Comorbid Addiction Research Articles

Sexual Addiction in Incarcerated Sexual Offenders

The prevalence and features of sexual addiction in sexual offenders incarcerated in a Canadian Federal prison were examined. Eighty male respondents (40 sexual offenders, 40 community subjects) completed questionnaires on sexual addiction and drug and alcohol problems. Sexual offenders were significantly more likely than the comparison group to be classified as sexual addicts. Fourteen of 40 sexual offenders (35%), and 5 of 40 community subjects (12.5%) were classified as sexual addicts. Sexual offender sexual addicts were more likely than non-addicts to report a preoccupation with sex and having been a victim of childhood or adolescent sexual abuse. However, sexual offender sex addicts were no more likely than sexual offender non-addicts to report co-morbid addiction problems with drugs or alcohol. Results are discussed in terms of their implication for the notion of sexual addiction and its relationship to sexual offending.

0223 SUBSTANCE USE AND ABUSE IN FIRST EPISODE PSYCHOSIS: PREVALENCE BEFORE AND AFTER EARLY INTERVENTION

Comorbid substance abuse disorders have emerged as one of the greatest obstacles to the effective treatment of persons with schizophrenia. Estimates of the prevalence of such comorbidity vary, but as many as half of persons with schizophrenia may suffer from a comorbid drug or alcohol disorder. Younger age, male gender, and lower educational attainment are associated with greater risk for addiction. Persons with schizophrenia and comorbid addiction tend to have an earlier onset of schizophrenia than do those without comorbid addiction. Research does not support a link between specific symptoms of schizophrenia and choice of abused drugs. Rather, drug choice is correlated with the pattern of ambient drug use in the community. Comorbid substance disorders are associated with a variety of poorer outcomes, including increased psychotic symptoms, poorer treatment compliance, violence, housing instability and homelessness, medical problems (including human immunodeficiency virus infection), poor money management, and greater use of crisis-oriented services that result in higher costs of care. Considerable progress has been made over the past decade in understanding the need to integrate substance abuse treatment and mental health treatment to provide more effective care for this population.

Is Compulsive Buying a Real Disorder, and Is It Really Compulsive?

Is Compulsive Buying a Real Disorder, and Is It Really Compulsive?

Utilidad de la Escala Multidimensional de Craving de Alcohol (EMCA) en la práctica clínica

Introduction: Craving is a central symptom of addictive behaviors. Craving levels are usually related to patient’s evolution. The MACS scale has prove a valid and reliable instrument to assess this symptom. The aim of this study is to test the usefulness of MACS to assess the efficacy of treatment and to improve the alcoholism treatment planning. Patients and Method: A sample of 151 alcohol-dependence patients has been used to study the relationship between the MACS scale and dependence severity, psychiatric and addictive comorbidity and other alcoholism scales. Furthermore, the sensitivity of MACS to detect changes in patient’s evolution during a six months follow-up study has been assessed. Results: The MACS discriminate between the severe level of dependence severity and moderate (p0.001) and slight levels (p0.0001), as well as between patients with and without addictive comorbidity. The “desire to drink” factor of the MACS discriminate between patients with and without psychiatric comorbidity (p=0.041). The MACS show a good sensitivity to detect changes in alcohol consumption during the follow-up study. Conclusions: The craving severity seems to be modulated by the alcohol-dependence severity and psychiatric and addictive comorbidity. The MACS is sensitive to the changes that happen during the recovery process of alcoholism. Therefore it can be a useful instrument for alcoholism treatment planning and outcome treatment assessment.

Psychoneurobiology of Co-Occurring Trauma and Addictions

Abstract The primary goals of this chapter are threefold. First, a general overview of psychoneurobiology and the stress response will be given to help the clinician gain a basic understanding of normative and pathological stress responses. This information will not only provide clinicians with a basic understanding but could be useful for psychoeducational purposes in treatment settings. Secondly, reviews of some recent research findings are provided to further facilitate understanding of the implications of co-morbid trauma and addictions. Finally, suggestions for conducting in integrative assessment to facilitate treatment planning will be discussed.

Lifetime positive symptoms in patients with schizophrenia and cannabis abuse are partially explained by co-morbid addiction

Recent prospective findings have shown that cannabis use by young people could be a risk factor for psychotic symptoms in adulthood, but the long-term impact of cannabis abuse on the clinical features of declared schizophrenia remains to be explored. We assessed the independent influence of cannabis abuse on the clinical symptoms of schizophrenia, after controlling for frequently co-occurring addictive disorders. Patients with schizophrenia, and with ( N = 66), or without ( N = 139) cannabis abuse, were compared for lifetime positive and negative symptoms, taking into account presence of any other addictive disorders. The incidence of the abuse of drugs other than cannabis was nearly five times greater amongst patients with both schizophrenia and cannabis abuse. When the analyses were limited to subjects with no other abuse, less avolution and fewer apathy symptoms were still detected in patients with schizophrenia and cannabis abuse than in those with no abuse ( p = 0.0001). In contrast, between-group differences for positive symptoms were abolished when multiple substance abuses were taken into account. The strong association between cannabis abuse and fewer negative symptoms in schizophrenia was thus replicated in this sample, but once co-morbid addictive disorders had been controlled no influence of cannabis abuse on hallucinations was detected. Distinguishing the effects of co-occurring addictive disorder(s) in patients with schizophrenia and cannabis dependence may thus be important when attempting to analyse the impact of cannabis abuse.

Pain medicine: Why and when to call for the addictionologist and/or psychiatrist

Substance abuse and psychopathology are frequently present in pain patients and often complicate pain treatment. Whereas the pain physician does not necessarily need to possess the tools needed to effectively treat these complicating conditions, it is incumbent on the pain physician to determine their presence and secure appropriate consultation. Aberrant drug behaviors may be present when patients manifest one or more of the following: continued use despite self harm, daily functionality deteriorates, impaired control over use (unable to take medications as prescribed), preoccupation with use of analgesics for non-analgesics purposes, inability to use non-opioid pain interventions, and/or preference for medications with high reinforcing characteristics (ie, achieve rapid plasma levels). The most common psychopathology is depression and anxiety. The clinical presentation of depression is commonly: persistent low moods (“feeling blue”/down, anhedonia), self-attitude changes (feeling of guilt, being a “bad” person), and/or changes in vital sense (changes in sleep, appetite, or energy levels). Anxiety is somewhat different and the clinical signs are: personality trait (ie, periodically becomes excessive), symptom of another disorder (eg, depression) or triggered by stressful situation (eg, chronic pain), worry out of proportion about negative results, kinesophobia, thoughts of serious illness, amplification of pain perception, muscle tension, sleep disturbances, restlessness, and/or fatigue. Depression and anxiety (most commonly Generalized Anxiety Disorder) are most effectively treated by Cognitive Behavioral Therapies in combination with pharmacologic means. Practicing in an interdisciplinary manner, with appropriate specialty consultation, is indicative of a comprehensive pain management program which is associated with the best possible patient results when dealing with patients manifesting comorbid addiction and/or psychopathology conditions.

Chronic pain management: Is addiction a risk? Is consultation a necessity?

The medications most often implicated in prescription drug abuse are opioid analgesics, sedative-hypnotics, and stimulants. Because they are exposed to these drugs, patients with acute or chronic pain are at increased risk of addiction comorbidity. It is important to ask patients about their family and substance-use history, including alcohol, illicit drugs, and prescription drugs. Patients who abuse prescription drugs may exhibit certain patterns, such as escalating use, drug-seeking behavior, and doctor shopping. Physicians who purposefully over-prescribe are in the minority; however, sloppy practice or inattention to detail can contribute to the problem of drug seeking. Maintaining a high index of suspicion, documenting the decisions that guide the treatment process, and seeking consultation early are important risk-management strategies that improve clinical care and outcomes in patients treated for chronic pain. This article discusses the implications of treating chronic pain in patients suspected of chemical dependency, optimal ways to achieve pain control, and how to avoid adverse outcomes or descent into addiction. Finally, a review of how supportive measures, such as seeking consultation, individual and group psychotherapy, and Twelve Step participation, can assist the pain management physician is presented.

Neuroleptic Dysphoria, Comorbid Drug Abuse in Schizophrenia and the Emerging Science of Subjective Tolerability—Towards a New Synthesis

One of the frequent but under-recognized side effects of antipsychotic medications is the subtle subjective changes including feelings of anxiety, distress and lack of pleasure, which are collectively labeled as neuroleptic-induced dysphoria and, ultimately, often lead to dislike and aversions to medications, with serious clinical consequences. Yet, those very patients take to frequent abuse of illicit drugs. Several surveys estimated the association of drug abuse in schizophrenia as ranging somewhere between 10–70%. One popular and frequently accepted explanation for such high association has been the self-medication hypothesis. In other words, patients take to illicit drugs as a way of dalleviating symptoms of the illness as well as medication-induced side effects, particularly neuroleptic dysphoria. Recent clinical and neuro-imaging studies have, for the first time, directly linked the genesis of neuroleptic dysphoria to the dopamine-binding ratios in the nigrostriatal complex. This recent evidence comes from the study of dopamine receptor occupancy using PET scanning as well as from dopamine depletion SPECT studies. Meanwhile, emerging evidence from research in the addiction field has implicated dopamine in the same neural circuitry in motivational and reinforcement behaviour, which is central to initiation and continuation of dependency states. As the self-medication hypothesis proved incapable of explaining all the varied pictures of dysphoria and comorbid addictions, a unifying hypothesis is put forward to argue that both vulnerability to drug addictions and medication-induced dysphoria vary on independent facets of the illness itself. The mechanism that possibly links both lies in a dysregulated dopamine signaling in the nucleus accumbens resulting from frontal/cortical and hippocampal dysfunction. Besides the neurochemical argument, clinical and epidemiological data seem also to add support to this proposition. Such proposal not only represents a major rethinking of the concept of schizophrenia and its varied domains and manifestations but has also significant clinical implications in understanding and better management of comorbid drug abuse in the context of the illness itself. The recent intensified research efforts to understand the central mechanisms related to the role of dopamine in reward, punishment and pleasurable experiences as well as motivational and reinforcement behaviour, opens a new vista in understanding how and why patients like or dislike their medications based on their subjective responses to medication-taking. It is possible that the field is on the verge of a new science, which can collectively be called: “The Science of Subjective Tolerability Disorders.”

Clinical Guidelines, Public Policy, and the Regulation of Opioids

This issue's Forensic Pain Medicine section juxtaposes several complimentary perspectives on the use of opioids in medical practice. Three academic U.S. medical organizations devoted to understanding the issue of opioids and chronic pain, the American Academy of Pain Medicine (AAPM), the American Pain Society (APS), and the American Society of Addiction Medicine (ASAM), have created and officially adopted a consensus document, Public Policy Statement on the Rights and Responsibilities of Health Care Professionals in the use of Opioids for the Treatment of Pain [1]. This statement poignantly compliments two other papers in this issue's Forensic Pain Medicine Section that present important information about the regulation of opioids in medical practice at both the state and federal levels. The Statement clarifies the rights and responsibilities of practitioners who prescribe opioids for pain relief, even with comorbid addiction disorder. The Statement supplements earlier consensus documents, Definitions …

Potentialisation par les hormones thyroïdiennes des traitements tricycliques et sérotoninergiques dans les dépressions résistantes

In response to the increase of resistant depressive disorders and in spite of improved treatments, numerous studies were conducted in the last thirty Years aiming at assessing the pre-morbid thyroid state of depressed patients resistant to well conducted tricyclic treatments. "Minimal" thyroid abnormalities were evidenced as well as central thyroid disorders which may not be detected by peripheral-i.e plasmatic- dosages. Regarding the premorbid thyroid status, the hypothesis of subclinical hypothyroidism was considered by many Authors. It is marked by four grades including T3 and T4 decreased levels, basal TSH concentration abnormalities as well as increased TSH response to TRH stimulation, and the presence of antimicrosomal and antithyroglobulin antibodies. Although, there are different views on the existence or not of these abnormalities, we'll focus our attention on a metaanalysis including six studies. It shows in a population with a resistant depression, 52% of patients with subclinical hypothyroidism, against 8 to 17% in patients with simple depression and 5% in the overall population.Similarly, antithyroid antibody levels (group IV hypothyroidism) were significantly higher in depressed patients (9% to 20% against 7,5% in the overall population). For many Years, a central hypothyroidism was hypothesized on the basis of an exhausted T3-T4 transference mechanism and a lowered TRH hypothalamic biodisponibility.In the last Years, new data emerged on the role of transthyretin, a cerebral carrier T4 protein, whose concentration in the CSF was found significantly lower in depressed patients than in a control group, the lowest levels being observed in the most severely depressed. This decreased level of transthyretin would result in a lower central T4 biodisponibility-hence, in view of a T4-T3 desiodation insufficiency, a T3 deficit is observed. A low transthyretin level associated or not to subclinical hypothyroidism could be a factor of depressive vulnerability on one hand, of resistance to tricyclic treatment on the other one. Conversely, subclinical hypothyroidism could be a predictive factor of a good response to a potentializing strategy. The pharmacological mechanisms involved in this potentializing phenomenon are now well known: they consist in an interaction between depression, adrenergic receptors and thyroid hormones biodisponibility. The decreased norepinephrine level observed in depressive patients is associated, in case of increased thyroid hormones biodisponibility, with a higher sensitivity of adre-nergic receptors, mostly betaadrenergic. This seems to underly the recovery process. According to some Authors, the serotoninergic system might be involved in the potentialization of tricyclics by thyroid hormones. We know that in animals with hypothyroidism, the serotonin synthesis is decreased and that the administration of T3 increases the brain levels of serotonin and its 5HIA catabolite. In addition, T3 could correct the down-regulation induced by serotoninergics on beta-adrenergic receptors. On the basis of numerous studies carried out on the potentializing of tricyclics, we suggest practical modalities of treatment - which until today did not materialize in every day practice in the absence of a clear consensus based on statistically reliable data: after four to six weeks of inefficient tricyclic or serotoninergic treatment on a correct dosage testified by plasmatic dosages, it is recommended to initiate a T3 treatment on a effective posology (25 to 50 micrograms per day), which must be reached in 2 or 3 days, except in case of rare and transitory side effects (sweating, shaking, tachycardia, nervousness, anxiety). If the treatment is not rapidly efficient, it must be discontinued in case there is no improvement after 3 weeks. Until today, there is no consensus about the duration of a T3 treatment. It is important to take into account the predictive criteria of good or bad response to a T3 potentialization, since they have direct consequences on the management of depressed patients. For example, a high degree of chronic evolution with resistance to numerous treatments, associated disorders according to the DSM IV axis I and a comorbidity of addiction, point to a bad prognosis of a potentialization treatment. In addition, we'll examine the few recent studies on the potentializing of serotoninergic antidepressant drugs by thyroid hormones.

Other: Changes in facial expressions during cold pressor pain stimulation

Chronic pain appears to be substantially more prevalent among patients with active addiction than in the general population (Rosenblum et al., 2003). Preliminary research suggests that individuals vulnerable to developing addictions may be more sensitive to pain (Stewart et al., 1995). Additionally, the presence of active addiction may facilitate tolerance to analgesics thereby rendering standard treatments less effective in this population (Compton et al., 2000). However, our understanding of the etiology of comorbid addiction and chronic pain is incomplete and this population continues to be underserved. The purpose of this presentation is to present a motivational theory of vulnerability to substance-related disorders and chronic pain. A theoretical rationale for the model based on the opiate system, which has important roles in controlling pain, addiction, reward and response to punishment (Sharifi et al., 2001), will be presented. Because opiates can both alleviate pain and suppress the inhibitory effects of punishment on previously rewarded behavior (Gray, 1987), pain can be considered a potentially powerful motivating factor for drug use. The convergence of this hypothesis with the Motivational Theory of Drug Abuse Vulnerability (Pihl & Peterson, 1995), which suggests that individual differences exist in the functioning of motivation systems, will be discussed. As well, a systematic review literature supporting the proposed motivational model of chronic pain and addiction will be provided. Given the barriers to treatment encountered by individuals with comorbid chronic pain and substance abuse (Merrill et al., 2002), enhanced understanding the relationship between pain and substance use could facilitate development of etiologically-relevant treatment for dually diagnosed individuals. Implications for the development of a treatment program that would address the particular needs and characteristics of individuals with both substance abuse and chronic pain problems will be discussed.

Comorbid alcohol addiction increases aggression level in soldiers with combat-related post-traumatic stress disorder

The aim of this study was to compare aggressive behavior in soldiers with combat-related posttraumaticstress disorder (PTSD), PTSD comorbid with alcohol addiction and alcohol addictiononly. Three groups of male combat experienced soldiers with PTSD (n = 43), PTSD comorbidwith alcohol addiction (n = 41) and alcohol addiction (n = 39) were compared by Aggressionrating scale A-87. PTSD was diagnosed according to DSM-IV criteria and Watsons PTSDrating scale. Alcohol addiction was diagnosed according to DSM-IV criteria and CAGEQuestionnaire. Combat-experienced soldiers with alcohol addiction as well as soldiers withcombat-related PTSD comorbid with alcohol addiction have a high level of verbal latentaggression (VLA), (F = 26.65; P < 0.001), physically latent aggression (PLA), (F = 37.86; P <0.001), indirect aggression (INA), (F = 56.94; P < 0.001), verbal manifest aggression (VMA),(F = 18.35; P < 0.001), and physically manifest aggression (PMA), (F = 43.22; P < 0.001), vs.soldiers with combat-related PTSD without comorbid conditions. Alcohol addiction is a severefactor in increasing aggression levels in soldiers with PTSD.

Linking mental health and addiction services: a continuity-of-care team model.

Reorganization of mental health care delivery services at a Department of Veterans Affairs medical center addressed problems with the coordination of addiction treatment and mental health programming for patients with significant psychiatric and addiction comorbidity. Clinical services were organized into interdisciplinary continuity-of-care teams that follow patients across different levels of care. The teams provide addiction treatment through "universally available" resources such as a partial hospital addiction rehabilitation module. Continuity of care remains within the team structure as clinicians follow patients throughout their rehabilitation course. Patient and staff satisfaction focus on improved accessibility of addiction services and continuity of care providers across time and levels of care. Overall inpatient utilization and recidivism decreased after model implementation.

Eating disorders co-morbidity in heroin addicts in MMT

Eating disorders co-morbidity in heroin addicts in MMT

Gambling co-morbidity in heroin addicts in MMT

Gambling co-morbidity in heroin addicts in MMT

Dual diagnosis of substance abuse in schizophrenia: prevalence and impact on outcomes

Comorbid substance abuse disorders have emerged as one of the greatest obstacles to the effective treatment of persons with schizophrenia. Estimates of the prevalence of such comorbidity vary, but as many as half of persons with schizophrenia may suffer from a comorbid drug or alcohol disorder. Younger age, male gender, and lower educational attainment are associated with greater risk for addiction. Persons with schizophrenia and comorbid addiction tend to have an earlier onset of schizophrenia than do those without comorbid addiction. Research does not support a link between specific symptoms of schizophrenia and choice of abused drugs. Rather, drug choice is correlated with the pattern of ambient drug use in the community. Comorbid substance disorders are associated with a variety of poorer outcomes, including increased psychotic symptoms, poorer treatment compliance, violence, housing instability and homelessness, medical problems (including human immunodeficiency virus infection), poor money management, and greater use of crisis-oriented services that result in higher costs of care. Considerable progress has been made over the past decade in understanding the need to integrate substance abuse treatment and mental health treatment to provide more effective care for this population.

Diagnosis and Treatment of Psychiatric Comorbidity in Alcoholics and Drug Addicts

Diagnosis and Treatment of Psychiatric Comorbidity in Alcoholics and Drug Addicts

Prevalence of psychiatric disorders in opiate dependent patients in contact with the drug treatment system

In the course of a 5-year follow-up study concerning comorbidity in opiate addicts, 350 patients were investigated initially in various addiction centres in Hamburg. More than two thirds of the participants of the study are male, with an average age of 29 years at the time of the investigation. Most of them are receiving methadone maintenance treatment (42%), about one fourth is in residential rehabilitation and another 17% in inpatient detoxification treatment. The patients have been consuming heroin for an average of 9 years. For 55% of the opiate addicts (at least) one more psychic disorder in accordance with ICD-10 has been diagnosed (lifetime prevalence). F6 personality disorders have not been taken into consideration. The 6-month prevalence is 37%, 2-week prevalence 23%. For 43% of the opiate addicts, the predominant disorders belong to the group of neurotic, endurance, and somatoform disorders (F4), and for 32% of the patients to the group of affective disorders (F3). Schizophrenic, schizotypic and delusional disorders (F2) are less frequent (5%). Another 5% of the opiate addicts suffer from eating disorders (F5). These are partly multiple diagnoses cases; there is an average of 1.3 diagnoses per patient. Women are clearly more often affected by comorbidity than men. Most disorders first occur between the age of 18 and 21 years. Therefore, (lifetime) prevalence rates are twice to three times as high as that of the average German population, according to the present state of knowledge. This underlines the great importance of specific diagnostic and explorative methods for the treatment of addiction. Psychic disorders or disturbances that might adversely affect the course of treatment should be given more consideration.

The epidemiology of the comorbidity of psychiatric and addictive disorders: a critical review.

Assessing the prevalence of the comorbidity of psychiatric and addictive disease using epidemiologic methods results in artifactually high rates. Use of a clinical sample will yield falsely high rates, because substance use is associated with exacerbation of mental illness. Cross sectional design will inflate rates of psychiatric comorbidity in addicts, who attribute substance use to psychological symptoms until well into recovery. Application of exclusionary criteria for independent diagnosis is subject to investigator bias, particularly about the unproven yet popular "self-medication" hypothesis. The psychiatric symptoms which are common in active addiction generally clear within weeks to months of treatment for addiction but do not respond to standard psychopharmacologic treatment for primary mental illness. When lengthy follow up periods are employed, substance induced psychiatric syndromes typically resolve. We conclude that while patients treated in psychiatric settings often have comorbid and independent addictive illness, patients treated in addiction settings uncommonly have comorbid psychiatric illness despite common psychiatric symptoms.