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Ruggiero E, Pambuku A, Caccese M, Lombardi G, Gallio I, Brunello A, Ceccato F, Formaglio F. Case report: The lesson from opioid withdrawal symptoms mimicking paraganglioma recurrence during opioid deprescribing in cancer pain. FRONTIERS IN PAIN RESEARCH 2023; 4:1256809. [PMID: 37810433 PMCID: PMC10556467 DOI: 10.3389/fpain.2023.1256809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/11/2023] [Indexed: 10/10/2023] Open
Abstract
Pain is one of the predominant and troublesome symptoms that burden cancer patients during their whole disease trajectory: adequate pain management is a fundamental component of cancer care. Opioid are the cornerstone of cancer pain relief therapy and their skillful management must be owned by physicians approaching cancer pain patients. In light of the increased survival of cancer patients due to advances in therapy, deprescription should be considered as a part of the opioid prescribing regime, from therapy initiation, dose titration, and changing or adding drugs, to switching or ceasing. In clinical practice, opioid tapering after pain remission could be challenging due to withdrawal symptoms' onset. Animal models and observations in patients with opioid addiction suggested that somatic and motivational symptoms accompanying opioid withdrawal are secondary to the activation of stress-related process (mainly cortisol and catecholamines mediated). In this narrative review, we highlight how the lack of validated guidelines and tools for cancer patients can lead to a lower diagnostic awareness of opioid-related disorders, increasing the risk of developing withdrawal symptoms. We also described an experience-based approach to opioid withdrawal, starting from a case-report of a symptomatic patient with a history of metastatic pheochromocytoma-paraganglioma.
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Affiliation(s)
- Elena Ruggiero
- Pain Therapy and Palliative Care with Hospice Unit, Veneto Institute of Oncology IOV—IRCCS, Padua, Italy
| | - Ardi Pambuku
- Pain Therapy and Palliative Care with Hospice Unit, Veneto Institute of Oncology IOV—IRCCS, Padua, Italy
| | - Mario Caccese
- Department of Oncology, Oncology Unit 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Giuseppe Lombardi
- Department of Oncology, Oncology Unit 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Ivan Gallio
- Pain Therapy and Palliative Care with Hospice Unit, Veneto Institute of Oncology IOV—IRCCS, Padua, Italy
| | - Antonella Brunello
- Department of Oncology, Oncology Unit 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Filippo Ceccato
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Fabio Formaglio
- Pain Therapy and Palliative Care with Hospice Unit, Veneto Institute of Oncology IOV—IRCCS, Padua, Italy
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Wemm SE, Sinha R. Drug-induced stress responses and addiction risk and relapse. Neurobiol Stress 2019; 10:100148. [PMID: 30937354 PMCID: PMC6430516 DOI: 10.1016/j.ynstr.2019.100148] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 12/07/2018] [Accepted: 01/30/2019] [Indexed: 12/21/2022] Open
Abstract
A number of studies have assessed the effects of psychoactive drugs on stress biology, the neuroadaptations resulting from chronic drug use on stress biology, and their effects on addiction risk and relapse. This review mainly covers human research on the acute effects of different drugs of abuse (i.e., nicotine, cannabis, psychostimulants, alcohol, and opioids) on the hypothalamic-pituitary-adrenal (HPA) axis and the autonomic nervous system (ANS) responses. We review the literature on acute peripheral stress responses in naïve or light recreational users and binge/heavy or chronic drug users. We also discuss evidence of alterations in tonic levels, or tolerance, in the latter relative to the former and associated changes in the phasic stress responses. We discuss the impact of the stress system tolerance in heavy users on their response to drug- and stress-related cue responses and craving as compared to control subjects. A summary is provided of the effects of glucocorticoid responses and their adaptations on brain striatal and prefrontal cortices involved in the regulation of drug seeking and relapse risk. Finally, we summarize important considerations, including individual difference factors such as gender, co-occurring drug use, early trauma and adversity and drug use history and variation in methodologies, that may further influence the effects of these drugs on stress biology.
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Affiliation(s)
- Stephanie E. Wemm
- Yale Stress Center, Yale School of Medicine, 2 Church St South Suite 209, New Haven, CT, 06519, USA
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Maremmani AGI, Pallucchini A, Rovai L, Bacciardi S, Spera V, Maiello M, Perugi G, Maremmani I. The long-term outcome of patients with heroin use disorder/dual disorder (chronic psychosis) after admission to enhanced methadone maintenance. Ann Gen Psychiatry 2018; 17:14. [PMID: 29692860 PMCID: PMC5905164 DOI: 10.1186/s12991-018-0185-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 04/09/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Over-standard methadone doses are generally needed in the treatment of heroin use disorder (HUD) patients that display concomitant high-severity psychopathological symptomatology. A flexible dosing regimen may lead to higher retention rates in dual disorder (DD), as we demonstrated in bipolar 1 HUD patients, leading to outcomes that are as satisfactory as those of HUD patients without high-severity psychopathological symptomatology. OBJECTIVE This study aimed to compare the long-term outcomes of treatment-resistant chronic psychosis HUD patients (PSY-HUD) with those of peers without dual disorder (HUD). METHODS 85 HUD patients who also met the criteria for treatment resistance-25 of them affected by chronic psychosis and 60 without DD-were monitored prospectively for up to 8 years while continuing to receive enhanced methadone maintenance treatment. RESULTS The rates of endurance in the treatment of PSY-HUD patients were 36%, compared with 34% for HUD patients (p = 0.872). After 3 years of treatment, these rates tended to become progressively more stable. PSY-HUD patients showed better outcome results than HUD patients regarding CGI severity (p < 0.001) and DSM-IV-GAF (p < 0.001). No differences were found regarding good toxicological outcomes or the methadone dosages used to achieve stabilization. The time required to stabilize PSY-HUD patients was shorter (p = 0.034). CONCLUSIONS An enhanced methadone maintenance treatment seems to be equally effective in patients with PSY-HUD and those with HUD.
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Affiliation(s)
- Angelo G I Maremmani
- Department of Psychiatry, North-Western Tuscany Local Health Unit, Versilian Zone, Viareggio, Italy.,AU-CNS, Association for the Application of Neuroscientific Knowledge to Social Aims, Pietrasanta, Lucca, Italy.,G. De Lisio Institute of Behavioural Sciences, Pisa, Italy
| | | | - Luca Rovai
- Department of Psychiatry, North-Western Tuscany Local Health Unit, Apuan Zone, Massa, Italy
| | | | | | - Marco Maiello
- 4School of Psychiatry, University of Pisa, Pisa, Italy
| | - Giulio Perugi
- 6Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Icro Maremmani
- AU-CNS, Association for the Application of Neuroscientific Knowledge to Social Aims, Pietrasanta, Lucca, Italy.,G. De Lisio Institute of Behavioural Sciences, Pisa, Italy.,7Vincent P. Dole Dual Diagnosis Unit, Department of Specialty Medicine, Santa Chiara University Hospital, University of Pisa, Pisa, Italy
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Fan HY, Sun L, Li XX, Zhou SB, Liang JC, Yan BY, Li Y, Deng YP. Effects of Jitai tablet, a traditional Chinese medicine, on plasma adrenocorticotropic hormone and cortisol levels in heroin addicts during abstinence. J Altern Complement Med 2014; 20:527-34. [PMID: 24786196 DOI: 10.1089/acm.2012.0804] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To investigate the changes in adrenocorticotropic hormone (ACTH) and cortisol in heroin addicts given Jitai tablet treatment during abstinence. DESIGN Double-blind, randomized, placebo-controlled clinical trial. SETTINGS/LOCATION Drug Rehabilitation Bureau of Shanghai Police, China. PARTICIPANTS 99 volunteers, including 69 heroin addicts and 30 healthy volunteers. INTERVENTIONS 69 heroin addicts randomly divided into two groups: the Jitai tablet group, which comprised 34 heroin addicts given Jitai tablet treatment during abstinence, and the placebo group, which comprised 35 heroin addicts given placebo. A control group consisted of 30 sex- and age-matched healthy volunteers. OUTCOME MEASURES ACTH and cortisol in plasma were measured in all groups at baseline and in the Jitai tablet and placebo groups on the third, seventh, and 14th days of abstinence. RESULTS Levels of both ACTH (p<.01) and cortisol (p<.001) were significantly higher in heroin addicts at baseline than in the healthy volunteers. Jitai tablet treatment restored plasma cortisol levels to normal more rapidly than did placebo treatment (p<.05), but not ACTH levels. A positive correlation between ACTH and cortisol values at baseline (p<.01) was also found with withdrawal symptom scores and daily dosages of heroin. CONCLUSIONS Heroin addicts could respond to Jitai tablets through changes in the hypothalamus-pituitary-adrenal axis.
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Affiliation(s)
- Hua-ying Fan
- 1 Department of Clinical Pharmacology, National Institute on Drug Dependence, Peking University , Beijing, China
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Shi J, Li SX, Zhang XL, Wang X, Le Foll B, Zhang XY, Kosten TR, Lu L. Time-dependent neuroendocrine alterations and drug craving during the first month of abstinence in heroin addicts. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2010; 35:267-72. [PMID: 19591065 DOI: 10.1080/00952990902933878] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
RATIONALE Heroin use and withdrawal cause abnormality in the endocrine system. However, the time course of neuroendocrine alterations in heroin addicts during pharmacologically unassisted withdrawal is still unclear. OBJECTIVES To investigate alterations in cortisol, adrenocorticotrophic hormone (ACTH), beta-endorphin (beta-EP), leptin, and neuropeptide Y (NPY) during the first month of abstinence in heroin addicts. METHODS Twelve heroin addicts and eight matched healthy control subjects were recruited for this study. The neuroendocrine alterations and self-reported heroin craving, anxiety, and depression in heroin addicts were assessed at different time points (days 3, 10, and 30) of first month of abstinence from heroin use. RESULTS Self-reported heroin craving, anxiety, and depression in heroin addicts decreased gradually during the first month of abstinence. The cortisol levels increased from abstinence day 3 to 30, while ACTH and beta-EP levels decreased over this period in heroin addicts. The leptin and NPY levels were significantly decreased on days 3 and 10 but had normalized on day 30 of abstinence. A positive correlation between cortisol level and heroin craving, anxiety, and depression was observed, while a negative correlation was observed between beta-EP level and craving and anxiety and between leptin and depression and NPY and anxiety. CONCLUSIONS Abnormal alterations in the neuroendocrine system, including levels of cortisol, ACTH and beta-EP persist throughout the first month of abstinence. These results suggest that neuroendocrine system dysfunctions in heroin abusers is independent of the acute and protracted withdrawal syndromes, and may thus contribute to relapse to heroin use.
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Affiliation(s)
- Jie Shi
- National Institute on Drug Dependence, Peking University, Beijing, China.
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Iwahashi K, Aoki J. A review of smoking behavior and smokers evidence (chemical modification, inducing nicotine metabolism, and individual variations by genotype: dopaminergic function and personality traits). Drug Chem Toxicol 2010; 32:301-6. [PMID: 19793020 DOI: 10.1080/01480540903203976] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The nicotine metabolism of CYP2A6 (CYP2A6*1A,*1B, and *1C), and the cholecystokinin (CCK; which modulates the release of dopamine) and CCK-A receptor gene and personality traits for NEO-FFI, was investigated for the mechanism for elucidation of the smoking behavior in Japanese populations. The frequency of the CYP2A6*4C allele, which is a whole deleted allele of the human CYP2A6 gene, was higher, whereas that of CYP2A6*1A/*1B heterozygotes with higher nicotine metabolism activity was lower in nonsmokers than in smokers. There was also a significant difference between the current smoking and nonsmoking groups in the allele frequency of the CCK -45C/T polymorphism. It was also shown that the Openness (O) factor for smokers was significantly higher than that of nonsmokers; however, there were no significant differences in the Neuroticism (N), Extraversion (E), Agreeable (A), and Conscientiousness (C) scores among smokers than nonsmokers. It was suggested that the CYP2A6*4C allele may prevent the carrier from smoking, and being a CYP2A6*1A/*1B heterozygote and the CCK T allele may be risk factors for developing smoking behavior. Also, it is possible that persons with a low score in Openness may be refraining from smoking because they have a general negative impression toward smoking.
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Affiliation(s)
- Kazuhiko Iwahashi
- Graduate School of Azabu University/Health Administration Center, Kanagawa, Japan.
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Arnold-Reed DE, O'Neil P, Holman CDJ, Bulsara MK, Rodiguez C, Gawthorne G, Tait RJ, Hulse GK. A Comparison of Mental Health Hospital Admissions in a Cohort of Heroin Users Prior to and After Rapid Opiate Detoxification and Oral Naltrexone Maintenance. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2009; 33:655-64. [PMID: 17891658 DOI: 10.1080/00952990701522666] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Mental health (MH) hospital admissions were investigated in a cohort (N=1184) of heroin dependent persons using linked health records. All MH in-patient admissions were extracted 36 months before to 36 months after commencing rapid opioid detoxification (ROD) and oral naltrexone. Results show that the incidence rate ratio (IRR) of drug-related and other MH admissions peaked in the 3 months immediately prior to treatment. All categories subsequently declined to baseline levels by 36 months following treatment. The authors conclude that treatment for heroin dependence reduces risk of MH admissions.
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Affiliation(s)
- D E Arnold-Reed
- School of Psychiatry and Clinical Neurosciences, University of Western Australia, Crawley, Western Australia
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Effects of olanzapine on aggressiveness in heroin dependent patients. Prog Neuropsychopharmacol Biol Psychiatry 2006; 30:1291-8. [PMID: 16766110 DOI: 10.1016/j.pnpbp.2006.04.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2006] [Revised: 03/27/2006] [Accepted: 04/20/2006] [Indexed: 11/20/2022]
Abstract
This study compared the anti-aggressiveness effects of the atypical anti-psychotic olanzapine with that of selective serotonin reuptake inhibitors (SSRI) and benzodiazepines (BZD) among patients with heroin dependence submitted to opioid-agonists substitution treatment. Sixty-seven (67) patients who met the DSM-IV criteria for heroin dependence and showed aggressive personality traits, not affected by comorbid schizophrenia or bipolar disorder, accepted to participate in a 12-week prospective, observational trial. Patients were included into two subgroups in relationship with treatment, for the evaluation of the endpoints at week 12: group 1: substitution treatment in combination with OLA (32 patients); group 2: substitution treatment in combination with fluoxetine/paroxetine and clonazepam (35 patients). Efficacy measures were Buss Durkee Hostility Inventory (BDHI), Symptoms Check List-90 (SCL 90) anger--hostility scores, incidence rates of aggressive incidents and attacks. The rates of patients who remained in treatment at week 12 in group 1, treated with OLA, and group 2, treated with SSRI and BDZ, were not significantly different (17 = 53.1% vs 16 = 45.7%). BDHI total, direct aggressiveness, verbal aggressiveness scores, SCL 90 aggressiveness scores and aggressive incidents rates showed a significantly more consistent decrease from baseline in group 1 than in group 2 subjects, in the patients who completed the treatment (p < 0.001; p < 0.01; p < 0.05; p < 0.01; p < 0.001). Among the completers, 69.3% achieved early full substance abuse remission, while 30.7% achieved partial substance abuse remission, with no significant difference between 1 and 2 treatment subgroups. Although obtained by an observational--open clinical study, with multiple limitations, our findings suggest that OLA may be useful as an adjunctive agent in reducing aggressive/hostile behaviour in heroin addicted individuals during maintenance substitution treatment. Otherwise, atypical anti-psychotic OLA seems to be unable to improve the outcome in terms of addictive behavior and relapse risk in the addicted patients not affected by overt psychotic disorders.
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Rapeli P, Kivisaari R, Autti T, Kähkönen S, Puuskari V, Jokela O, Kalska H. Cognitive function during early abstinence from opioid dependence: a comparison to age, gender, and verbal intelligence matched controls. BMC Psychiatry 2006; 6:9. [PMID: 16504127 PMCID: PMC1489929 DOI: 10.1186/1471-244x-6-9] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2005] [Accepted: 02/24/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Individuals with opioid dependence have cognitive deficits during abuse period in attention, working memory, episodic memory, and executive function. After protracted abstinence consistent cognitive deficit has been found only in executive function. However, few studies have explored cognitive function during first weeks of abstinence. The purpose of this study was to study cognitive function of individuals with opioid dependence during early abstinence. It was hypothesized that cognitive deficits are pronounced immediately after peak withdrawal symptoms have passed and then partially recover. METHODS Fifteen patients with opioid dependence and fifteen controls matched for, age, gender, and verbal intelligence were tested with a cognitive test battery When patients performed worse than controls correlations between cognitive performance and days of withdrawal, duration of opioid abuse, duration of any substance abuse, or opioid withdrawal symptom inventory score (Short Opiate Withdrawal Scale) were analyzed. RESULTS Early abstinent opioid dependent patients performed statistically significantly worse than controls in tests measuring complex working memory, executive function, and fluid intelligence. Their complex working memory and fluid intelligence performances correlated statistically significantly with days of withdrawal. CONCLUSION The results indicate a rather general neurocognitive deficit in higher order cognition. It is suggested that cognitive deficit during early abstinence from opioid dependence is related to withdrawal induced neural dysregulation in the prefrontal cortex and is partly transient.
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Affiliation(s)
- Pekka Rapeli
- Psychiatric unit for drug dependence, Department of Psychiatry, Helsinki University Central Hospital, Finland
- Unit on Prevention and Treatment of Addictions, Department of Mental Health and Alcohol Research, National Public Health Institute, Finland
- Department of Psychology, University of Helsinki, Finland
| | - Reetta Kivisaari
- Medical Imaging Center, Helsinki University Central Hospital, Finland
| | - Taina Autti
- Medical Imaging Center, Helsinki University Central Hospital, Finland
| | - Seppo Kähkönen
- BioMag Laboratory, Engineering Center, Helsinki University Central Hospital, Finland
- Cognitive Brain Research Unit, University of Helsinki, Finland
| | - Varpu Puuskari
- Department of Psychiatry, Helsinki University Central Hospital, Finland
| | - Olga Jokela
- Psychiatric unit for drug dependence, Department of Psychiatry, Helsinki University Central Hospital, Finland
| | - Hely Kalska
- Department of Psychology, University of Helsinki, Finland
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Abstract
The relationship between nicotine metabolism of CYP2A6 and the smoking behavior in a Japanese population was investigated. The CYP2A6 genotypes were determined by the PCR method. There was a significant difference in the frequency of the CYP2A6AST;4C allele, which is a whole deleted allele for the human CYP2A6 gene, between smokers and nonsmokers. The frequency of the CYP2A6AST;4C allele was higher in nonsmokers than in smokers, whereas the frequency of CYP2A6AST;1A/AST;1B heterozygotes with a higher activity of nicotine metabolism was lower. In this study it was suggested that the CYP2A6AST;4C allele may prevent the carrier from smoking and the CYP2A6AST;1A/AST;1B heterozygote may be at risk for developing smoking behavior.
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Affiliation(s)
- Kazuhiko Iwahashi
- Department of Neurophysiology, Graduate School of Azabu University, Sagamihara, Japan.
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