Use Disorder pa7ents Icro Maremmani, MD Qualified Full Professor of - - PowerPoint PPT Presentation

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Use Disorder pa7ents Icro Maremmani, MD Qualified Full Professor of - - PowerPoint PPT Presentation

Jan 18, 2024 101 likes •512 views

! ! Psychopharmacology of Dual Disorder Heroin Use Disorder pa7ents Icro Maremmani, MD Qualified Full Professor of Psychiatry Professor of Addic7on Medicine, University of Pisa, Italy VP Dole DD-Unit, Santa Chiara University Hospital, Pisa,

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Psychopharmacology of Dual Disorder Heroin Use Disorder pa7ents

Icro Maremmani, MD

Qualified Full Professor of Psychiatry Professor of Addic7on Medicine, University of Pisa, Italy VP Dole DD-Unit, Santa Chiara University Hospital, Pisa, Italy President World Federa7on for the Treatment of Opioid Dependence

NGO with Special Consulta7ve Status with United Na7ons Economic and Social Council (ECOSOC)

New York, NY, USA

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WELCOME THE NEW PARADIGM IN NEUROSCIENCE TO UNDERSTAND MENTAL HEALTH

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Presidente : Giampaolo Spinnato (Palermo) DireNore Scien7fico:

Icro Maremmani (Pisa)

Segretario:

Vinico C. Romano (Piazza Armerina, Enna)

Rappresentan7 degli associa7

Francesco Lamanna (Pisa) Riccardo Gionfriddo (Siracusa) Sedi: Via Generale Gaeta, 14 Piazza Armerina, Enna Via XX Settembre, 83, Pietrasanta, Lucca

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JOINT STATEMENT ON DUAL DISORDERS:

ADDICTION AND OTHER MENTAL DISORDERS

Addiction is a Mental Disorder, not a voluntary, self-indulgent act

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  • The above menConed naConal and internaConal scienCfic

associaCons have drawn up a statement supporCng the noCon that addicCons are mental disorders in response to unfounded claims to this asserCon.

  • PaCents with mental disorders, including addicCons,

should have access to a mulCdisciplinary care model that integrates and/or coordinates the mental health network and the addicCon network, thereby avoiding the so-called “wrong door syndrome”.

Joint Statement on Dual Disorders: AddicCon and other Mental Disorders

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Main contradicCons in the addicCons

Blocking opioid receptors by agonist

  • pioid medica7ons is

not encouraged

Blocking opioid receptors by antagonist

  • pioid medica7ons is

encouraged

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Main contradicCons in the addicCons

The treatment is limited in 7me The disease is chronic

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Main contradicCons in the addicCons

Only CRAVING and RELAPSE?

GO

STOP

Psychopathology?

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PSYCHOPATHOLOGY SPECIFIC TO SUD PATIENTS AND ITS TREATMENT

Psychopharmacology

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Psychic structure of SCL-90

  • SomaCzaCon
  • Obsessive-compulsive
  • Interpersonal sensiCvity
  • Depression
  • Anxiety
  • HosClity
  • Phobic anxiety
  • Paranoid ideaCon
  • PsychoCc ideaCon
  • Worthlessness and Being

Trapped

  • SomaCc-Symptoms
  • SensiCvity – PsychoCcism
  • Panic – Anxiety
  • Violence – Suicide

Psychiatric paCents Addicted paCents

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Psychopathological typology

14% 24% 20% 22% 20% Worthlessness and being trapped SomaCzaCon SensiCvity- psychoCcism Panic-anxiety Violence-suicide Maremmani, I., P. P. Pani, et al. (2010). Annals of General Psychiatry 9(1): 15 65 50 52 48 47 25 30 35 40 45 50 55 60 65 70 W-BT SS S-P PA V-S

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Old HUDs are generally typified as Worthlessness-Being Trapped pa7ents Young HUDs are generally typified as Sensi7vity-Psycho7cism and Violence-Suicide pa7ents

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! The five-dimension SCL-90 solu7on is independent of the treatment choice

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! The five-dimension SCL-90 solu7on is independent of the intoxica7on status

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! The five-dimension SCL-90 solu7on is independent of the life7me psychiatric problems

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! The five-dimension SCL-90 solu7on is independent of the involved drug

  • Alcohol, Cocaine, or Heroin as principal substance of abuse
  • Heroin, Heroin+Alcohol or Heroin+Cocaine
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! Specific psychopathology of Addic7on is independent of the primary substance of abuse in pa7ents without a secondary substance of abuse

14.9 14.1 8.8 22.8 21.2 22.8 26.3 23.5 19.3 28.1 29.4 29.8 7.9 11.8 19.3

ALC (N=114) HERO (N=85) COC (N=57)

Worthlessness-Being trapped Somatic symptoms Sensitivity-Psychoticism Panic-Anxiety Violence-Suicide Chi-square 6.27; df 8; p=0.617

Unpublished

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The high-level correla7on between five-dimension SCL-90 solu7on and addic7ve behaviour stands as further evidence, at least in Heroin Use Disorder pa7ents, of the existence of a psychopathology that is specific to addic7on

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The five-dimension SCL-90 solu7on can discriminate psychopathology between Major Depression and Heroin Use Disorder Pa7ents qualita7vely (77% correctly classified) and quan7ta7vely

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The five-dimension SCL-90 solu7on can par7ally discriminate psychopathology between Obese (non psychiatric) and Heroin Use Disorder Pa7ents qualita7vely (47.2 of obese individuals were reclassified as HUD pa7ents) and quan7ta7vely

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! Psychopathology of addic7on: May the SCL90-based five dimensions structure be applied in a no-substance-related addic7ve disorder such as Gambling Disorder? STEP OR 95% CI p HUD paCents 1.00 1 Age 0.78 0.75-0.82 <0.001 2 EducaCon, low 12.19 5.66-26.2 <0.001 3 Total SCL-90 1.02 1.01-1.03 <0.001 4 Worthlessness-Being trapped 1.00 SomaCc Symptoms 5.43 1.48-19.8 0.010 5 Unemployed 3.07 1.39-6.78 0.005

chi square 444.18 df(8) p<0.001 95.7% of original grouped cases correctly classified

Unpublished

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Mood dysregula7on: Worthlessness and being trapped Anxiety dysregula7on: Panic anxiety Impulse-control dysregula7on: Violence and suicide Soma7c symptoms, Sensi7vity and Psycho7cism

Stress sensi7vity?

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Research line

  • Gerra G., Somaini L., Zaimovic A., Gerra M. L., Maremmani I., Amore M., Ciccocioppo R. (2010):

Developmental TraumaCc Experiences, PTSD and Substance Abuse Vulnerability: The Neurobiological Link. In: Sher L., Vilens A. (Eds.): Neurobiology of Post-Trauma7c Stress Disorder. Nova Science Publishers, Inc, Hauppauge NY. pp.

  • Rugani F., Maremmani A. G. I., Rovai L., Mautone S., Perugi P., Pani P. P., Dell’osso L., Maremmani I. (2011):

Life events (loss and traumaCc) and emoConal responses to them in heroin-dependent paCents before and aier the dependence age of onset. Heroin Addict Relat Clin Probl. 13(3): 17-26.

  • Dell’Osso L., Carmassi C., Straja P., Massimek G., Akiskal K. K., Akiskal H. S., Maremmani I., Rossi A. (2013):

Gender differences in the relaConship between maladapCve behaviours (drug abuse included) and PTSD. A study on 900 L’Aquila 2009 earthquake survivors. . Front Psychiatry. 3(111): 10.3389/fpsyt.2012.00111.

  • Dell’Osso L., Rugani F., Maremmani A. G. I., Bertoni S., Pani P. P., Maremmani I. (2014): Towards a unitary

perspecCve between Post-TraumaCc Stress Disorder and Substance Use Disorder. Heroin use disorder as case

  • study. Compr Psychiatry. 55: 1244-1251.
  • Dell'osso L., Massimek E., Rugani F., Carmassi C., Fareed A., Straja P., Rossi A., Massimek G., Maremmani I.

(2015): Life events (loss and traumaCc) and emoConal responses to them in acute catastrophe survivors and long-lasCng heroin use disorder paCents never exposed to catastrophic events. Heroin Addict Relat Clin Probl. 17(6): 49-58.

  • Maremmani A. G. I., Maiello M., Carbone M. G., Pallucchini A., Brizi F., Belcari I., Conversano C., Perugi G.,

Maremmani I. (2017): Towards a psychopathology specific to Substance Use Disorder: Should emoConal responses to life events be included? Compr Psychiat.

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  • Before and aler heroin dependence age of onset, Life Events are

very common

  • Aler heroin dependence age of onset, pa7ents who report more life events

are the majority

  • Aler heroin dependence age of onset, reac7ons to life events tend to increase
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  • Are correlaCons between PTSD spectrum and severity of heroin

addicCon significant?

  • Are opioid medicaCons able to reduce reacCons to life events in

Heroin Addicts during treatment?

QuesCon Marks

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Are correlaCons between PTSD spectrum and severity of heroin addicCon significant?

Dell'Osso, L., F. Rugani, et al. (2014). Compr Psychiatry.

5 10 15

Life Events Grief ReacCon Trauma EmoConal, Phisical and Re- experiencing, Re- experiencing, MaladapCve coping Arousal Personality Traits

NO YES Polyabuse

5 10 15 Life Events Grief ReacCon Trauma EmoConal, Phisical and Re- experiencing Re- experiencing MaladapCve coping Arousal Personality Traits

NO YES Previous Treatments

5 10 15

Life Events Grief ReacCon Trauma EmoConal, Phisical and CogniCve Re-experiencing, Avoidance Re-experiencing, Numbing MaladapCve coping Arousal Personality Traits

Stages 1 and 2 Stage 3 10 20

Life Events Grief ReacCon Trauma EmoConal, Phisical and Re- experiencing, Re- experiencing, MaladapCve coping Arousal Personality Traits

Daily or less More than daily

p<0.01 p<0.01 p<0.01 p=ns

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Correla7ons between opioid medica7on dosage and severity of reac7ons to life events in Heroin Addicts during treatment Opioid Medica7on Dosage Severity of reacCons to life events

N=82 r=-0.225 p=0.042

Are opioid medicaCons able to reduce reacCons to life events in Heroin Addicts during treatment?

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CAN HEROIN ADDICTION GENERATE A PTSD SPECTRUM?

Does psychopathology of addicCon exist?

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ROC analysis on PTSD spectrum database of survivors of the 2009 L’Aquila earthquake.

32 32

Subjects developing PTSD aier L’Aquila earthquake Subjects No- developing PTSD aier L’Aquila earthquake

Dell'Osso, L., E. Massimek, et al. (2015). Heroin Addict Relat Clin Probl 17(6): 49-58.

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Percentage of subjects with a PTSD spectrum >32 in long lasCng HUD paCents, No-PTSD and PTSD earthquake survivors No-PTSD earthquake survivors PTSD earthquake survivors Long las7ng HUD pa7ents

11 (14.3%) (b) 56 (72.7%) (a) 51 (66.2%) (a)

Dell'Osso, L., E. Massimek, et al. (2015). Heroin Addict Relat Clin Probl 17(6): 49-58.

Each leNer denotes a subset of categories whose column propor7ons do not differ significantly from each other at the 0.05 level

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Grief ReacCons ReacCon LE Re-experiencing Avoidance & Numbing MaladaptaCve Coping Arausal EQ-NO-PTSD EQ-PTSD LL-HUD

PTSD spectrum in long lasCng HUD paCents, No- PTSD and PTSD earthquake survivors

Dell'Osso, L., E. Massimek, et al. (2015). Heroin Addict Relat Clin Probl 17(6): 49-58.

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  • The high-level correla7on between five-dimension SCL-90 solu7on and PTSD

spectrum in HUD pa7ents stands as evidence that PTSD spectrum should be included in the psychopathology specific to addic7on

  • The five-dimension SCL-90 solu7on is independent of the life7me psychiatric

problems

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Psychic structure of SCL-90

  • SomaCzaCon
  • Obsessive-compulsive
  • Interpersonal sensiCvity
  • Depression
  • Anxiety
  • HosClity
  • Phobic anxiety
  • Paranoid ideaCon
  • PsychoCc ideaCon
  • Worthlessness and Being

Trapped

  • SomaCc-Symptoms
  • SensiCvity – PsychoCcism
  • Panic – Anxiety
  • Violence – Suicide
  • Trauma and Loss Spectrum

Psychiatric paCents Addicted paCents

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Future QuesCon Marks

  • Is early Opioid Agonist Treatment able to block the

development of Trauma and Loss spectrum in Heroin Addicts?

  • Is long-term Opioid Agonist Treatment able to restore

Trauma and Loss spectrum in Heroin Addicts

  • Is 32 the Trauma and Loss spectrum cut-off for recovered

HUD paCents?

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! Icro Maremmani, Orieja Zolesi, Tommasa Agueci, Paolo Castrogiovanni (1993):

Methadone Doses and Psychopathological Symptoms during Methadone Maintenance.

Journal of Psychoac7ve Drugs. 25(3): 253-263.

  • 0.2

0.2 0.4 0.6 0.8 1 PsychoCcism Depression Paranoid ideaCon SomaCzaCon Anger Anxiety Phobic anxiety Interpersonal sensiCvity Obsessive compulsive Load

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20 40 60 80 100 120 5-Violence-suicide 4-Panic-anxiety 3-SensiCvity-psychoCcism 2-SomaCzaCon 1-Worthlessness-being trapped 0-Independently of psychopathology Methadone Buprenorphine

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! The SCL-90 5-factor dimensions can be appropriately used as a prognosCc tool for drug-dependent subjects entering a residenCal treatment.

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! The impact of psychopathological subtypes on reten7on rate of pa7ents with substance use disorders entering residen7al therapeu7c community treatment

Maremmani, A. G. I., P. P. Pani et al. (2016). Ann Gen Psychiatry 15(29).