM-11). Sans être une révolution, le DSM-5 est donc une véritable évolution, avec une vision dimensionnelle moderne des conduites addictives, selon un continuum progressif entre usage et trouble de l'usage, de léger à sévère. Cette approche permet de changer la représentation des addictions, et de proposer des stratégies thérapeutiques variées et adaptées aux objectifs du patient, en s'inspirant des stratégies de réduction des risques et des dommages, l'abstinence n'étant que l'une de ces stratégies.

[Alcohol and Neurology]. / Alcool et neurologie.

The nervous system is a particular target tissue for alcohol due to desired effects and numerous acute and chronic consequences. Acute consequences are due to episodes of overconsumption, withdrawal syndromes, or decompensation of nutritional deficiencies. Chronic consequences are dominated by sleep disorders, chronic pain and cognitive-behavioral disorders, stroke, and impairments of balance, peripheral nerves and muscles, resulting from direct toxicity and/or nutritional deficiencies. There is a bidirectional relationship requiring seeking: alcohol use as a causal or aggravating factor in any neurological disorder ; and neurological disorders in cases of alcohol use, especially when problematic. Management of alcohol-related neurological consequences can help reduce or stop alcohol consumption, prevent relapse, and improve patients' quality of life.

Neuroticism and anxious attachment as potential vulnerability factors of repeat suicide attempts.

The recurrence risk of suicide attempts can reach 50% in the first year, each attempt increasing suicide-risk by 32%. No screening tool efficiently identifies potential repeat suicide attempters who are too often regarded as borderline personality. Our aim was to identify individual and interpersonal psychopathological dimensions that could represent a vulnerability to repeat suicide attempts. Sixty first-time and repeat suicide attempters consecutively admitted in emergency rooms were compared for fundamental dimensions of personality, patterns of attachment, personality and mental disorders using standardized questionnaires. Confounding and significantly different factors were evaluated using univariate and multivariate logistic regressions. Repeat suicide attempters differed from first-attempters by higher neuroticism and anxious attachment. Combined in an 11-item measure, these two parameters identified a 3.99 times higher risk of repeat suicide attempt. These traits associated with the other two best predictors (non-suicidal self-injury history, current psychotropic drugs) provide a vulnerability model with better screening performance compared to each factor individually. Repeat suicide attempters have more psychological features impairing emotional stability and social interactions than first attempters. Cross-sectional study design, sample size, lack of independent sample and of fearful-avoidant attachment evaluation are the main limitations. The model needs to be validated in a prospective and controlled study.

Omega-3 supplements reduce self-reported physical aggression in healthy adults.

There is emerging evidence that Omega-3 polyunsaturated fatty acids (PUFA) supplements can decrease aggression. However, experimental studies with adults from non-specific populations are scarce. We hypothesized that Omega-3 supplements would decrease self-reported aggression among non-clinical participants. In a double-blind randomized trial, two groups of participants (N = 194) aged 18-45 from the general population followed a 6-weeks treatment with 638mg docosahexaenoic acid (DHA) and 772mg eicosapentaenoic acid (EPA) per day or the equivalent quantity of copra oil (placebo). Self-reported aggressiveness was measured at baseline and after the 6-week treatment period. Findings showed that Omega-3 supplements significantly decreased self-reported aggressiveness at the end of the 6-week period (d = 0.31). In conclusion, this experiment indicates that Omega-3 administration has beneficial effects in reducing aggression among the general population.

Is suicide under the influence of alcohol a deliberate self-harm syndrome? An autopsy study of lethality.

BACKGROUND: Alcohol is a risk factor for suicide and is often involved in violent actions. The aim of the study was to assess the involvement of alcohol in suicides and its relationship with the lethality of suicide methods. METHODS: In a retrospective study on autopsy reports, we compared suicide and non-suicide victims, suicides with positive and negative blood alcohol concentration (BAC), and studied the lethality of suicide methods using a multivariate analysis. RESULTS: Suicide victims (n=88) were not different to non-suicide victims (n=270) for positive BAC and narcotics, but were more often positive for prescription medications (59.1 vs. 35.6%, p=0.003) and medications in blood (72.7 vs. 54.8%, p=0.004). Whereas non-suicidal victims died mainly of traumas (60%, p<0.001), two populations of suicides emerged with regard to BAC, self-poisoning predominating with positive BAC (38.9%, p=0.039) and asphyxiation with negative BAC (41.4%, p=0.025). Positive BAC appeared as the unique and strong independent predictive factor, increasing the risk of self-poisoning suicide by 4.36 [1.29-14.76], and decreasing the risk of suicidal asphyxiation by 84% (OR=0.16 [0.03-0.83]). Positive blood narcotics tended to behave in the similar way to alcohol. LIMITATIONS: Recruitment bias (victims declared by the Forensic authorities) and incomplete autopsy reports are the two main limitations. CONCLUSIONS: Characteristics of suicide victims with positive BAC are suggestive of Deliberate Self-Harm Syndrome (low lethality methods, substance misuse). These being at high risk of repeated suicide attempts, previous self-harm involving alcohol may represent a warning sign and access to medication should be limited to prevent recidivism.

Alcohol and violence in the emergency room: a review and perspectives from psychological and social sciences.

Our objective is to present a focused review of the scientific literature on the effect of alcohol consumption on violence related-injuries assessed in the emergency room (ER) and to show how psychological and behavioral sciences could lead to a better understanding of the factors contributing to alcohol-related injuries in the ER. We retrieved published literature through a detailed search in Academic Search Premier, MEDLINE with Full Text PsycARTICLES, Psychology and Behavioral Sciences Collection, PsycINFO, PUBMed and SocINDEX with Full Text for articles related to emergency rooms, medical problems and sociocognitive models addressing alcohol intoxication articles. The first search was conducted in June 2011 and updated until August 2013. Literature shows that compared to uninjured patients; injured ones have a higher probability of: (i) having an elevated blood-alcohol concentration upon arrival at the ER; (ii) reporting having drunk alcohol during the six hours preceding the event; and (iii) suffering from drinking-related consequences that adversely affect their social life. The main neurocognitive and sociocognitive models on alcohol and aggression are also discussed in order to understand the aetiology of violence-related injuries in emergency rooms. Suggestions are made for future research and prevention.

[Current knowledge on gamma-hydroxybutyric acid (GHB), gamma-butyrolactone (GBL) and 1 ,4-butanediol (1,4-BD)]. / Données actuelles sur le GHB, la GBL et le 1,4-BD.

Gamma-hydroxybutyric acid (GHB) is an old anaesthetic drug which was misused in the 80-90's as an anabolic agent (bodybuilding), recreational drug (drunkenness, euphoric, disinhibiting and aphrodisiac effects) and as a date rape drug (disinhibiting, hypnotic and amnesic effects). Its use in the general population is low, and mainly concerns gay population in nightclubs and young people in parties. The intoxications, above all with alcohol combination, can be severe, with coma and breathing depression, or even fatal. Chronic use leads to psychic and physical dependence; withdrawal syndrome can be severe, with agitation and delirium. In 1999, GHB classification as a narcotic resulted in the increased use of GHB prodrugs gamma-butyrolactone (GBL) and 1,4-butanediol (1,4-BD), which were easily commercially available as solvent and cleaning products. Like GHB, they have a narrow window of use, and share similar toxicity. Their increased cases of recreational use and of severe drug intoxication, abuse and dependence, led the French Ministry of Health in 2011 to prohibit their sale and transfer to the public.