Abstract
When psychiatric illness and substance use disorder coexist, the clinical approach to the patient is, unsurprisingly, awkward. This fact is due to a cultural context and, more directly, to the patient’s psychiatric condition and addiction behaviors—a situation that does not favor a scientific approach. In dual disorder facilities, several types of professionals work together: counselors, social workers, psychologists, and psychiatrists. Treatment approaches vary from one service to another and even within the same service. It is crucial to provide dual disorder patients with multiple treatments, comprising hospitalization, rehabilitative and residential programs, case management, and counselling. Still, when treating dual disorder (DD) heroin use disorder (HUD) patients, it is advisable to follow a hierarchical algorithm. First, we must deal with addiction: by detoxification, whenever possible. This means starting most patients on anti-craving pharmacological maintenance, though aversion therapy may be appropriate for a few of them. Opiate antagonists may be used with heroin-addicted patients as long as those patients are only mildly ill. In contrast, agonist opioid medications, i.e., buprenorphine and methadone suit moderately and severely ill patients, respectively. Achieving control of mood instability or psychotic episodes is the next step, to be followed by a prevention strategy to counteract residual cravings and dominate mood disorders or psychotic episodes through long-term pharmacological maintenance that is focused on a double target.
Highlights
Many different terms have been introduced to define the co-occurrence of a psychiatric disease and a substance use disorder
How can primary psychiatric disorders be distinguished from substance-induced transient or persistent disorders with similar symptoms? A DSM-based classification is of little help, since the exclusion of putative substance-induced disorders from a primary psychiatric category resulted in little attention being paid to these secondary disorders
The result is that we are forced to reason over treatment approaches to methamphetamine addicts with psychotic symptoms who are lumped together with opioid addicts, who have to cope with depression, or alcoholics, who have to contend with social phobia
Summary
Several studies or reviews have discussed the issue of the disease chronology of dual disorder. The emergence of psychiatric symptoms after the end of agonist opioid treatment may indicate a therapeutic effect of that kind of treatment on an independent psychiatric disorder, as in the case of methadone-withdrawal psychoses. These disorders are often hard to recognize during agonist treatment. Apart from addiction-centered studies, other authors have indicated stimulant use, possibly coupled with alcohol and cannabis, as peculiar to a bipolar diathesis. Med. 2020, 9, 2098 the concept of bipolar-stimulant spectrum disorders, going beyond the causal distinction between spontaneous, associated, and induced bipolar disorders [17]
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