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Heroin Addiction and Related Clinical Problems: 2025, 27, 32

Not bipolar but under-treated: How high-dose methadone rewrote the clinical narrative

Manuel Glauco Carbone, Giulia Gastaldello, Luca Mazzetto, Alessandro Bellini,
Roberta Rizzato, Rossella Miccichè, Beniamino Tripodi, Claudia Tagliarini,
Filippo Della Rocca, and Angelo Giovanni Icro Maremmani,

Digital Object Identifier:
https://doi.org/10.62401/2531-4122-2025-32

Summary: Background: Severe substance use disorders (SUDs) may generate complex psychopathology extending beyond craving, withdrawal, and relapse. In advanced addiction, neurobiological dysregulation can give rise to affective and psychotic-like symptoms that closely resemble bipolar disorder, complicating the distinction between primary mood pathology and substance-induced or addiction-driven bipolar-like presentations. This diagnostic uncertainty lies at the core of dual disorder. Methods: A clinical case is presented involving a 38-year-old man with severe opioid and alcohol use disorders, chronic emotional dysregulation, and recurrent manic-, hypomanic-, and mixed-like episodes temporally associated with fluctuations in substance use. His course was characterised by early-onset intravenous heroin use, polysubstance involvement, repeated hospitalisations, homelessness, and chronic hepatitis C with cirrhosis and hepatic encephalopathy. Despite extensive psychopharmacological interventions, affective instability and behavioural dyscontrol persisted while opioid agonist therapy remained suboptimally dosed. Results: The psychiatric symptom burden appeared partly attributable to the phenotypic expression of advanced addiction rather than to a distinct comorbid bipolar disorder. A turning point occurred after adopting an integrated dual-disorder framework with hierarchical prioritisation of SUD treatment. Gradual optimisation of methadone to 120 mg/day, within coordinated psychiatric–addiction care, was followed by marked reductions in heroin use, decreased alcohol consumption, improved affective stability, and cessation of emergency department visits and psychiatric admissions. Conclusions: This case underscores the importance of hierarchical SUD stabilisation and integrated, longitudinal care in the assessment and management of complex dual disorder, particularly when addiction mimics bipolarity.

Keywords: Dual Disorder; Bipolar Disorder; Addiction; Addiction-Related; Psychopathology; Methadone Maintenance Therapy; Integrated Hierarchical Treatment.