What we have learned from the Methadone Maintenance Treatment of Dual Disorder Heroin Use Disorder patients

Major Depression in Comorbidity with Substance use Disorders: Patients' Features and Clinical-Neurobiological Rationale of Antidepressant Treatments

The frequent co-occurrence of major depressive disorder (MDD) and substance use disorders (SUDs) entails significant clinical challenges. Compared to patients with MDD alone, patients with MDD and SUD often show increased anhedonia, emotional blunting, and impaired cognitive function. These symptoms lead to an inability to control cravings, more substance use, increased relapse rates, and poor adherence to the treatment. This fosters a detrimental cycle leading to more severe depressive symptoms, functional impairment, and chronicity, culminating in heightened morbidity, mortality, and healthcare resource utilization. Data on antidepressant treatment of MDD-SUD patients are inconclusive and often conflicting because of a number of confounding factors in clinical trials or difficulty in dissecting the specific contributions of pharmacological versus psychological interventions in real-world studies. The patient's unique clinical features and specific SUD and MDD subtypes must be considered when choosing treatments. Ideally, drug treatment for MDD-SUD should act on both conditions and address core symptoms such as anhedonia, craving, and cognitive dysfunction while ensuring minimal emotional blunting, absence of drug interactions, and no addictive potential. This approach aims to address unmet needs and optimize the outcomes in a clinical population often underrepresented in treatment paradigms.

The Future is Now for Precision Genomic Addiction Medicine as a Frontline Modality for Inducing "Dopamine Homeostasis" in Reward Deficiency Syndrome (RDS)

INTRODUCTION

In this genomic era of addiction medicine, ideal treatment planning begins with genetic screening to determine neurogenetic antecedents of the Reward Deficiency Syndrome (RDS) phenotype. Patients suffering from endotype addictions, both substance and behavioral, and other mental health/comorbid disorders that share the neurobiological commonality of dopamine dysfunction, are ideal candidates for RDS solutions that facilitate dopamine homeostasis, addressing the cause, rather than symptoms.

OBJECTIVE

Our goal is to promote the interplay of molecular biology and recovery as well as provide evidence linked to RDS and its scientific basis to primary care physicians and others.

METHODS

This was an observational case study with a retrospective chart review in which an RDS treatment plan that utilized Genetic Addiction Risk Severity (GARS) analysis to evaluate neurogenetic challenges was used in order to develop appropriate short- and long-term pharmaceutical and nutraceutical interventions.

RESULTS

A Substance Use Disorder (SUD) treatment-resistant patient was successfully treated utilizing the GARS test and RDS science.

CONCLUSION

The RDS Solution Focused Brief Therapy (RDS-SFBT) and the RDS Severity of Symptoms Scale (SOS) may provide clinicians with a useful tool for establishing neurological balance and helping patients to achieve self-efficacy, self-actualization, and prosperity.

Principal component regression analysis of familial psychiatric histories and suicide risk factors among adults with opioid use disorder

This study explores familial psychiatric risk factors that are closely linked to suicide risk among patients with opioid use disorder (OUD) as measured by the Family History Assessment Module (FHAM). Data was derived from adults diagnosed with OUD (N = 389). To analyze the covariance between the 11 items of the FHAM, principal component analysis was applied to infer principal components (PC) scores. Log-binominal regression was conducted to quantify the associations between PC scores and mental health symptoms (e.g., lifetime suicidal attempt, P30D suicidal ideation, depression, and anxiety). Analyses revealed that the first 3 three PCs could account for 56% of the total variance of the FHAM items within the data. Family history of substance misuse (PC1) was positively associated with lifetime suicide attempts and severe anxiety. Family history of serious mental illness (PC2) and of suicidal behavior (PC3) were not significantly associated with any outcomes. Our findings suggest current suicide risk is associated with an array of familial psychiatric issues among people with OUD. However, family history of suicide attempts and death by suicide has less bearing on current suicide risk in OUD patients whereas family history of substance use confers significant risk. Findings underscore suicide-related preventive interventions as necessary components of treatment plans among people with OUD, who commonly report family histories of substance misuse.

Prevalence of mental disorders among people with opioid use disorder: A systematic review and meta-analysis

BACKGROUND

Opioid use disorder (OUD) and mental disorders are major public health issues and comorbidity is common. Among people with OUD, comorbid mental disorders are associated with poorer health outcomes. To our knowledge, this is the first systematic review and meta-analysis to estimate prevalence of specific mental disorders among people with OUD.

METHODS

We searched Embase, MEDLINE, and PsycInfo from 1990 to 2021 for observational studies of depression, anxiety, post-traumatic stress disorder (PTSD), bipolar, personality, and other pre-specified mental disorders among people with OUD. We pooled current and lifetime estimates of each disorder using random-effects meta-analyses with 95% Confidence Intervals (CIs). Meta-regressions and stratified analyses were used to assess heterogeneity of prevalence estimates by methodological factors and sample characteristics.

FINDINGS

Of the 36,971 publications identified, we included data from 345 studies and 104,135 people with OUD in at least one pooled estimate. Among people with OUD, the prevalence of current depression was 36.1% (95%CI 32.4-39.7%), anxiety was 29.1% (95%CI 24.0-33.3%), attention-deficit/hyperactivity disorder was 20.9% (95%CI 15.7-26.2%), PTSD was 18.1% (95%CI 15.4-20.9%), and bipolar disorder was 8.7% (95%CI 6.7-10.7%). Lifetime prevalence of anti-social personality disorder was 33.6% (95%CI 29.1-38.0%) and borderline personality disorder was 18.2% (95% CI 13.4-23.1%). Sample characteristics and methodological factors, including sex, were associated with variance of multiple prevalence estimates.

INTERPRETATION

Our findings emphasise the need for access to mental disorder treatment among people with OUD. Specific mental disorder estimates may inform clinical guidelines, treatment services, and future research for people with OUD, including subpopulations with distinct treatment needs.

How do people who use drugs receiving Opioid Medication Therapy perceive their treatment ? A multicentre study

Background

The resurgence of heroin use and the misuse of pharmaceutical opioids are some of the reasons for a worldwide increase in opioid dependence. Opioid Medication Therapies (OMT) have amply demonstrated their efficacy. From a medical point of view, the main objectives of OMT concern medical and social outcomes, centred on risk reduction and the cessation of opioid use. But patient points of view can differ and few studies have explored opioid-dependent patient viewpoints on their OMT. This variable seems important to consider in a patient-centred approach. The aim of our study was to explore points of view of people who use drugs (PWUD) treated with OMT, in a large multicentre sample.

Method

A cross-sectional multicentre study explored the points of view of PWUD with Opioid Use Disorder following OMT. Data regarding the patients’ points of view were collected using a self-administered questionnaire developed by the scientific committee of the study. A descriptive analysis and an exploratory factor analysis were performed to explore the structure of items exploring patient viewpoints.

Results

263 opioid dependent PWUD were included, a majority were men consuming heroin prior to being prescribed OMT. 68% were on methadone, 32% were on buprenorphine. Most PWUD identified a positive impact on their lives, with 92.8% agreeing or strongly agreeing that OMT had changed a lot of things in their lives. The exploratory factor analysis identified three factors: (F1) items related to points of views concerning the objectives and efficacy of OMT; (F2) items related to the legitimacy of OMT as a treatment compared to a drug, (F3) items related to experiences and relationships with OMT.

Conclusion

Patient viewpoints on efficacy were correlated with the pharmacological benefits of OMT and with the associated psychosocial measures. The implications of OMT in relationships, such as the feeling of being judged, concerned a majority. Points of view were ambivalent concerning the role of OMT as a treatment or as a drug. Involving patient points of view in therapeutic strategies decisions could help enhance positive views among PWUD on OMT and help PWUD towards their recovery.

Trial registration: OPAL study was registered: (NCT01847729).

Hypothesizing in the Face of the Opioid Crisis Coupling Genetic Addiction Risk Severity (GARS) Testing with Electrotherapeutic Nonopioid Modalities Such as H-Wave Could Attenuate Both Pain and Hedonic Addictive Behaviors

In the United States, amid the opioid overdose epidemic, nonaddicting/nonpharmacological proven strategies are available to treat pain and manage chronic pain effectively without opioids. Evidence supporting the long-term use of opioids for pain is lacking, as is the will to alter the drug-embracing culture in American chronic pain management. Some pain clinicians seem to prefer classical analgesic agents that promote unwanted tolerance to analgesics and subsequent biological induction of the "addictive brain". Reward genes play a vital part in modulation of nociception and adaptations in the dopaminergic circuitry. They may affect various sensory and affective components of the chronic pain syndromes. The Genetic Addiction Risk Severity (GARS) test coupled with the H-Wave at entry in pain clinics could attenuate pain and help prevent addiction. The GARS test results identify high-risk for both drug and alcohol, and H-Wave can be initiated to treat pain instead of opioids. The utilization of H-Wave to aid in pain reduction and mitigation of hedonic addictive behaviors is recommended, notwithstanding required randomized control studies. This frontline approach would reduce the possibility of long-term neurobiological deficits and fatalities associated with potent opioid analgesics.

Comparing Sexual Function between Opioid Dependents Consuming Methadone or Opium Tincture

Objective: Sexual dysfunction is a side effect of methadone maintenance therapy (MMT). Opium Tincture (OT) has been used as a maintenance treatment. This study aimed to determine and compare the trend of sexual function and its related factors during treatment with both drugs. Method : An observational study was designed to measure the blood tests including free and total testosterone, prolactin, and sex hormone-binding globulin and a battery of questionnaires, including demographics and drug use history, in 42 and 53 patients entering MMT and OT treatment before and 1 and 3 months after the treatment. Results: Significant changes in testosterone levels were observed in the MMT but not the OT group. The difference between the two groups was not significant. Neither between nor within changes in the sexual function and premature ejaculation scores were significant (P =0.370& 0.698). Anxiety levels were significantly different (P= 0.001) within and between groups. There was a considerable difference in the trend of depression changes in the OT group, but not different in MMT group and between the two groups. Conclusion: No difference was found between MMT and OT effects on sexual function variables. The decrease in Testosterone during the three months of MMT, was not associated with diminished sexual function. In the MMT group, anxiety levels diminished during treatment. It seems that decreased testosterone in the MMT group was compensated by improved anxiety. Gonadotropin levels may not be the sole determinant in sexual activity, and complex interaction of mood and anxiety, agonist levels, and gonadotropins are involved.

Effects of opioid rotation to buprenorphine/naloxone on pain, pain thresholds, pain tolerance, and quality of life in patients with chronic pain and opioid use disorder

ABSTRACT

Long-term opioid use in patients with chronic noncancer pain (CNCP) can lead to opioid use disorder (OUD) and has been associated with hyperalgesia and reduced quality of life (QoL). Studies suggest antihyperalgesic properties of buprenorphine, and buprenorphine or naloxone (BuNa) has shown beneficial effects on QoL in patients with OUD without CNCP. This study investigated the added value of BuNa in patients with CNCP with OUD on self-reported pain, pain thresholds, pain tolerance, and QoL. In the current study, 43 outpatients with CNCP and OUD were included for inpatient conversion from full μ-receptor agonist opioids to BuNa. Self-reported pain, pain thresholds, pain tolerance, and QoL were determined at baseline and after 2 months of follow-up, using, respectively, a Visual Analogue Scale (VAS-pain and VAS-QoL), quantitative sensory testing, and EuroQol-5 dimensions. In total, 37 participants completed the protocol, and their data were analyzed. The mean VAS-pain score decreased from 51.3 to 37.2 (27.5%, F = 3.3; P = 0.044), whereas the pressure pain threshold and electric pain threshold or tolerance increased after substitution (F = 7.8; P = 0.005 and F = 44.5; P < 0.001, respectively), as well as QoL (EuroQol-5 dimensions questionnaire: F = 10.4; P = 0.003 and VAS-QoL: F = 4.4; P = 0.043). We found that conversion of full μ-receptor agonists to BuNa, in patients with CNCP with OUD, was accompanied with lower self-reported pain, higher pain thresholds, higher pain tolerance, and improved QoL. Despite several study limitations, these data suggest that BuNa might be of value in patients with CNCP with OUD. Future studies should investigate long-term effects of BuNa in randomized trials.

Depressive symptoms in early alcohol or opioid abstinence: course & correlates

BACKGROUND

Depressive symptoms are common during abstinence from psychoactive substances. Research caveats limit the study of persistence of significant depressive symptoms beyond four weeks of abstinence. This prospective study examined the course and correlates of depressive symptoms in patients with alcohol or opioid use disorder over 5-8 weeks.

METHODS

Sample consisted of 100 men randomly selected out of 307 inpatient men with either alcohol or opioid use disorder. Weekly assessments focused on depressive symptoms (HDRS, BDI), and their correlates (HAM-A for anxiety symptoms, CIWA-Ar and COWS for withdrawal symptoms, OCDS and OCDUS for craving for alcohol and opioids respectively). Other correlates assessed were severity of dependence and family support. PRISM (Psychiatric Research Interview for Substance and Mental disorders) was used for diagnosis of substance-induced depression and major depressive episode. Repeated measures ANOVA was used for weekly comparison of depressive symptoms.

RESULTS

Participants were dependent on opioids (56%), or alcohol (41%), or both (3%). Mean age was 33.5 years. Eighty-eight participants completed the study. Substance-induced depressive episode was diagnosed by PRISM in 59% participants. Weekly assessments of depressive symptoms recorded significant reductions (p < 0.0001; Wilk's Lambda for HDRS and BDI 137.01 and 105.4 respectively). Baseline depressive symptoms correlated significantly with anxiety, withdrawal symptoms, and negatively with social support. No participant was diagnosed with a major depressive episode at 6-8 weeks.

CONCLUSION

Depressive symptoms in early alcohol or opioid abstinence resolve significantly over a month; therefore, clinicians should exercise watchful waiting before starting antidepressant therapy.

Suicide Risk and Addiction: The Impact of Alcohol and Opioid Use Disorders

Purpose of Review

Suicide is a major public health concern and a leading cause of death in the US. Alcohol and opioid use disorders (AUD/OUD) significantly increase risk for suicidal ideation, attempts, and death, and are the two most frequently implicated substances in suicide risk. We provide a brief overview of shared risk factors and pathways in the pathogenesis of AUD/OUD and suicidal thoughts and behaviors. We also review clinical recommendations on inpatient care, pharmacotherapy, and psychotherapeutic interventions for people with AUD/OUD and co-occurring suicidal ideation and behavior.

Recent Findings

Among people with an underlying vulnerability to risk-taking and impulsive behaviors, chronic alcohol intoxication can increase maladaptive coping behaviors and hinder self-regulation, thereby increasing the risk of suicide. Additionally, chronic opioid use can result in neurobiological changes that lead to increases in negative affective states, jointly contributing to suicide risk and continued opioid use. Despite significantly elevated suicide risk in individuals with AUD/OUD, there is a dearth of research on pharmacological and psychosocial interventions for co-occurring AUD/OUD and suicidal ideation and behavior.

Summary

Further research is needed to understand the effects of alcohol and opioid use on suicide risk, as well as address notable gaps in the literature on psychosocial and pharmacological interventions to lower risk for suicide among individuals with AUD/OUD.

What Differs between Patients under Methadone and under Buprenorphine for Opioid Use Disorder (OUD) in Daily Clinical Practice in France? A Short Report

(1) Background: Opioid use disorder (OUD) is a complex condition that can require long-term treatment. Pharmacological therapy for OUD involves treatment with opioid agonists (OMT) tailored to individual profiles. The aim of our study in daily clinical practice was to compare the profiles of patients treated with methadone (MTD) and those using buprenorphine (BHD or BHD-naloxone-NX). (2) Methods: A cross-sectional multicentre study explored the psychological, somatic and social profiles of patients with Opioid Use Disorder (OUD) following Opioid Maintenance Treatment (BHD, BHD/NX, or MTD). Descriptive and comparative analyses were performed (3) Results: 257 patients were included, a majority were men using heroin. 68% (178) were on MTD, 32% (79) were on BHD. Patients with MTD were significantly more likely to report socio-affective damage, and more likely to be younger and not to report oral or sublingual use as the main route for heroin or non-medical opioids (4) Conclusions: In daily clinical practice, regarding OUD damage, only socio-affective damage was significantly more prevalent among patients on MTD than among those on BHD in the multivariate model. Age and route of administration also differed, and our results could raise the issue of the type of OMT prescribed in case of non-medical use of prescribed opioids. These hypothesis should be confirmed in larger studies.

Prescribing Buprenorphine for Opioid Use Disorders in the ED: A Review of Best Practices, Barriers, and Future Directions

ED-initiated addiction treatment holds promise for enhancing access to treatment for those with opioid use disorder (OUD). We present a literature review summarizing the evidence for buprenorphine induction in the ED including best practices for dosing, follow-up care, and reducing implementation barriers. A literature search of Pubmed, PsychInfo, and Embase identified articles studying OUD treatment in the ED published after 1980. Twenty-five studies were identified including eleven scientific abstracts. Multiple studies suggest that buprenorphine induction improves engagement in substance treatment up to 30 days after ED treatment. Many different induction protocols were presented, but no particular approach was best supported as criteria for induction and initial dosing vary widely. Similarly, transition of care models focused on either a "hub and spoke" model or "warm hand-offs" model, but no studies compared these approaches. Common barriers to implementing induction programs were provider inexperience, discomfort with addiction treatment, and limited time during the ED visit. No studies described the number of EDs offering induction. While ED buprenorphine induction is safe and enhances adherence to addiction treatment, uncertainty persists in how to best identify patients needing treatment, how to initiate buprenorphine, and how to enhance follow-up after ED-initiated treatment.

Potentially addictive drugs dispensing to patients receiving opioid agonist therapy: a register-based prospective cohort study in Norway and Sweden from 2015 to 2017

OBJECTIVES

To compare the use of benzodiazepines, z-hypnotics, gabapentinoids, opioids and centrally acting stimulants (CAS) among patients who had received opioid agonist therapy (OAT) in Norway and Sweden during the period 2015 - 2017.

DESIGN

A register-based prospective cohort study using information about dispensed drugs from the Norwegian Prescription Database and Swedish Prescribed Drug Register.

SETTING

Patients who were dispensed OAT opioids from pharmacies.

PARTICIPANTS

A total of 7176 Norwegian and 3591 Swedish patients on OAT were included.

OUTCOME MEASURES

The number and frequency of potentially addictive drugs dispensed were calculated for the two countries. The mean daily doses of dispensed benzodiazepines and z-hypnotics were summarised by calculating benzodiazepines in diazepam equivalents and z-hypnotics in zopiclone equivalents.

RESULTS

In 2017, 46% of patients in Norway, and 15% in Sweden, were dispensed a benzodiazepine. Moreover, 14% in Norway and 26% in Sweden received z-hypnotics. Gabapentinoids were dispensed to 10% of patients in Norway and 19% of patients in Sweden. In Norway, 6% and 12% of the patients received strong and weak non-OAT opioids, respectively, whereas in Sweden 10% were dispensed strong non-OAT opioids and 5% weak non-OAT opioids . CAS were dispensed to 4% in Norway and 18% in Sweden. The mean daily doses of benzodiazepines were 16 and 17 mg diazepam equivalents in Norway and Sweden, respectively. For z-hypnotics, the mean daily dose was 8 mg zopiclone equivalents in both countries. 'Benzodiazepines and z-hypnotics' was the most dispensed drug combination in 2017. Similar results were found in 2015 and 2016.

CONCLUSIONS

Nearly half of those patients who were dispensed an OAT opioid in Norway and Sweden were dispensed potentially addictive drugs. The differences identified between Norway and Sweden might be related to differences in eligibility guidelines and restrictions with respect to OAT.

Methadone maintenance treatment and survival of schizophrenic patients with a lifetime comorbid substance use disorders: a long-term follow-up study

Background Methadone maintenance treatment (MMT) remains the most widely used effective therapeutic approach for opioid use disorders. However, there is paucity of empirical data regarding the relationship between the MMT and survival of subjects with schizophrenia. Aim The aim of this study was to examine the effect of MMT on the long-term survival of subjects with schizophrenia and a lifetime comorbid substance use disorders. Methods The charts of 277 consecutive subjects admitted in our center during a period from January 1, 2002 to February 1, 2007 were assessed. Psychiatric diagnoses have been established according to international classification of diseases and health related problems-10th edition (ICD-10). The risk of all-cause mortality was assessed by Cox proportional-hazards regression models, including time-dependent covariates. Results Out of MMT subjects, 31 (11.2%) had mental and behavioral disorders due to multiple psychoactive substance use, 5 (1.8%) had mental and behavioral disorders due to use of opioids. All of 13 (4.7%) subjects with opioid use disorders were treated. MMT has been found to be predictive of lower long-term survival, in time-independent (hazard ration [HR] = 1.88; 95%CI: 1.06-3.37; p<.05) and in time-dependent adjusted models (HR = 2.01; 95%CI: 1.21-3.60; p<.05). MMT daily dose of <120 mg (adjusted HR = 1.83; 95%CI: .95-3.54) and MMT daily dose of ≥120 mg (adjusted HR = 2.70; 95%CI: .97-7.54) were associated with less long-term survival, all compared with no lifetime MMT (p<.046). Conclusions Among subjects with schizophrenia and a lifetime comorbid substance use disorders, overall mortality was higher in those who received lifetime MMT, then in patients without MMT.

The therapeutic potential of exercise for neuropsychiatric diseases: A review

Exercise is known to have a myriad of health benefits. There is much to be learned from the effects of exercise and its potential for prevention, attenuation and treatment of multiple neuropsychiatric diseases and behavioral disorders. Furthermore, recent data and research on exercise benefits with respect to major health crises, such as, that of opioid and general substance use disorders, make it very important to better understand and review the mechanisms of exercise and how it could be utilized for effective treatments or adjunct treatments for these diseases. In addition, mechanisms, epigenetics and sex differences are examined and discussed in terms of future research implications.

Fear and anxiety managing methods during dental treatments: a systematic review of recent data

INTRODUCTION

The management of anxiety and fear of patients experiencing medical treatment is always a major issue. Dentistry is a branch of medicine that is daily in managing these problems, especially in the case of pediatric patients. Odontophobia can be managed in different ways, and the purpose of this study is to eventually review which methods are currently accepted and which are the most effective.

EVIDENCE ACQUISITION

The literature analysis was conducted on a number of articles, suitably skimmed, after a first research, obtained from the most common scientific databases. The number of works included in the review is 28.

EVIDENCE SYNTHESIS

From the RCTs evaluated we could highlight that there are different methods in the literature, equally effective and certainly conditioned by the systemic condition of the patient. Another chapter instead turns out to be that linked to the management of the syndromic patient.

CONCLUSIONS

It is clear that there are different methods and equally different ways to manage our patients in the event of non-cooperation in the case of dental care. In addition to proper management by the clinician, in the literature methods linked to audiovisual distractions, hypnosis or pharmacological methods that produce conscious sedation are effectively reported.

Conformations and interactions comparison between R- and S-methadone in wild type CYP2B6, 2D6 and 3A4

Methadone is a morphine-substitute drug in methadone maintenance treatment (MMT) program to treat patients with opioid dependency. However, the methadone clinical effects are depending on the methadone metabolism rates that vary among the patients with genetic polymorphism of cytochrome P450s (CYPs). Our previous study showed methadone has different binding affinity due to the polymorphisms in CYP2B6, CYP2D6 and CYP3A4 that could contribute to the methadone metabolism rate. In this work, the conformation and interactions of R- and S-methadone in wild type CYP2B6, CYP2D6 and CYP3A4 were further studied in order to understand behaviour of R- and S-methadone at the CYP binding site. Clustering analysis showed that the conformation of R- and S-methadone in CYP2B6 are most stable, thus could lead to a higher efficiency of methadone metabolism. The conformation fluctuation of methadone in CYP2D6 could due to relatively smaller binding pocket compared with CYP2B6 and CYP3A4. The binding sites volumes of the studied CYPs were also found to be increased upon the binding with methadone. Therefore, this might contributed to the interactions of both R- and S-methadone in CYPs were mainly by hydrophobic contacts, van der Waals and electrostatic interactions. In the future, should an inhibitor for CYP is to be designed to prolong the prolonged opioid effect, the inhibitor should cater for single CYP isozyme as this study observed the behavioural differences of methadone in CYP isozymes.

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