[Opioids substitution therapy: A respect for the dignity of the human person]. / Les traitements de substitution aux opiaces : un parcours de respect de la dignité de la personne humaine.

The Opioid substitution treatment (OST) has been highly argumentative in ways that raise important ethical issues. The stigma in treating opioid addiction continues to be a major barrier to effective management plan. It prevents individuals from seeking treatment and is associated with poor mental and physical health. OST are considered to improve outcomes in opioid dependency. They are legitimate therapeutic options because they comply with the four principles of bioethics: autonomy, no maleficence, beneficence and justice. OST plan should conceived in a way that outcomes only giving a medication to the patient. It has many ethical aspects that should be valued: fairness, respect and solidarity. However, OST may be misused or diverted, resulting in negative treatment outcomes, here comes the important role of the multidisciplinary treatment plan to contain and prevent from misuse. We will be discussing in this paper the ethical aspect of the OST and the values that should be promoted, in order to cherish and enhance the dignity of the human being, by replacing a deadly disease with a chronic one giving the patient a chance to lead a normal life.

[Problematic gambling and criminal responsibility]. / Jeu d'argent problématique et responsabilité pénale.

OBJECTIVES: In total, 14% to 30 % of individuals with gambling disorder engage in illegal acts to finance such behavior. This clinical situation could be explained by higher gambling severity, associated substance use disorder, antisocial personality disorder and economic factors (debts, financial problems). The present work focuses, more broadly, on criminal responsibility of problematic gamblers. METHODS: We will discuss this question through different typical situations that medical experts of criminal responsibility may have to face. We will address each of the following cases: 1) isolated problematic gambling; 2) problematic gambling associated with antisocial personality disorder; 3) problematic gambling associated with a manic episode; 4) problematic gambling associated with substance use disorders; and 5) problematic gambling associated wiht dopamine agonist treatment. RESULTS: Isolated problematic gambling, (not associated with any psychiatric or addictive disorder): it seems consensual that individuals committing infractions in this case are criminally responsible. However, impeded ability to action control and possible sentence attenuation could be discussed in case of severe gambling disorder. Problematic gambling associated with antisocial personality disorder: if the penal offence reports solely to personality disorder, criminal responsibility would be attributed. However, if illegal or violent acting is directly linked to co-cocurrent delusional symptoms, it could be a cause of criminal non-responsibility. Problematic gambling associated with manic episode: manic episode related offence could lead to negation of criminal responsibility, while a hypomanic episode may provide grounds for sentence reduction. Problematic gambling associated with substance use disorders: in France, addiction is not considered to remove nor to impede a person's ability to understand or control his actions and is excluded from criminal non-responsibility causes. However, substance induced delusional or confusional episodes could abolish a subject's discernment or his ability to control his actions yielding to penal non-responsibility. Problematic gambling associated with dopamine agonist treatment: Criminal responsibility for dopamine agonist induced gambling related illegal acts is still controversial. Nevertheless, people committing an infraction linked to associated dementia or dopamine agonist induced mania should be considered as criminally non-responsible. CONCLUSIONS: Some clinical dimensions such as craving intensity, compulsivity, disorder's severity, volitional control might be forensic targets to assess criminal responsibility.

[Consequences of tobacco, cocaine and cannabis consumption during pregnancy on the pregnancy itself, on the newborn and on child development: A review]. / Conséquences potentielles de la consommation de tabac, de cannabis et de cocaïne par la femme enceinte sur la grossesse, le nouveau-né et l'enfant : revue de littérature.

BACKGROUND: Substance use has increased worldwide. Based on these data, we may think that substance use has also increased during pregnancy, but epidemiological data are scarce in this population. The potential consequences of tobacco, cocaine or cannabis use during pregnancy are a major public health concern. The combined use of different substances during pregnancy may have serious consequences on the pregnancy and on child development. METHODS: In this paper, we will describe the potential consequences for the newborn, child and adolescent after being exposed to tobacco, cannabis and cocaine in utero. For this purpose, we will review all retrospective and prospective studies (in English and French) referenced in PubMed reporting on the somatic or psychiatric consequences of alcohol, tobacco and drug consumption by pregnant women on newborn and children. Consumption during pregnancy was assessed in these studies using simple questionnaires, biomarkers analysis or both. RESULTS: Generally speaking, these pregnancies are at high risk for both the mother and the foetus: for example, an increased risk of miscarriage or of reduced length of gestation, an increased risk of uterine apoplexy and placenta praevia, more premature births and/or hypotrophy were reported. The occurrence of a newborn's withdrawal syndrome may be misdiagnosed. Many consequences on child development may be observed such as growth disorders, learning or motor disorders, language disorders, cognitive disorders (attention, memory, executive functions), attention deficit disorders with impulsivity or with hyperactivity (ADHD), and memory disorders. The prevalence of depressive or anxiety disorders may also be increased in these children. The risk of addictive disorders or schizophrenia in children exposed in utero to illicit drugs or tobacco is still unknown. The combined use of different substances increases, consequently it is difficult to disentangle the consequences on child development of each of the drugs used during pregnancy owing to potential interactions between these drugs. The consequences on child development will also depend on the dose and on the time of drug use during pregnancy. DISCUSSION: The National Institute of Drug Abuse reported that 75% of the infants exposed in utero to one or more substances will present medical problems during childhood, as compared to only 27% of the non-exposed infants. However, the medical consequences are still a matter of controversies. Methodological biases, such as the use of different rating scales among studies, and the heterogeneity of the populations included are main limitations. Further studies are needed using larger cohorts and longer follow-up periods.

[Review of cases of prolonged QTC and wave burst arrhythmia in patients treated with methadone]. / Revue des cas d'allongements du QTC et de torsades de pointe chez des patients traités par méthadone.

INTRODUCTION: For the past 40 years, methadone has been known to be an efficient treatment of substitution. Its use allowed a significant reduction in the mortality related to opioid addiction. Since 2001, many articles have reported some cases of syncope, wave burst arrhythmia, ventricular tachycardia due to prolonged QT interval and sudden death secondary to cardiac arrest, with a risk of prolongation of the QT interval above 440 ms (men) and 460 ms (women). Many explorations have helped in understanding the physiopathology by showing that opioids, including methadone, cause a blockage of the potassium channels of the gene HERG K+P. This event could slow the repolarisation and the atrioventricular cardiac synchronization and could induce ventricular arrhythmia. LITERATURE FINDINGS: Nearly 20 studies showed a prolonged QT interval secondary to methadone in patients exhibiting the following features: (1) patients with cardiac pathologies, notably bradycardia, congenital long QT interval, myocardial pathologies related to AIDS and electrolyte disturbances; (2) patients receiving concomitant treatment with substances known to prolong QT interval, such as psychoactive stimulants, narcoleptics, tricyclic antidepressants, antiarrhythmic agents, macrolids, quinolones, non diuretic hypokalemiants and certain corticoids; (3) patients receiving treatments that inhibit methadone's metabolism, particularly those that act on the cytochrome P450 3A4 such as SSRI, antifungal agents, some macrolids and some retroviral agents. Many recent studies, while evaluating the dose-dependent effect of methadone on the QT prolongation, showed a tendency to a prolonged QT when using higher doses of methadone. CONCLUSION: Screening for these risk factors should be carried out before prescribing methadone. EKG should not be systematically performed unless the conditions described above are present or if a higher dose of methadone is needed.

[Mindfulness based interventions for addictive disorders: a review]. / Interventions basées sur la pleine conscience en addictologie.

INTRODUCTION: In substance use disorders, the lack of empirically supported treatments and the minimal utilization of available programs indicate that innovative approaches are needed. Mindfulness based therapies have been used in addictive disorders for the last 10years. Mindfulness can be defined as the ability to focus open, non-judgmental attention to the full experience of internal and external phenomena, moment by moment. Several therapies based on mindfulness have been developed. The aim of this study is to review the existing data on the use of these programs in addictive disorders. METHODS: We have reviewed the literature published from January 1980 to January 2009, using the following keywords: mindfulness, mindfulness based stress reduction program, dialectical behavior therapy, acceptance and commitment therapy, mindfulness based cognitive therapy, addiction, substance use, alcohol and smoking. RESULTS: Results of six clinical trials evaluating four different programs were found. Five studies were controlled and four were randomized. Drop-out rates were relatively high (from 28 to 55%). In five cases out of six, the program significantly reduced substance use. In four comparative trials out of five, interventions based on mindfulness proved more effective than control conditions. The effectiveness of interventions based on mindfulness and the differential improvement across conditions became greater and was maintained during follow-up when it was long enough. Participants in mindfulness programs were less likely to endorse the importance of reducing emotions associated with smoking and reported significant decreases in avoidance of thoughts which partially mediated alcohol use reduction. Psychiatric symptoms and the level of perceived stress were also significantly reduced. DISCUSSION: Mindfulness may help substance abusers to accept unusual physical sensations that might be confused with withdrawal symptoms, decentre from a strong urge and not act impulsively. It may reduce an individual's susceptibility to act in response to a drug cue. Practice of mindfulness may develop the ability to maintain perspective in response to strong emotional states and mood fluctuations and increase the saliency of natural reinforcers. Mindfulness based programs require an intensive participation, and should therefore be proposed to highly motivated patients. In smoking cessation, they should be used in patients who were unable to quit with less intensive interventions. Some programs are specifically designed for patients with co-occurring psychiatric disorders. CONCLUSION: The first clinical studies testing mindfulness based interventions in substance use disorders have shown promising results. They must be confirmed by larger controlled randomized clinical trials. By developing a better acceptance of unusual physical sensations, thoughts about drugs and distressing emotions, mindfulness may help in reducing the risk of relapse.

[Abuse of alcohol and benzodiazepine during substitution therapy in heroin addicts: a review of the literature]. / Abus d'alcool et de benzodiazépines lors des traitements de substitution chez l'héroïnomane : une revue de la littérature.

INTRODUCTION: In spite of its seriousness, dependence on alcohol and benzodiazepines during substitution treatment are poorly documented. Its frequency is nonetheless significant. According to studies, between one and two thirds of patients are affected. This consumption is under verbalized by patients and underestimated by carers. In one study, where the average diazepam doses were from 40 to 45 mg per day, 30% of the patients were taking 70 to 300 mg per day, two thirds having experimented with a fixed dose of 100mg. Benzodiazepines, especially diazepam and flunitrazepam, were studied versus placebo. Thus, 10 to 20mg of diazepam gave rise to euphoria, a sensation of being drugged, sedation and lessening of cognitive performance. The aim of this consumption is to potentiate the euphoria induced by opioids, a "boost" effect during the hour after taking it, or the calming of the outward signs of withdrawal. The most sought after molecules are the most sedative, those with pronounced plasmatic peaks, and the most accessible. LITERATURE FINDINGS: In multidependant subjects, opioid dependence had been earlier in adolescence, with a number of therapeutic failures. They had been faced with repetitive rejection and separation during childhood, medicolegal and social problems. Somatization, depression, anxiety and psychotic disorders are frequent in this subgroup. Heavy drinkers under methadone treatment are highly vulnerable to cocaine. Their behaviour is at risk, with exchange of syringes; their survival rate is 10 years less than that of moderate consumers of alcohol. Most are single, with a previous prison, psychiatric or addictive cursus and they present significant psychological vulnerability. For some authors, benzodiazepines indicate a psychiatric comorbidity. Methadone significantly reduces the consumption of alcohol by nonalcoholic heroin addicts. Although alcohol is an enzymatic inductor of methadone catabolism, with bell-shaped methadone plasma curves over 24 hours, a substitution treatment is recommended. It has a minimum impact on care, in spite of efficiency and retention in therapeutical programs, allowing the subject's inclusion in the framework of a more regular and sustained medical follow-up. Treatment of benzodiazepine dependence by a progressive regression of doses has little efficacy in subjects which cannot control how much medication they are taking. Certain authors have suggested maintenance treatments of clonezepam. The most appropriate therapeutic propositions are: (1) maintenance of therapeutic links though a framework of deliverance from flexible substitution treatment; (2) prevention by cautious prescribing and control of dispensing medication; (3) parallel treatment of psychiatric comorbidities and related personality disorders; (4) individual psychiatric treatment, either institutional or in consistent networks.

[Smoking and schizophrenia: epidemiological and clinical features]. / Tabac et schizophrénie: aspects épidémiologiques et cliniques.

FREQUENCY: The prevalence of cigarette smoking is significantly higher among patients with schizophrenia (60-90%) than in the general population (23-30%). While tobacco smoking decreases in the general population (from 45% in the 1960's to 23-30% in the 2000's), smoking in patients with schizophrenia remains high. Patients with schizophrenia smoke more cigarettes than control subjects. Patients smoke more deeply, thereby increasing their exposure to the harmful elements in tobacco smoke. IMPACT OF SMOKING IN SCHIZOPHRENIC PATIENTS: As in the general population, smoking contributes to the reduced life expectancy in patients with schizophrenia. Patients with schizophrenia are at increased risk for cardiovascular disease due to high rates of cigarette smoking. In the Department of Mental Health of the commonwealth of Massachusetts, cardiovascular disease was the factor the most strongly associated with excess mortality. Cardiac deaths were elevated more than six-fold. Weight gain, insulin resistance, metabolic syndrome and diabetes mellitus are frequent in patients with schizophrenia, and may worsen the risk of cardiovascular diseases. It has been reported that the risk for lung cancer in patients with schizophrenia is lower than that of the general population, despite increased smoking. However, in a study conducted in Finland, a slightly increased cancer risk was found in patients with schizophrenia. Half of the excess cases were attributable to lung cancer. IMPROVEMENT OF COGNITIVE DEFICITS: Patients with schizophrenia may use nicotine to reduce cognitive deficits and negative symptoms or neuroleptic side effects. Smoking may transiently alleviate negative symptoms in schizophrenic patients by increasing dopaminergic and glutamatergic neurotransmission in the prefrontal cortex. In patients with schizophrenia, nicotine improves some cognitive deficits: (1) sensory gating deficits and abnormalities in smooth pursuit eye movements associated with schizophrenia are transiently normalized with the administration of nicotine ; (2) high-dose nicotine transiently normalizes the abnormality in P50 inhibition in patients with schizophrenia and in their relatives; (3) in tasks that tax working memory and selective attention, nicotine may improve performance in schizophrenia patients by enhancing activation of and functional connectivity between brain regions that mediate task performance (Jacobsen et al. 2004; Paktar et al.2002); (4) cigarette smoking may selectively enhance visuospatial working memory and attentional deficits in smokers with schizophrenia. However, Harris et al., found that nicotine affects only the attention without effects of nicotine on learning, memory or visuospatial/constructional abilities. In addition, smoking could facilitate disinhibition in schizophrenic patients.

[Induced psychiatric and somatic disorders to cannabis]. / Les troubles psychiatriques et somatiques induits par le cannabis.

Cannabis is the most consumed illicit drug. For a number of years it was thought to be not very toxic, although this idea has no scientific backup. The object of much controversy, it is a public health problem for the most vulnerable populations, adolescents, subjects with evolutive psychopathologies and certain highly cognitive situations: driving a car, the professional environment and students. Cannabis breeds, in international classifications of mental disorders, intoxication charts, abuse and dependence, although this last could have been challenged. The complications are basically anxious and psychotic. It is the object of a number of debates associated with schizophrenic disorders, where it seems to be a risk factor where there is a large consumption before the age of fourteen. Like all psychoactive substances, it is an aggravating factor in all evolutive psychopathologies.

[Tobacco and schizophrenia: therapeutic aspects]. / Tabac et schizophrénie: aspects thérapeutiques.

Although patients with have low motivations to quit smoking, smoking cessation treatment can be effective for these patients. Patients schizophrenia who achieve significant smoking reduction during a treatment intervention can at least maintain that level of reduction at 2 years. Cigarette smoking by patients with frequently goes unaddressed, contributing to excess mortality in this population. Behavioural interventions improve smoking cessation in schizophrenia patients. Nicotine replacement can substantially reduce withdrawal symptoms. Bupropion enhances smoking abstinence rates. Bupropion is well-tolerated and safe for use in schizophrenia patients: bupropion does not worsen clinical symptoms of schizophrenia. Atypical antipsychotics may reduce smoking consumption in schizophrenia patients, in particular clozapine. Atypical antipsychotic medication, in combination with the nicotine transdermal patch, significantly enhance the rate of smoking cessation. Interactions between smoking and antipsychotic medication - Smoking increases the metabolism of the antipsychotic medications by inducing the cytochrome P450 1A2 isoform. Smoking lowers the blood levels of typical or atypical antipsychotic medication, in particular haloperidol, chlorpromazine, olanzapine and clozapine. -Abstinence can increase many psychotropics' blood levels. Accordingly, smoking appears to reduce neuroleptic-induced parkinsonism. In contrast, smoking is a risk factor for tardive dyskinesia, independent of neuroleptic exposure.

[Methadone: from pharmacokinetic profile to clinical pharmacology]. / Méthadone: de la pharmacocinétique à la pharmacologie clinique.

In January 2002, the official French methadone legislation prescription was modified. Thus, the number of clinicians authorized to introduce methadone substitution was increased. Knowledge of the pharmacokinetic and pharmacological properties of this compound remains particularly important for its appropriate prescription. Bearing this in mind, we linked methadone pharmacokinetics to its pharmacological use in this article. METHADONE PHARMACOLOGY: Methadone is a synthetic opiate. Its mean bioavailability is around 75%. Cytochrome P450 3A4 and 2D6 are involved in its hepatic metabolism. Its volume of distribution is of around 4 L/kg. The value of half-life elimination is of around 22 hours. These pharmacokinetic properties (long half-life, steady state concentration) are in favour of substitution use of this opiate. In practice, clinicians progressively introduce this substitution therapy to reach 80 mg +/- 20 mg per day, once daily. Therapeutic clinical goals are mainly to reduce craving, withdrawal symptoms, and to manage psychosocial problems and psychiatric co-morbidity. Practitioners should bear the latter in mind once substitution therapy has been appropriately initiated and stabilized. However, wide, interpatient, interindividual variability impacts on pharmacokinetic parameters. Subjects may be either high or poor metabolizers. Thus, bioavibility ranges from 36 to 100%. Induction or inhibition of CYP450 significantly modifies methadone pharmacodynamic properties. Genetic variability and medication can induce non response to substitution, craving, or withdrawal symptoms. PHARMACOLOGICAL INTERACTIONS: We describe here a large number of medications involved in pharmacokinetic or pharmacological interactions. Classical enzymatic inductors, such as antiepileptic molecules (phenobarbital, carbamazepin), antituberculosis compounds (rifampicin), or antiretroviral therapy (efavirenz, nevirapin, ritonavir), could possibly lead to respiratory depression for example. Metabolism inhibitors such as selective serotonin reuptake inhibitors (fluvoxamine, fluoxetine, paroxetine, sertraline) or antifungals of the azol groups could enhance plasma concentration and may sometimes lead to respiratory depression or death. Nevertheless, clinicians should know methadone pharmacokinetic properties and pharmacological interactions for the optimal opiate-dependant patients' management. CLINICAL USE: Clinicians can use plasma concentrations as a useful indicator to reach substitution goals. The methadone plasmatic target value of 400 microg/ml can be recommended for therapeutic drug monitoring. This dosage not only facilitates interaction detection, but also hand encourages communication with the patient.

[Schizophrenia and amphetamine dependence. A case report]. / Schizophrénie et dépendance aux amphétamines.

UNLABELLED: Whereas observations of psychotic disorders induced by amphetamines are common, few observations described the impact of chronic amphetamine abuse on schizophrenic patients. We report the case of a schizophrenic patient who presented with amphetamine dependence for several years, without other accompanying addiction. CASE REPORT: During his adolescence, Mr. X. gradually developed delusional beliefs of persecution and telepathy. He believed that the other pupils and teachers spoke about him in malicious terms. At the age of 23, Mr. X began to consume 60-100 mg/week of amphetamines orally. He consumed amphetamines during 7 years. The delusions, in particular the auditory hallucinations worsened after the use of amphetamines. Subsequently, he married and was declared unfit for national service due to the psychotic disorders. Mr. X received neuroleptic treatment with moderate effects on the psychotic symptoms. Between the age of 24 and 30, the patient presented persecutory, megalomanic and physical transformation beliefs, delusions of being controlled as well as auditory, somatic-tactile and visual hallucinations. At the age of 30, while he had stopped his consumption of amphetamines for 9 months, the patient, overwhelmed with the delusions, murdered his wife. He was sent in jail for 13 months, and subsequently hospitalized for one year in a high security psychiatric department and 7 years in our psychiatric department. The neuroleptic treatment was effective, particularly against the hallucinations. Following stabilisation, the symptomatology of the patient was marked by a disorganization syndrome, including prominent thought disorder, disorganized speech, associative loosening, frequent derailments and negative signs of schizophrenia, in particular affective flattening and blunting of emotional expression. When the patient was 43, a trial discharge was authorized owing to improvement of his condition. The neuroleptic treatment was switched with single-drug olanzapine therapy, 10 mg/day which improved the negative symptoms. Mr. X. resumed part-time professional activities and remarried. DISCUSSION: The patient fulfilled the DSM IV criteria for schizophrenia and for amphetamine dependence assessed using the Composite International Diagnostic Interview (CIDI). He presented, in particular, withdrawal syndrome when amphetamines were discontinued. The amphetamine consumption was followed by a marked deterioration in the delusions, particularly the hallucinations. Worsening of the positive symptoms in schizophrenic patients by amphetamines has been established in single dose studies, in particular characterized by persecutory delusions and hallucinations. On the other hand, amphetamines tend to transiently and moderately reduce the negative symptoms. Some stu-dies have shown that amphetamine consumption promoted violent acting out in non-schizophrenic subjects. In our observation, the acting out may be not related to the acute effects of these substances, since it occurred 9 months after stated discontinuation of amphetamine consumption. However, the cerebral toxicity and psycho-behavioural disturbances related to amphetamines might be prolonged after withdrawal. In non-schizophrenic patients, the existence of prolonged neurotoxicity of amphetamines and related psycho-behavioral disturbances has been suggested. The prolonged administration of amphetamines to animals produces neuro-axonal degeneration in the striatum, the frontal cortex, the nucleus accumbens and the amygdala. In human, there are some evidence of persistant deteriorations of the serotoninergic and dopaminergic systems in the caudate nucleus, the putamen and the nucleus accumbens following amphetamine consumption. CONCLUSION: The neurobiological and psycho-behavioural effects of amphetamines may be prolonged following withdrawal in both schizophrenic and non-schizophrenic patients.

Is substance abuse in schizophrenia related to impulsivity, sensation seeking, or anhedonia?

OBJECTIVE: The authors compared impulsivity, sensation seeking, and anhedonia in a group of schizophrenic patients with and without lifetime substance abuse or dependence. METHOD: Patients (N=100) with schizophrenia or schizoaffective disorder (per DSM-III-R criteria) were assessed with the Composite International Diagnostic Interview's section on psychoactive substance use disorder, the Positive and Negative Syndrome Scale, the Barratt Impulsivity Scale, the Zuckerman Seeking Sensation Scale, and the Chapman Physical Anhedonia Scale. RESULTS: The mean scores for impulsivity and sensation seeking were higher in the group with substance abuse (N=41) than in the group without substance abuse (N=59). No significant difference between groups was found regarding physical anhedonia. CONCLUSIONS: As in the general population, high levels of impulsivity and sensation seeking are associated with substance abuse in patients with schizophrenia.

Treatment of depressive syndromes in detoxified drug addicts: use of methadone.

Depressive syndromes are very frequent in drug-addicted patients. Their study is particularly difficult on account of the toxic intake which disturbs the clinical analysis. Methadone has improved our understanding of these pathologies. In fact, methadone permits treatment of some depressive disorders typically linked to addiction, such as a motivational symptoms and depressive mood following intoxication. It brings to the fore the other mood disorders which are often associated with drug intake.

[The Tuaregs addiction to tea, to smokeless tobacco and to milk: ethnological and clinical approach]. / La dépendance au thé, au tabac chiqué et au lait chez les Touaregs: approche ethnologique et clinique.

Some rituals about a regular consumption of tea, smokeless tobacco (chewing) and milk are described by one of the authors at the time of his anthropological investigation among the Tuaregs of Timbuktu's region (Mali). He carries out some ethnographical and clinical materials which highlight the dependence to these substances and the role of their psychostimulant and anorexigene effects in a society much ritualised. The subject of this article appears original in the literature which approaches more the dependence to coffee than tea, to cigarettes than to chewing tobacco. The observation of daily life of a tuareg encampment shows a ritual consumption of tea at four time a day. The motivations of the Tuaregs are the increase of vigilance and performance with that psychostimulant substance. They describe an intoxication syndrome related to caffeineism, observed among European tourists. The Tuaregs are aware of their addiction to tea and distinguish psychological dependence from physical dependence. The psychological dependence corresponds to a powerful desire to drink tea at ritual moments, while the physical dependence appears at waking-up and when the time of preparing this beverage is too late. The Tuaregs describe also a phenomenon of loss tolerance after an abstinence period. In spite of the maraboutic prohibition to drink tea, which diverts Tuaregs of their religious practice, they defy this ban from the waking-up to take that infusion before the matinal prayer. That addiction appears also in the identity of the Tuaregs who are called "the sons of tea". The consumption of chewing tobacco, mixed with ash, rhythms the daily life. The mean number of chewing is about fifteen by day; every chewing last 30 minutes. The first chewing of the day occurs 15 minutes after waking-up. The Tuaregs use tobacco in order to get relaxation and vigilance. They suggest intoxication symptoms and especially a withdrawal syndrome which appears at the waking-up or after an important interval between chewing. The authors raise the idea about the dependence to this type of tobacco, consistent with the Anglo-Saxon literature of the 80th which tried to implement scales and criteria as to assess the dependence to smokeless tobacco. The Tuaregs could be more addicted than American consumers in regard to american studies: they use more chewing a day and they can't refrain from chewing at the waking-up. Empirical addition of plant ash, made up of hydroxide of calcium, may act a role in pharmacokinetic by alkalinising the pH. It could increase the absorption of nicotine through the mouth mucus membrane. The authors raise the idea about the dependence to the milk, much consumed and ritualised among those nomadic breeders. They rely on the observation of a withdrawal syndrome clearly identified in the tuareg medical nosography. These regular consumptions integrate the daily life within other rituals. Tea and tobacco facilitate certain motor stimulation, a struggle against hunger and some relaxation regarding an hostile environment over climatological, ecological and economical plan. The brutal and unexpected occurring of one of those rituals disrupt, indeed invert, the usual order of social rituals. Those social and religious disruptions materialise the pathological effect of that double dependence to nicotine and caffeine. That one is called by a term which translate its subjective and social appearance, reflecting so the interaction between man, environment and psychoactive substance. This article highlight the importance of cultural factors in the etiopathogeny of poly-dependence among Tuareg subjects. The question about the diagnostic of the dependence in the DSM IV and the CIM-10 is raised. The DSM IV could be completed because it doesn't evoke addiction to caffeine of tea such like it is consumed in West actually. That hermeneutic approach, including anthropological observations and clinical investigations, allow to understand that addiction to psychoactive substances among Tuareg subjects is consistent with their survival in hostile environments.

[Cannabis and schizophrenia: demographic and clinical correlates]. / Cannabis et schizophrénie: données cliniques et socio-démographiques.

UNLABELLED: The high prevalence of psychoactive substance abuse or dependence among schizophrenic patients has now been well established. Mueser et al. stressed the need to assess the abuse of specific classes of substances and analyse the data accordingly. The objective of this study was to compare the socio-demographic correlates and the clinical features in a group of schizophrenic patients with a lifetime cannabis abuse or dependence according to the DSM III-R with a group of schizophrenic patients who had never presented any abuse or dependence. SUBJECTS AND METHODS: The study included 124 subjects with diagnoses of schizophrenia or schizoaffective disorders according to the DSM III-R. Inclusion criteria for participation in the study were age 18 years or older and willingness to provide consent to participate in the study. The inpatients were evaluated when their condition was stabilised. Assessment tools were the psychoactive substance use disorder section of the Composite International Diagnostic Interview (CIDI), the Positive and Negative Syndrome Scale (PANSS), the Global Assessment of Functioning Scale (GAF). Subjects with cannabis abuse or dependence during their lifetime were compared with subjects without abuse or dependence, using chi(2) test for categorical variables and analyses of covariance (ANCOVA) for quantitative variables. RESULTS: Forty-nine subjects (42,6%) presented lifetime abuse or dependence on one or more substances. Since 19 patients with alcohol, stimulant, sedative or opiate abuse or dependence were excluded, the study finally included 96 subjects including a first group of schizophrenic patients with cannabis abuse (n=6) or dependence (n=24) and a second group without any psychoactive substance abuse (n=66). Thirteen (11.3%) patients presented cannabis abuse or dependence within the 6 months prior to the assessment. The mean SD age of onset of cannabis abuse or dependence was 19.6 +/- 3.0 years. Cannabis abuse/dependence preceded the first psychiatric treatment in 70% of the subjects (n=21). 83.3% of the schizophrenic patients with cannabis abuse or dependence were male (n=25) compared to 62.1% in the group without substance abuse (n=41) (chi(2)=4.32, df=1, p=0.04). Schizophrenic patients with cannabis abuse were significantly younger (mean age: 28.9 +/- 6.3 vs 37.0 +/- 12.7, ANCOVA, F=7.2, df=1,96 p=0.009). There was no significant difference between the two groups for marital status, (chi(2)=5.34, df=2, p=0.07), level of education, (chi(2)=0.93, df=2, p=0.62) professional status, (chi(2)=8.7, df=5, p=0.11), on PANSS total score (ANCOVA, F=0.42, df=1,93, p=0.52), GAF score (ANCOVA, F=0.06, df=1,92, p=0.80), mean number of hospitalizations (ANCOVA, F=3.25, df=1,85, p=0.08), mean age of first psychiatric contact (ANCOVA, F=0.74, df=1,93, p=0.39), and neuroleptic dosages (ANCOVA, F=0.03, df=1,90, p=0.87). In contrast, the total duration of hospitalization was significantly longer for the group with cannabis abuse. Patients with cannabis abuse were more likely to have an history of suicide attempts than subjects without substance abuse (chi(2)=11.52, df=1, p=0.0007). DISCUSSION: The prevalence rates for substance abuse and the socio-demographic characteristics of the population of our study are consistent with findings of previous studies. Male gender and age were significantly related to history of cannabis abuse or dependence. Cannabis abuse frequently preceded the onset of psychiatric treatment. However, both schizophrenia and substance abuse tend to develop gradually, with no clear demarcation for the onset of schizophrenia. The absence of any link between the scores for the subscales of the PANSS and cannabis abuse, both in our study and in some retrospective previous studies, is not suggestive of cannabis abuse as a self-medication of positive or negative symptoms of schizophrenia. Self-medication could concern other symptoms, such as cognitive deficits. In addition, the hypothesis of self-medication has especially been suggested in cocaine abuse or dependence. Some limitations to this study can be discussed. First, although the recruitment was systematic and done in a public mental health service, the patients of our study are not necessarily representative of all schizophrenic patients. Secondly, as in any retrospective study, the prevalence of lifetime substance abuse may have been under-estimated. Urinary toxicology tests may have been able to improve the sensitivity of the diagnosis of recent substance abuse, but structured interviews are more appropriate for the diagnosis of lifetime substance abuse in schizophrenic patients than urinary toxicology tests. CONCLUSION: The socio-demographic characteristics of cannabis abuse or dependence in schizophrenia are similar to those found in general population. Cannabis using schizophrenic patients were more likely to be younger and male than non users. The duration of hospitalization was significantly longer for the group with cannabis abuse. Prevalence of suicide attempts in schizophrenia is closely correlated to cannabis abuse.

[Heroin addiction treated with methadone. Experience in 50 patients]. / Héroïnomanie traitée par méthadone. Expérience sur 50 malades.

The authors have reviewed the records of 50 heroin addicts treated with methadone, a drug which, in France, is delivered under strict and daily supervision to only few patients. This retrospective study yielded the following data: (1) the success rate of maintenance treatment with methadone exceeded 50 percent and remained the same in HIV positive patients; (2) social and environmental factors predictive of poor response to methadone were the absence of professional activity at the beginning of treatment and a painfully disturbed family context. A history of trouble with the law was not a factor of poor prognosis. These data raise the problem of importance of an early treatment which might have a strong influence on subsequent developments.

[Predictive factors of response to buprenorphine in the substitutive treatment of heroin addicts. Results of a multicenter study of 73 patients]. / Facteurs prédictifs de la réponse à la buprénorphine en traitement substitutif des héroïnomanies. Résultats d'une étude multicentrique sur 73 patients.

OBJECTIVE: Buprenorphine has a partial morphine-agonist pharmacological profile. It is proposed as alternative to methadone in opiate drug addicts with greater safety of use and less cost in terms of public health. The aim of this study was to determine the clinical factors of response to this molecule. METHOD: The study was conducted in 73 patients treated for 3 months with adaptable doses. Mean dose was 8.5 mg/d (range: 3 to 16 mg/d). Response to treatment was defined as: still in the study at 3 months and absence of opiates in 75% of urinary samples over the past month. RESULTS: Forty-eight patients responded and 25 did not. The determinating clinical variables of response were: opiate drug addiction less than 10 years, high score on the Addiction Severity Index (ASI), absence of depression according to the Minnesota Multiphasic Personality Inventory (MMPI) and low rate of disinhibition on Zukerman's sensation seeking scale. Conversely, the dose of buprenorphine within the limits specified in the Marketing Authorisation did not intervene in the response. CONCLUSION: In view of its partial agonist effect, administration of buprenorphine must be reserved for patients addicted to opiates for less than 10 years, non-depressive and with low disinhibition on Zukerman's scale.

[Treatment of heroin addicts by substitution with methadone. Importance, limits and experience in France]. / Les traitements de substitution des héroïnomanes par la méthadone. Intérêt, limites et pratiques en France.

The authors present a review of literature and their personal experience concerning the practice of methadone substitutive therapy for heroin addicts in France. In their experience, the use of methadone, within the frame of a controlled administration and in the perspective of a specific pharmaco-therapeutic profile, is a valuable therapeutical option. Otherwise, methadone could only induce a new and further pharmacological dependence. The use of methadone has often been the subject of controversies overlooking the clinical reality of drug addiction. Therefore, a controlled use of methadone remains a valuable therapeutic tool if its indications are strictly delimited.

[Current clinical aspects of drug addiction]. / Aspects cliniques actuels des toxicomanies.

Drug addiction is a serious behavioral disorder. It is a long term evolving process characterized by dependency. It is not only biological and psychological but also social. It should be differentiated from occasional drug use, from drug abuse with minor consequences as well from medical drug dependency in which the individual does not seek a psychological effect. Drug addiction causes are multiple and include psychological, family, social and obviously biological factors (drug addicting potential). In to-day clinical practice, addiction to benzodiazepines or opioids prescribed for maintenance therapy and the newly described secondary addiction of later onset are predominant. Severe social consequences and many psychiatric and medical disorders in particular due to HIV infection also result from drug addiction. Depressive and psychotic disorders cause specific therapeutic problems when patients deny their troubles or when drug use produces special relief. These psychological disorders frequently underlie medical care needs.