Published: Volume 01 • Issue 1 • June 1999 (pages: 9 - 12)

Title: Heroin Addiction as normal illness

Authors: Tagliamonte A.

Summary: History teaches us how difficult it is to challenge some axioms that are rooted in common culture, even when they are not supported by scientifically indisputable evidence. The two most famous examples of controversial scientific novelty were the Copernican theory and the theory of evolution. Do analogous mechanisms underlie the refusal of behaviour disorder, i.e. psychiatric disease or drug addiction, as a biological phenomenon? Man, it is said, was created by God in his own image and likeness, and God gave him a soul; according to this view, it must be the soul that is responsible for his behaviour. With increasing precision, modern psychobiology is succeeding in correlating specific aspects of animal and human behaviour with definite brain areas, and with the neurotransmitters that are located in them. Various behaviours have a clear genetic basis, but particular genes take part in organizing each behaviour; similarly, various neurotransmitters in specific brain areas interact, so causing a given form of behaviour. Psychiatric disturbances, including drug addiction, are leaving the limbo of approximation or even of utopianism, to enter into the scientific dimension of medical empiricism

Published: Volume 01 • Issue 1 • June 1999 (pages: 13 - 17)

Title: Methadone Maintenance. Comes of age

Authors: Dole V. P.

Summary: Methadone maintenance treatment in the United States is reaching maturity. During the past three decades it has progressed from an innocent childhood, through a turbulent adolescence, to recognition as an essential medical procedure. At present approximately 115,000 former heroin addicts in the United States are being treated in 750 clinics located in 40 of the 50 states. The treatment has survived challenge by professional sceptics, by ideologically hostile agencies, by competitive modalities, and even by well-intentioned clinicians in methadone programs who have prescribed inadequate doses of the medication

Published: Volume 01 • Issue 1 • June 1999 (pages: 19 - 34)

Title: Pharmacokinetics and pharmacogenetics of methadone: clinical relevance

Authors: Eap C. B., Deglon J. J., Baumann P.

Summary: Recent data on the pharmacokinetics and the pharmacogenetics of methadone, taking into account its enantiomers, have been collected. In particular, it has been demonstrated that isozymes belonging to the cytochrome P450 superfamily play a major role in the metabolism of methadone. During the past ten years, a large amount of informations has been collected on this enzymatic system. In particular it is now well known that these isozymes can be inhibited or can be induced by specific compounds. A large variability in the activities of these isozymes has been shown, a variability which is both genetically and environmentally controlled. These data allow us to explain and possibly avoid the majority of metabolic interactions involving methadone and to undestand the interindividual variability of methadone pharmacokinetics. This latter point is of major clinical relevance and stresses the importance of individualization of methadone treatment

Published: Volume 01 • Issue 1 • June 1999 (pages: 35 - 41)

Title: Integrating Methadone Treatment in the Slovenian Public Health System

Authors: Kastelic A., Kostnapfel-Rihtar T.

Summary: In this article on the quality of service in the methadone maintenance program the authors wished to determine whether the establishment of the network of centers for the prevention and treatment of dependence on illegal drugs enabled higher quality professional services in the execution of the methadone maintenance program, greater relevance in the program and more satisfaction on the part of those involved.

Published: Volume 01 • Issue 1 • June 1999 (pages: 42 - 42)

Title: Treatment of opiate dependency: A comment [Letter]

Authors: Vossenberg P.

Summary: Not Available

Published: Volume 01 • Issue 1 • June 1999 (pages: 43 - 44)

Title: Methadone as a mood stabilizer [Letter]

Authors: Pani P. P., Agus A., Gessa G. L.

Summary: Not available

Published: Volume 01 • Issue 1 • June 1999 (pages: 1 - 8)

Title: Treating Heroin Addicts i.e. 'Breaking through a Wall of Prejudices"

Authors: Maremmani I.

Summary: The medical, psychiatric, psychological and social manifestations of heroin addiction require more than an integrated intervention. To effectively treat addiction, rehabilitation and/or prevention is necessary but we must also treat the patients according to the phase of illness. In other words, it is often necessary to adapt the intervention to the clinical phase of illness, by trying to raise the programme “retention rate”. This condition is indispensable in the rehabilitative process. The nature of drug addiction will often make it necessary for patients to be contacted in the street, so that they can benefit from counselling and “harm reduction”. Finally, primary or secondary prevention cannot be separated from a global intervention philosophy.

Published: Volume 01 • Issue 2 • December 1999 (pages: 7 - 13)

Title: Alcohol, benzodiazepines and other drugs use in heroin addicts treated with methadone. Polyabuse or undermedication?

Authors: Maremmani I., Shinderman M. S.

Summary: The authors, on the basis of their clinical experience suggest that polydrug abuse in heroin addicts could be correlated with a condition of opiate dependence improperly compensated by street heroin or by substitutive treatment dosages. Thus the search for an appropriate methadone dosage is crucial not only because it enhances patient's retention rate within the treatment group, so allowing an improvement in social rehabilitation, but also because it reduces the risk of polydrug abuse.

Published: Volume 01 • Issue 2 • December 1999 (pages: 15 - 18)

Title: What tells us Switzerlands drug policy. Switzerland: drug policy of mountain dwellers?

Authors: Seidenberg A.

Summary: Switzerland's drug problems became notorious, when 'needlepark' Platspitz and heroin trials made international headlines. Its mass of drug addicts and the dilemma they caused shook Swiss society. An overwhelming majority of the Swiss voted to make it legal to treat drug addicts with heroin. Drugs have threatened the independence and the liberal foundations of the Swiss federation. Drug problems still threaten all that.

Published: Volume 01 • Issue 2 • December 1999 (pages: 19 - 26)

Title: Methadone Treatment and spread of AIDS in Europe in the 1987-1993 years

Authors: Reisinger M.

Summary: All the data currently available seem to indicate that the fact that the availability of methadone treatment was limited may one day be seen as an inexcusable error of judgement (much more serious than that committed in some countries with regard to haemophiliacs and transfusion recipients) which will cost the lives of hundreds of thousands of people and wreak havoc on the health care budgets of several European countries

Published: Volume 01 • Issue 2 • December 1999 (pages: 27 - 34)

Title: Adolescent Narcotism in Russia

Authors: Dineeva N. R.

Summary: Part I. In Russia, units of narcological dispensaries for adolescents are the basic organizational structure conducting treatment and prophylactic work with adolescents who consume alcohol, drugs and toxic substances. Over a five-year period, the incidence the incidence of drug-addicted adolescents rose to 13 times the 1992 level, when 4.5 per 100 thousand adolescents were registered. In 1996, 3891 adolescent drug addicts were counted, corresponding to 59.8 per 100 thousand adolescents. The group of adolescents using spirits is the largest – 4067 people, The group using toxic substances is the second largest, comprising 1118 patients. The third largest group, with 914 subjects, consists of drug addicts and patients who consume drugs. Their number is 914 subjects. Consumers of “strong” drugs are adolescents in the 16-18 age who have been hospitalized with a non-remissional history of drug addiction, or with only short-term periods of abstinence from using drugs. Part II. In order to set away from settled conceptions, an attempt has been made to treat the assessment of the prevalence of narcomanias and toxicomanias from the point of view of social rather than exclusively medical factors connected with them. As predictors of narcomanias we considered medical, socio-economic, demographic, cultural, physical training and sports indices. As a result, it was established that the prevalence of narcotism depends on 4 basic indices, as follows: (1) the specific gravity of group B production (i.e. the production of means of consumption); (2) wages per family member per month; (3) average number of square meters in the dwelling-place per inhabitant; (4) the number of those working in the non-production field.

Published: Volume 01 • Issue 2 • December 1999 (pages: 35 - 38)

Title: The treatment of viral hepatites in drug addicts

Authors: Guffens J. M.

Summary: The incidence of hepatitis C in intravenous drug addicts is widespread; while that of hepatitis B is frequent; the co-infection of both with the HIV virus is not rare.

Published: Volume 01 • Issue 2 • December 1999 (pages: 39 - 42)

Title: General Practitioners and Heroin Addiction. Chronicle of a Medical Practice

Authors: Michelazzi A., Vecchiet F., Cimolino T.

Summary: In the summer of 1994, family doctors in Trieste (Italy) began to treat patients who had opiate drug-addiction problems by giving them methadone substitute therapy within therapeutic programmes decided in surgeries. The drug-addict became just a patient once again, often a chronic patient who could be treated in the family doctor's surgery. More than 50 doctors now prescribe substitute medicine in their surgeries, in Trieste.

Published: Volume 02 • Issue 1 • June 2000 (pages: 1 - 8)

Title: Women, pregnancy and methadone

Authors: Finnegan L. P.

Summary: The abuse of psychoactive drugs by women of childbearing age has placed an untoward burden on the fetus, new-born and child. This included: marijuana-2.9%; cocaine-1.1%; with lesser percentages of other illicit drugs. Effective methadone maintenance prevents the onset of opioid abstinence syndrome for 24-36 hours, reduces or eliminates drug craving, and blocks the euphoric effects of illicit narcotics. Because of the extremely high risk environment of the pregnant drug-dependent woman, her infant is predisposed to a host of neonatal problems. Infants exposed to methadone in-utero, with mothers receiving prenatal care, generally have higher birth weights and a decreased incidence of premature birth and other medical complications. Infant medical complications are usually influenced by maternal prenatal care, incidence of maternal complications, and multiple drug use by the mother causing an unstable intrauterine milieu complicated by withdrawal and overdose. Infants exposed to methadone generally have a higher incidence and a longer duration of abstinence. The majority of this increased cost has stemmed from drug-affected infants born with significant/major medical needs and premature delivery related to maternal drug abuse. Over three-fourths (77%) of drug-affected infants have had significant/major medical needs compared with 27% of all new-borns. Seventeen per cent of drug-affected infants were born prematurely, compared with 6% of all new-borns. The total cost in 1997 for longer, specialised, and more intensive medical care for Florida's drug-affected infants is estimated at $ 6.7 million.

Published: Volume 02 • Issue 1 • June 2000 (pages: 9 - 14)

Title: Sexual dysfunction associated with methadone maintenance: Treatment with bromocryptine

Authors: Shinderman M. S., Maxwell S.

Summary: Sexual dysfunction, a side effect of methadone maintenance treatment, may be caused by opioid-induced hyperprolactinemia; on this basis, a dopamine agonist could reverse the effect. We treated 34 (23 male; 11 female) patients with bromocryptine, 2.5-10mg/d. 65% of males and 36% of females reported a positive response. Responders and non-responders had a similar age (44 Vs 40 yrs), time in MMT (45.5 mos), and use of serotonergic antidepressant therapy (21.1% Vs 26.7%). Responders took higher doses of methadone (220.3 Vs 165.6 mg/d), and were more likely to be taking bupropion or methylphenidate (42.1% Vs 26.7%). Alternative therapies with other dopaminergic agonists are discussed

Published: Volume 02 • Issue 1 • June 2000 (pages: 15 - 21)

Title: Attitudes and Beliefs towards Methadone of staff working in substance abuse treatment

Authors: Vossenberg P.

Summary: This study investigates the possible use of the Abstinence Orientation Scale (AO-scale), which has been developed to study the impact of attitudes towards methadone maintenance treatment (MMT) on treatment retention.

Published: Volume 02 • Issue 1 • June 2000 (pages: 22 - 22)

Title: Is prescribing higher doses of methadone likely to promote elevate drop-out rates? [Letter]

Authors: Vetere C.

Summary: Not available

Published: Volume 02 • Issue 1 • June 2000 (pages: 23 - 31)

Title: The Pacific Drug Policy Institute and research findings that led to its founding

Authors: Smart D. C.

Summary: The failure of currently employed drug control measures is caused by what I call the “drug/crime subsidy”. Because the drug/crime subsidy is caused by our government's $17 billion investment (per annum) in drug control measures. Apologists for the war on drugs argue that the illegal drug could be controlled, if we would just enforce the drug laws. As well as being the primary victims of the drug/crime epidemic, drug users are also major carriers in the contagions of drug use and addiction. Experts estimate that addicts consume 80% of illegal drugs. An estimated 20% of illegal drugs is consumed by recreational or casual drug users. We could eliminate 20% of the drug/crime subsidy by serving the drug-related needs of these users

Published: Volume 02 • Issue 1 • June 2000 (pages: 32 - 32)

Title: Methadone treatment: an interesting analogy [Letter]

Authors: Newman R. G.

Summary: Not available

Published: Volume 02 • Issue 1 • June 2000 (pages: 33 - 38)

Title: Take-home and compliance with methadone maintenance treatment

Authors: Pani P. P., Pirastu R.

Summary: One of the most important restrictions placed on patients during methadone treatment is the need for daily attendance at the outpatient unit providing the medication. While this may be obvious for patients beginning the treatment, many patients stabilized on appropriate doses of methadone complain of its interference with their activities (home, work, leisure). To see if take-home methadone promoted the retention of patients in treatment, we compared, on the basis of various demographic and clinical characteristics, the patients enrolled in the take-home programme with those attending the clinic daily. The opportunity to broaden the investigation by including the relationship between take-home policy and retention in treatment partly derwed from the law which, between 1991 and 1993, prohibited the take-home option. The comparison of patients with and without the take-home advantage seems to show a longer retention in treatment for the first group, without specifying anything about the role of take-home in promoting retention. Our clinical practice suggests that when sufficient guarantees as to the reliability of the patient exists, take-home methadone practice may be a useful tool for promoting compliance and improving the retention rate of patients in treatment

Published: Volume 02 • Issue 1 • June 2000 (pages: 39 - 46)

Title: Methadone dose and retention in treatment of heroin addicts with Bipolar I Disorder comorbidity. Preliminary Results

Authors: Maremmani I., Canoniero S., Pacini M.

Summary: We studied 71 opioid-dependent subjects, 19 with additional DSM-IV diagnosis of Bipolar I disorder and 52 with no psychiatric comorbidity. There were significant differences between these two groups regarding the methadone dose required for clinical stabilization, but not in the rate of retention in treatment. Patients with bipolar I psychiatric comorbidity required an average stabilization dose of 146±80 of methadone, compared with 99±49 mg/die for patients whose only Axis I diagnosis was Opioid Dependence. In the 990-day period considered there were no significant differences between the two groups of patients in terms of retention on treatment; even so, bipolar I heroin addicts patients tend to be less compliant to treatment

Published: Volume 02 • Issue 1 • June 2000 (pages: 47 - 48)

Title: Discontinuation symptoms are not addiction/dependence [Letter]

Authors: Newman R. G.

Summary: Not available

Published: Volume 02 • Issue 2 • December 2000 (pages: 1 - 18)

Title: Menaging benzodiazepine withdrawal

Authors: Frare F., Perugi G.

Summary: The long-term use of Benzodiazepines (BZs) is currently a source of growing concern, owing to increasing doubts about their efficacy, and evidence of important adverse effects, including physical dependence and neuropsychological impairment. The long-term use of BZs in patients with anxiety and mood disorders calls for special concern; in these patients, in fact, interepisodic chronicity and residual symptoms often appear to be related to inappropriate long-term use of BZs. The problem of dependence on benzodiazepines has been aggravated by iatrogenic physiological dependence on these medications and by polysubstance-abusing patients using them in addition to other agents, in particular opioids or cocaine. A safe, rapid, and effective way to detoxify patients from benzodiazepines is of prime importance in facilitating further treatment of their psychiatric or substance use disorder. Correct withdrawal strategies should combine gradual dosage reduction, psychological support and adjuvant medications in selected patients. The tapering schedule should be individually titrated and adjusted according to the patient's reactions; substitution with a long-acting BZ is often useful. Psychological support should include information about BZ withdrawal, general encouragement and the correction of misconceptions about discontinuing medicines; it should be available both during tapering and after withdrawal. Some antiepileptics and sedative antidepressants may be useful to mitigate withdrawal phenomena. Adequate dosages of antidepressants should be used to treat the re-emergence of an underlying mood or anxiety disorder. Success rates of withdrawal are high (54-92%); the follow-up studies, however, indicate that long-term discontinuation of BZ is a slow process, taking many weeks or months - in some cases years - with a protracted clinical course after drug cessation.

Published: Volume 02 • Issue 2 • December 2000 (pages: 19 - 27)

Title: Addiction and methadone: One American's view

Authors: Newman R. G.

Summary: To refer to America's “war on drugs” as a failure is overly generous. It is a disaster! Other nations should ignore what Americans say and consider instead the consequences of what they do. With specific regard to the treatment of addiction, all modalities that offer hope should be supported. None, however, approaches the proven ability of methadone maintenance to attract, retain and help addicts. Accordingly, the unique constraints on methadone's availability must be removed, and the general practicing physician given the same authority to prescribe methadone as she/he has to prescribe any other medication.

Published: Volume 02 • Issue 2 • December 2000 (pages: 29 - 33)

Title: An evaluation study on share care methadone treatment between a specialized clinic and a network of General Practitioners

Authors: Coppel A.

Summary: This article discusses recent changes in France from what has mainly been a repressively oriented drug policy towards accepting and supporting a variety of harm reduction measures. The introduction of harm reduction in the early nineties proved to be very successful in terms of harm reduction and is already a reality. Most officials, however, are still reluctant to support this implicit policy change openly, or work coherently for a reduction of current inconsistencies or admit the overwhelming success those changes have brought about, so the author is afraid of a serious backlash. The positive effects may be threatened if the public is not adequately informed about the new situation and its positive effects. The government may be unwilling to continue supporting harm reduction in the face of increasing public criticism based on ignorance and an inadequate conception of how to preserve public order in connection with illicit drugs.

Published: Volume 02 • Issue 2 • December 2000 (pages: 35 - 42)

Title: Opioids and cannabinoids abuse among bipolar patients

Authors: Maremmani I., Canoniero S., Pacini M., Lazzeri A., Placidi G. F.

Summary: Substance abuse is known to be a risk factor for the development of some types of mental illness, especially in individuals with premorbid vulnerability or psychopathology, but the psychopathology itself may be a risk factor for addictive disorders or a modifier of the course of addictive disorders. In our clinical experience with heroin addiction, the prevalence rates for the bipolar disorder was quite high. More than 50% of the patients had an adjunctive diagnosis of bipolar disorders. In many cases they met the criteria for a diagnosis of bipolar I, bipolar II or cyclothymic disorder. So bipolar I and bipolar II disorders are more frequent than depressive ones. Bipolar patients are well represented among cannabinoid abusers, and schizophrenic spectrum patients among cannabinoid non-abusers. Interestingly, the number of bipolar patients who continued to abuse cannabinoids after the onset of the first episode was higher than that of schizophrenic spectrum patients. In conclusion, our data support the increasing evidence of high rates of co-occurring bipolar and addictive disorders.

Published: Volume 02 • Issue 2 • December 2000 (pages: 43 - 50)

Title: Pregnant addict care in Methadone Treatment Programs

Authors: Bilangi R. J.

Summary: Since 1992 Connecticut Counseling Centers, Inc. has been providing two models of pre-natal and post-natal care, including obstetrical and gynaecological examinations, and patient education and care, to our pregnant opioid addicts in two methadone treatment programmes in Connecticut, U.S.A. Connecticut Counseling Centers, Inc.'s two pregnant addict care programmes provide a wealth of patient education, nutritional analysis and education, parenting skills training and pre-natal and post-natal medical care, along with comprehensive methadone treatment.

Published: Volume 02 • Issue 2 • December 2000 (pages: 51 - 55)

Title: Aprohibitionism, a feasible way forward

Authors: Michelazzi A.

Summary: Drug (ab)use is a phenomenon that has continued to advance in western and westernised society, starting at the end of the sixteenth century and the beginning of the seventeenth. In the same period a capitalist form of society developed out of a mercantile one. Psychiatric disease can be viewed as representing the failure of production based on the division of work; similarly, disease connected with addiction can be seen as representing the failure of reproduction resulting from work mechanisation.

Published: Volume 02 • Issue 2 • December 2000 (pages: 57 - 58)

Title: Hepatitis C infected patients and higher doses of methadone [Letter]

Authors: Okruhlica L., Klempova D.

Summary: Not available

Published: Volume 02 • Issue 2 • December 2000 (pages: 59 - 60)

Title: Introducing the European Collaborating Centres in Addiction Studies [Letter]

Authors: Schifano F.

Summary: Not available

Published: Volume 03 • Issue 1 • June 2001 (pages: 7 - 12)

Title: The promise of opioid receptor antagonist drugs in the treatment of neuropsychiatric disorders

Authors: Deltito J., Maremmani I.

Summary: The endogenous opioid system, either directly or through its influence on other neurotransmitter systems, has far-reaching effects on normal as well as abnormal (maladaptive) behaviours, thoughts and mood states. Altering this system through the use of an opioid antagonist medication may not only be useful in treating recognized psychiatric illnesses, but may also prove to be valuable in elucidating psychophysiological abnormalities that could contribute to the foundation of these disorders.

Published: Volume 03 • Issue 1 • June 2001 (pages: 13 - 22)

Title: Haematic concentrations versus oral doses of methadone. Comparative assessment of two reference systems during substitute therapy in opiate addiction

Authors: Scarlata S., Chiarotti M., Fucci N., De Giovanni N.

Summary: Therapeutic failures in MMP patients may be due to an inadequate oppioidergic replacement effect of the drug on specific receptors for endogenous opiates. Even with oral doses considered adequate in the current literature, haematic levels may be low, due to genetic or induced over-metabolization of the drug; in addition, even when haematic levels are high, the results may be poor, due to acquired receptor tolerance. 61 heroin addicts on MMP doses agreed on between therapist and patient have been evaluated with Europasi at the beginning and at the end of observational and therapeutic periods ranging between 12 and 57 months. Addicts who showed a positive development revealed haematic levels (non-oral ones) higher than non-responder patients, and some of the former reached haematic levels higher than those reported in current literature. Estimates of the haematic concentration of methadone may be useful, even if availed of “una tantum” during the treatment period.

Published: Volume 03 • Issue 1 • June 2001 (pages: 23 - 28)

Title: Therapeutic effects of paroxetine on the cocaine abuse in heroin addicts

Authors: Manna V.

Summary: During the last few years, cocaine abuse has been detected in increasing numbers of heroin addicts taking part in a methadone maintenance programme. Paroxetine, a serotoninergic reuptake blocker, was administered, 20 mg p.o. a day, to 12 outpatients, cocaine abusers with heroin addiction, during a methadone maintenance treatment, to evaluate the possible anti-craving and therapeutic effects of the prescribed drug on cocaine use. Four patients discontinued paroxetine treatment after a few days. Eight patients received paroxetine for at least eight weeks. Cocaine abuse was detected by weekly toxicology screening. After eight weeks of treatment, three patients had completely stopped using cocaine, and four had considerably reduced their consumption. One patient reported no change. So, paroxetine, as suggested for other serotonin reuptake inhibitor drugs, may be considered a safe, effective therapeutic agent in treating of cocaine abuse in heroin addicts.

Published: Volume 03 • Issue 1 • June 2001 (pages: 29 - 34)

Title: Methadone regulations in USA: Comments, proposal to adopt new regulations and proposed rule

Authors: Newman R. G.

Summary: The current regulatory process governing methadone treatment of addiction is associated with one problem that overshadows all others: it effectively limits the prescribing of methadone to “programmes” that, collectively, can accommodate no more than 15-20% of all who need and could benefit from this medication. As a consequence, lives are lost (literally as well as figuratively), and there are staggering costs to the general community. The proposed new Rule does nothing about this problem. To the contrary: it exacerbates it, and by implicitly endorsing the status quo reduces the prospects for future change. In addition to raising further the barriers to expanding methadone availability, the Rule would complicate rather than streamline the bureaucratic process that governs treatment, do nothing to enhance quality of care of the lucky few who do gain access to methadone, and raise costs for Government, providers and patients.

Published: Volume 03 • Issue 1 • June 2001 (pages: 35 - 42)

Title: Articulation of codeine treatment and methadone maintenance programs

Authors: Okruhlica L., Klempova D., Timulakova K.

Summary: The Centre for Treatment of Drug Dependencies in Bratislava is implementing a complex integrative model which provides fourteen different programme options for its clients. This paper studies the relashionship and interaction between the treatment process in two maintenance programmes: 1) with codeine phosphate (n=74), and 2) with methadone hydrochloride (n=132). There were no differences in the gender composition or working status of the groups, but a significant difference was found in age composition; differences in retention rates and dosages were focused on, too. Codeine substitution had been introduced into our practice prior to the availability of methadone maintenance. It has still not been eliminated, largely due to the fact that it is requested by the patients, but also because of some other aspects considered by the therapist in managing the treatment process. The different characteristics of these two programmes, their possible determinants, as well as practical considerations and the advantages of keeping the two programmes running side by side on a non-competitive basis are discussed.

Published: Volume 03 • Issue 1 • June 2001 (pages: 43 - 48)

Title: The differences between inpatients and outpatients with illegal drug use: Prevalence of comorbid mental disorders

Authors: Lovrecic M., Dernovsek M. Z., Tavcar R., Maremmani I.

Summary: The aim of the survey was to compare clinical and sociodemographic differences between patients with substance abuse or dependence and mental illness who, over a three-month period, sought psychiatric help in a hospital (UPH) or a methadone clinic (CPTIDD).

Published: Volume 03 • Issue 2 • December 2001 (pages: 7 - 20)

Title: The problem of drug dependence

Authors: Tagliamonte A., Maremmani I.

Summary: Knowledge about psychoactive substances has always had to challenge sociocultural dogmas and expectations, which usually prevail over scientific evidence. Along with that, addictive disorders have mostly been thought to arise from a choice of inappropriate sources of stimulation and blame addressed at addicts who lack judgement. The definition and assessment of the differences between use, abuse and dependence have therefore been a controversial matter. Stimuli differ in nature and different dynamics are there for behaviours to be elicited and structured. Some objects are pursued along with the need for them, as soon as they become unavailable, whereas others are craved for most strongly when they are available. Behavioural dynamics are crucial in discriminating between what we struggle not to run out of, and what we strive to win, i.e. between loss avoidance and self-empowerment. Need-satisfying behaviours tend to dwindle through satisfaction, and develop through the experience of frustration, whereas pleasure-seeking is reinforced by success and is structured upon subjective reward. Both forms of behaviour are displayed as habits, and stay functional as long as control over behavioural production is maintained. The neurobiological bases for these conceptualizations are discussed, and clinical models are described to draw a line between physiological habits and addictive diseases, and between benign transient behavioural conditioning and the proneness to malignant relapse which underlies true addiction. The debate on addictive diseases, setting aside the question of resorting to irrational methods, should be referred to strictly medical models, so as to let meaningful interventions follow scientific knowledge.

Published: Volume 03 • Issue 2 • December 2001 (pages: 21 - 28)

Title: Evaluation survey of a Methadone Treatment share care programme between a specialized clinic and a network of GPs

Authors: Coppel A., Bloch-Laine J. F., Charpak Y., Spira R.

Summary: Emergence Espace-Tolbiac is a methadone treatment clinic. Over the last 5 years, EET has initiated methadone treatment with 738 patients, including 548 who have been referred to a network of 220 GPs The way of service functions is defined by the French regulations for methadone treatment. Such treatment must be initiated by specialized clinics, but once patients have stabilized, can be referred to GPs. Our service initiates the treatment, and patients stay at the clinic, where methadone is administered every day by a specialized team. During the first few weeks, the patient's needs are evaluated and he or she is referred to various professionals, such as social workers, doctors and psychiatrists, according to whatever is appropriate in each case. Patients are referred to GPs when the evaluation is made that they no longer abuse drugs such as heroin or cocaine, or other substances such as alcohol or benzodiazepine. They must have social resources and available accommodation. Patients suffering from a psychiatric disorder do not receive referrals until their condition has been stabilized by any kind of treatment. So far 40% of our patients have received a referral after an average of 2 months at the clinic, and 30% after an average of 9 months, while 18% have stayed at the clinic for over 2 years. A follow-up has been conducted on 296 patients referred to GPs (32 GPs failed to answer) After an average of a year and a half on treatment, 5% were no longer available for follow-up, and 85% are still being advised by their GP. Of these, 95% are still being treated with methadone. Most of the others (9/13), are being treated with high-dosage buprenorphine (Subutex). The mean dosage is 60mg/day, 15 mg less than at the end of the stay at the centre. Relationships with other professionals are frequent (67% of patients). 20% are still in contact with the centre

Published: Volume 03 • Issue 2 • December 2001 (pages: 29 - 32)

Title: Treatments of substance users detainees in 'La Santé' prison

Authors: Yakoub S.

Summary: In France, care for addict detainees is provided under Ministry of Health responsibility. The psychiatric, psychological and social aspects depend on the Treatment Centre for Addicts in jail (created in 1987). In this report, on the basis of the characteristics of our patients in 1999, we describe the treatments given to substance-user detainees in our Centre at La Santé prison.

Published: Volume 03 • Issue 2 • December 2001 (pages: 33 - 38)

Title: Intensive sport and risk of heroin addiction

Authors: Deglon J. J.

Summary: Results from Loewenstein's study on heroin addicts in his methadone programme have led us to verify a correlation between intensive sports and addiction. In our four methadone programmes based on a medical-psychosocial treatment model, 378 patients answered a 200-item questionnaire distributed last year. 25% said they had played a sport on an intensive basis, several hours a day for several months. 32% said they had practised a highly competitive sport. It therefore seems that most of our patients have been intensive sports-players — certainly more so than the majority of the population in a similar age range. Significant statistical correlations to be noted among the athletic group are: higher frequency of parents with psychological problems, higher methadone dosage, a greater use of cigarettes before beginning methadone, a higher score on the Beck Depressive Scale, a lower score on a quality of life test and a need for more psychotropic drug prescriptions. These results allow us to formulate the hypothesis that intensive sports for certain young people can be a means to escape from an underlying depression. The stimulation of endorphins and the ensuing activation of dopamine tracts incite temporary psychological improvement. It would thus appear that the association of narcotics, especially heroin, which gives a pleasure that is incomparably stronger than that obtained through intensive sports, with neurobiological/psychological fragility, can lead to a high risk of addiction in this population.

Published: Volume 03 • Issue 2 • December 2001 (pages: 39 - 44)

Title: The differences between heroin addicts with and without comorbidity

Authors: Lovrecic M., Dernovcek M. Z., Tavcar R., Maremmani I.

Summary: The aim of this study was to discover what clinical and sociodemographic differences separate heroin addicts without (AWC) and those with comorbidity (substance abuse and mental illness-SAMI) among those seeking help in an outpatient methadone clinic. The RSDA instrument and ICD-10 were used.

Published: Volume 03 • Issue 2 • December 2001 (pages: 45 - 45)

Title: Methadone Treatment: Italy vs. USA - Methadone Treatment in Europe [Letter]

Authors: Tidone L., Riglietta M., Campana M.

Summary: not available

Published: Volume 04 • Issue 1 • April 2002 (pages: 5 - 12)

Title: Mortality among problem drug users in Europe: A project od the European Monitoring Centre for Drugs and Drug Addiction (EMCDD)

Authors: Bargagli A. M., Sperati A., Davoli M., Perucci C., Vicente J., Hartnoll R., Barry J., Brugal T., Buster M., Ferraz De Oliveira F., Haastrup L., Heinemann A., Kouklinos A., Risser D., Svensonn D., Vuori E.

Summary: The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is currently co-ordinating a project which aims to enrol and follow up prospective cohorts of problem drug users (PDUs) in several countries, so as to compare overall and cause-specific mortality. Within the project a literature overview of drug user mortality and a comparative analysis of data from already followed-up cohorts were performed. Although the joint analysis provided new knowledge on mortality trends among PDUs in several European countries, care should be taken in comparing data from retrospective cohorts due to the heterogeneity of study populations and their settings and follow-up procedures. The formation of prospective cohorts, in line with a standard methodology, should improve the comparability of results both for overall and cause-specific mortality

Published: Volume 04 • Issue 1 • April 2002 (pages: 13 - 24)

Title: Buprenorphine: Evidence for effectiveness

Authors: Pacini M., Maremmani I.

Summary: In all cases, opiate addiction is best treated by the use of opiate agonist agents. A maintenance regimen based on an opiate agonist leads to a gradual dwindling of the subjective effects due to street opiates, thanks to the blockade achieved by these agents on the receptors that are reached by heroin.

Published: Volume 04 • Issue 1 • April 2002 (pages: 25 - 28)

Title: 1995-2001 programme evaluation of the A-center for treatment of addicts consuming prohibited drugs at Maribor, Slovenia

Authors: Pisec A.

Summary: A study covering six years of treatment at our centre was dedicated to 570 patients addicted to prohibited (because illegal) drugs; those patients were enrolled in the period April 1995 - April 2001. Group A results are those for 284 addicts treated with methadone, while those for group B refer to the comprehensive treatment outcomes for all 570 addicts enrolled there in that period. Patients in group A had an average age of 26 years, and an average daily methadone dose of 80 mg of methadone, the following infections were recorded: (i) 21 patients (7.4%) had the hepatitis B virus, (ii) 105 (36.9%) had the hepatitis C virus, and (iii) no patients ( 0%) had the HIV virus . For 16 patients (5.6%) the results are unknown.

Published: Volume 04 • Issue 1 • April 2002 (pages: 29 - 36)

Title: Does therapeutic threshold of methadone concentration in plasma exist

Authors: Okruhlica L., Devinsk F., Valentova D., Klempova D.

Summary: This study was conducted among the group of 69 patients in the methadone maintenance programme in Bratislava. There were 56 males and 13 females, with an average age of 26.9 years (SD ± 5.4). Daily methadone doses (mean: 134 mg, SD ± 56.1, from 10 to 270 mg) were compared with methadone concentrations in plasma (mean: 376.6 ng/ml, SD ± 226.1, from 44 to 1103 ng/ml); of these, 17.4% of the patients had levels below the threshold of 200 ng/ml of plasmatic concentration of methadone, whereas 15.9% had levels above the level of 600 ng/ml. All of them had previously been stabilized clinically, with negative urinalysis for morphine

Published: Volume 04 • Issue 1 • April 2002 (pages: 37 - 46)

Title: Treatment characteristics and retention in methadone maintenance: High and stable retention rates in a Swedish two-phase programme

Authors: Gunne L., Gronbladh L., Ohlund L.

Summary: From 1967 to 1990, the Swedish methadone maintenance programme treated 345 heroin addicts, using a two-phase treatment model described in this paper. The retention rates remained remarkably stable throughout these 23 years, when measured as 1-year and as 3-year retention of newly admitted patients (mean 1-year retention was 86%, mean 3-year retention 73%) and 1-year retention of all patients in treatment (mean 89%). It is hypothesized that these high and stable retention rates might be associated with the high rates of social and vocational rehabilitation (between 71% and 81%) achieved during these years in the Swedish programme

Published: Volume 04 • Issue 2 • August 2002 (pages: 5 - 9)

Title: Correlation between hepatitis C serostatus and methadone dose requirement in 1.163 methadone-maintained patients

Authors: Maxwell S., Shinderman M. S., Miner A., Bennet A.

Summary: Hepatitis C infection is epidemic in intravenous drug users worldwide. This has great impact on opiate-addicted patients. Prevention of infection must depend on treatment of opiate addiction. This report discusses findings from 1,163 methadone-maintained patients tested for hepatitis C infection. The prevalence of HCV seropositivity in IVDU patients was 68%. Seropositive patients required significantly higher doses of methadone (169 mg/d vs. 100 mg/d, p<.05). This difference in dose was independent of duration of addiction and time in treatment. It is suggested that Hepatitis C infection may be associated with metabolic changes that lead to increased methadone requirement.

Published: Volume 04 • Issue 2 • August 2002 (pages: 11 - 17)

Title: Is craving for heroin and alcohol related to low methadone dosages in methadone maintened patients

Authors: Lubrano S., Pacini M., Giuntoli G., Maremmani I.

Summary: The craving for heroin, alcohol and cocaine of 84 heroin-addicted patients under Methadone Maintenance Treatment have been evaluated to highlight possible craving clusters, and to underline contingent correlations with clinical characteristics such as addiction history, positive symptom distress and methadone dosages. The results show a correlation between methadone dosage and a craving for heroin and alcohol. Patients treated with low dosages of methadone show more psychopathological symptoms and a stronger craving for heroin and alcohol. On this basis, the search for an appropriate methadone dosage should be viewed as crucial to the success of the treatment, because it minimizes alcohol and heroin craving, and reduces the risk of psychopathological symptoms during treatment.

Published: Volume 04 • Issue 2 • August 2002 (pages: 19 - 31)

Title: Clinical foundations for the use of methadone. Italian Consensus Panel on Methadone Treatment

Authors: Maremmani I., Barra M., Bignamini E., Consoli A., Dell'aera S., Deruvo G., Fantini F., Fasoli M. G., Gatti R., Gessa G. L., Guelfi G. P., Jarre P., Michelazzi A., Mollica R., Nardini R., Pani P. P., Polidori E., Siragusa C., Spazzapan B., Starace F., Tagl

Summary: not available

Published: Volume 04 • Issue 2 • August 2002 (pages: 33 - 37)

Title: “Manifesto of Barcelona”: Care programmes for health professionals with mental disorders and addictive behaviours in Europe

Authors: Aa.Vv.

Summary: not available

Published: Volume 04 • Issue 2 • August 2002 (pages: 39 - 42)

Title: Galicia document on problems related to addictive disorders in Europe

Authors: Aa.Vv.

Summary: not available

Published: Volume 04 • Issue 2 • August 2002 (pages: 43 - 46)

Title: 5th Conference of the European Opiate Addiction Treatment Association and The EUROPAD Awards 2002 'Chimera Award",

Authors: Www.Europad.Org

Summary: Not available

Published: Volume 04 • Issue 3 • December 2002 (pages: 5 - 11)

Title: Harm reduction and specific treatments for heroin addiction. Different approaches or levels of intervention?. An illness-centred perspective

Authors: Maremmani I., Pacini M., Lubrano S., Giuntoli G., Lovrecic M.

Summary: So far, harm-reduction campaigns have focused on the personal and social needs of heroin addicts, with the aim of preventing the consequences of addictive behaviours. An unduly sharp dichotomy usually seems to come to mind when harm-reduction interventions are compared with specific treatments for heroin addiction. In reality, some of the specific targets in the treatment of heroin addiction, as well as features of mentally ill subpopulations, may be reasonable targets for harm reduction, too. Convergence on overlapping targets may be hypothesized as long as harm reduction and specific treatment come to share the same therapeutic instruments. Opioid agonists, the primary option for the specific treatment of heroin addiction, are also valuable as harm reduction instruments, as long as harm reduction is conceived of as a means for acting on that disease, but only at a low-threshold level. The personal and social impact of possible agonist-mediated harm-reduction seems to carry special weight in higher-risk populations, such as mentally ill heroin users, who have turned out to be sensitive to therapeutic opioid agonism. Harm reduction can best be regarded as a low-level approach to more severely disabled subjects, bridging the gap between the street and clinical settings by a sub-therapeutic but specific pharmacotherapy. Stepping up from harm reduction to a higher level of intervention should, in fact, be the ultimate goal of harm reduction . Transition to specific treatment is particularly important for dually diagnosed addicts, who can be expected to receive a relatively greater benefit; without that transition, they are likely to quickly lose the opportunity to attain a positive outcome.

Published: Volume 04 • Issue 3 • December 2002 (pages: 13 - 19)

Title: Methadone treatment in Croatia

Authors: Ivancic A.

Summary: The war between 1991 and 1995, brought destruction, migrations and victims to Croatia, but it also brought a heron addiction epidemic. The supply of methadone was undermined by war-related crimes and demand was paralysed by confusion about the options that were available. Croatia did have a number of experienced specialists in the field of addiction, and, fortunately, their ideas were accepted and promoted. Methadone was introduced through a “slightly open door”, but no official announcements were made. The first patients were admitted to MT in 1991. Of an estimated 15,000 heroin addicts, about 7,000 were given some kind of treatment, including 3,000 in MT, and about 2,000 in MMT. Methadone policy specifics are: 1. Health insurance coverage that includes MT for virtually all addicts. 2. Centres for outpatient treatment in all major cities. 3. Completely decentralized prescription and dispensing of methadone through GP offices. Despite the lack of strict rules, or maybe just because of that, MT in Croatia is well established and is generally viewed favourably. The obstacles encountered so far have never reached a level that might jeopardize the fundamentals of the programme.

Published: Volume 04 • Issue 3 • December 2002 (pages: 21 - 25)

Title: The renaissance of methadone treatment in America

Authors: Parrino M. W.

Summary: The renaissance, or revitalization, of methadone treatment services in America is driven by new accreditation standards, as promulgated by the Centre for Substance Abuse treatment, the primary oversight federal agency for methadone treatment services in the United States. This project will take years to develop and a reasonable starting point is the accreditation oversight system. While accreditation is not expected to be the answer to all critical problems in methadone treatment, it will provide the ability to enhance quality of care as patients get access to a more consistent level of services.

Published: Volume 04 • Issue 3 • December 2002 (pages: 27 - 32)

Title: Methadone and commonplaces

Authors: Gioè P., Rosa B., Papa M., Troia M., Triolo F.

Summary: Research developments in methadone research point to the need to give adequate doses in maintenance programmes for the treatment of opiate dependence. This suggestion often clashes with the long-standing prejudices of users, who are not fully compliant with long-term substitution programmes; this makes it difficult to fully implement the correct treatment. Our service has therefore tested a different intervention methodology, in order to: 1) favour treatment retention; 2) improve the quality of the treatment itself. Small groups of users under substitution treatment were formed: they met for counselling in a group setting. This form of open discussion allowed: 1) health workers to provide correct information about methadone; 2) patients to learn more about drug addiction and its possible treatments, by following a new route to self-knowledge and taking part in interactive confrontation; 3) both groups (health workers and users) the opportunity to have a more genuine and confidential relationship. In order to make available to those outside the experimental group the subject of this experience, a comic strip directed to all the other users of the service was prepared. One year after the conclusion of this experimental technique, all the users who had been involved in it were still compliant with treatment, in line with the initial therapeutical project, and some of them have entered the detoxification phase.

Published: Volume 04 • Issue 3 • December 2002 (pages: 33 - 44)

Title: Methadone maintenance and HIV infection

Authors: Pacini M., Maremmani I.

Summary: Methadone therapy is widely ascertained to be the most effective treatment for opioid addiction. Its spreading was promptly followed by a dwindling spreading rates of HIV among heroin addicts. Non only among directly treated patients a clear benefit emerged, but also among non addicts sharing the same environment. The positive impact of methadone upon additive behaviours is to be read mainly as the reduction of the likelihood of seroconversion. Retention in treatment is the most reliable predictor for the lowered likelihood of seroconversion to be maintained through time. The administration of methadone, even in those cases for which stabilization has not been achieved, or for those subjects who do not comply to methadone maintenance programmes, is still an effective in a harm reduction perspective, as far as it keeps infective risk lower than expected.

Published: Volume 04 • Issue 3 • December 2002 (pages: 45 - 46)

Title: Breast-feeding for a methadone-maintened mother: a case report [Letter]

Authors: Lamanna F., Scuotto S., Tedici M.

Summary: Not available

Published: Volume 04 • Issue 3 • December 2002 (pages: 47 - 48)

Title: Methadone maintenance treatments in European extracommunity target [Letter]

Authors: Siconolfi M., Verde L., Auriemma F., Esempio C., Marguccio E., Moccia E., Stimolo R., Guardiana A.

Summary: Not available

Published: Volume 05 • Issue 1 • April 2003 (pages: 5 - 16)

Title: The impact of methadone substitution therapy (MST) on illicit drug use and drug abused-related quality of life: A European Study

Authors: Ghodse H., Clancy C., Oyefeso A., Rosinger C., Finkbeiner T., Schifano F., Forza G., Sommer B., Nielson K. R., Schodt J., Wieviorka S., Gionnet C., O'connor J., Tidone L., Riglietta M., Lopes I., Torrens M., San L., Montes M., Copez C. R.

Summary: commonly used treatments for opiate dependence, legitimate questions continue to be raised about its effectiveness. Objective: To evaluate the impact of MST on illicit drug use and drug abuse-related quality of life (QoL). Design: Multicentre, cross-sectional case control study. Setting: Eleven MST programmes in eight European countries. Participants: Heroin dependent patients in MST programmes. Main outcome measures: Data on illicit drug use in the last month and injecting behaviour was extracted from the patientʼs substance use profile derived from EuroSUD as part of intake and ongoing assessment. The Brief Addiction Recovery Status Scale (EuroSAAQ-BARSS). Results: In Treatment (IT) groups reported a significantly lower number of illicit drugs used in the last month than controls (IT1: t = -6.81, p <.00001; IT2: t = -7.61, p <.00001; IT3: t = -6.32, p <.00001; IT4: t = -10.14, p <.00001). IT patients reported significantly lower rates of injecting than controls IT1 (OR = 0.48, 95%CI = 0.24, 0.95), IT2 (OR = 0.21, 95%CI = 0.12, 0.37), IT3 (OR = 0.43, 95%CI = 0.22, 0.87) and IT4 (OR = 0.27, 95%CI = 0.13, 0.57). They also expressed better drug-abuse related QoL for those patients who had been in treatment for at least 7 months (IT2: t = 4.43, p <.00001; IT3: t = 4.52, p <.00001; IT4: t = 6.22, p <.00001). Furthermore, there was a consistently positive relationship between duration in treatment and QoL scores. Conclusions: MST impacts positively on illicit drug use, injecting and drug abuse-related QoL. MST has been demonstrated as a culture-free and

Published: Volume 05 • Issue 1 • April 2003 (pages: 17 - 32)

Title: When “enough” is still not “enough”. Effectiveness of high-dose methadone in the treatment of heroin addiction

Authors: Maremmani I., Pacini M., Lubrano S., Lovrecic M.

Summary: In the longstanding diatribe about methadone maintenance, Dole & Nyswander were the first to support the practice of standard methadone treatment with dosages above 100 mg/day. However, several clinicians persisted in their view that lower dosages could provide most patients with significant improvement. Data from the literature strongly support the evidence that 100 mg-maintenance is more effective than that with 50 mg- in treating opiate abuse during the first 5-10 months of treatment. High dosages can be useful, bringing special benefits to patients whose opiate use has proved to be particularly resistant to treatment. Higher dosages may be used where there is a concurrent psychopathology, persistent opiate use or symptoms of incomplete coverage by methadone. Dosages above 100 mg/die, seem to give the best results. Therefore there is no scientific justification for boycotting the use of dosages between 80 and 120 mg/day .

Published: Volume 05 • Issue 1 • April 2003 (pages: 33 - 38)

Title: The impact of continuing terror and stress on the use of psychoactive drugs in Israel

Authors: Arieli M., Greenspoon A., Glaser J., Blackman S., Kahan N.

Summary: An unprecedented wave of terrorism has plagued the Israeli population over the last two years. Between September 29, 2000 and October 1, 2002, Magen David Adom recorded a total of 4,535 casualties. Of these, 539 people were killed, 406 severely injured and 554 moderately injured. Among the additional 3,036 people lightly injured were 11 MDA staff members. 3 Fears of random shootings and of human bombs exploding in schools, restaurants, and buses have caused extreme stress in the general population. Because the country is so small, everyone knows a terror victim personally - or knows someone else who does. At the same time, the economic situation, with its rising unemployment, reflects both the reality of war and the international recession. Stress and uncertainty are widespread. This ongoing study explores the assumption that terror, stress and uncertainty influences the prescribing practices of community physicians. Initially, we were interested only in psychoactive drugs, namely anxiolytics, hypnotics and anti-depressants. However, as this pilot study was planned to become part of a larger study done by the Mental Health Services, we then decided to include analgesics, asthma medications and H1 antagonists for hyperacidity and anti-hypertensives We believed that by measuring changes in prescribing patterns and actually measuring the dispensing of these medications, we would also receive a certain picture regarding the coping mechanisms of Israeli society.

Published: Volume 05 • Issue 1 • April 2003 (pages: 39 - 46)

Title: Reduction in self-reported nicotine dependence after stabilization in methadone maintenance treatment

Authors: Okruhlica L., Devinsky F., Klempova D., Valentova J.

Summary: ICD-10 criteria have been used for the assessment of opioid dependence and the Fagerstrom Tolerance Questionnaire (FTQ) to assess tobacco smoking. The mean methadone dose was 106 mg (SD=45) in the studied group, after twelve months in the methadone maintenance treatment programme (MMTP). The mean FTQ score was 6.5 (SD+1.8) before entering, 5.6 (SD+2.1) after stabilization in the MMTP (p<0.001) and 3 were non-smokers at the time of the second FTQ testing. No smoking cessation programme has been implemented. The findings do show a tendency for nicotine dependence among patients to fall in their period of stabilization in the MMTP.

Published: Volume 05 • Issue 1 • April 2003 (pages: 47 - 48)

Title: Liver cytochrome overexpression in human HCV infection

Authors: De Bernardis E., Busà L.

Summary: Not Available

Published: Volume 05 • Issue 2 • August 2003 (pages: 7 - 98)

Title: Dual diagnosis heroin addicts. The clinical and therapeutic aspects

Authors: Maremmani I., Pacini M., Lubrano S., Lovrecic M., Perugi G.

Summary: Addiction and other mental disorders interact in various ways. Substance abuse tends to exacerbate psychiatric symptoms, and to induce a more chronic course with fewer and shorter disease-free intervals. It also often prevents the effectiveness of psychoactive therapies. At the same time coexisting mental disorders worsen the course of addiction itself. Mentally ill abusers tend to have a turbulent lifestyle and be prone to risky behaviours. Lastly, the risk of relapse is often heightened to the point of discouraging any therapeutic intervention. In this paper we focus on particularly important aspects of maintenance treatment and delineate guidelines for clinical practice. The authors have taken part in a collaborative effort to develop the field of comorbidity and this paper is built on literature surveys and clinical experiences in their own treatment centre. We suggest that dually diagnosed addicts should first be treated for their addictive disease by using adequate methadone dosages, which can be expected to be higher than those required for the treatment of uncomplicated addicts; stabilization should be considered a medium-term goal. Some dually diagnosed patients may benefit from treatment that targets their addictive problem while taking into account their mental disorder. Apart from their anticraving activity, opioid agonists should be reconsidered as psychotropic instruments for the treatment of mental illness, especially mood, anxiety and psychotic syndromes. Lastly, dually diagnosed addicts are expected to benefit from facilities offered within integrated programmes to the same extent as uncomplicated addicts, once programmes are based on adequate dosages for a sufficient length of treatment.

Published: Volume 05 • Issue 3 • December 2003 (pages: 5 - 12)

Title: Understanding the pathogenesis of drug addiction in order to implement a correct pharmacological intervention

Authors: Maremmani I., Pacini M.

Summary: Meaningful therapeutic interventions for addictive diseases should be designed with a hierarchy of targets from the very beginning. The ability to target the core symptoms and the underlying dynamics imply a deep knowledge of the clinical picture, the links between observed behaviours and their psychopathological roots. First of all, a distinction should be drawn between habit and addiction, as the former cannot be considered a target for medical intervention. The identification of craving, loss of control over appetitive behaviour, and relapse proneness are crucial to the singling out ot drug addicts within a wider population of drug users. Secondly, addiction should be approached as a relationship between the addict and the substance he is hooked on, as most environmental variables are consequential, and, in any case, aspecific. Effective treatments target the relationship between the individual and the substance from within the addicted patient's brain. Different strategies may be indicated for the disease process, at its different stages, but all available options do share a common psychopathological target. Moreover, treatments should be planned so as to fit the spontaneous chronic course of addiction, that is, as maintenance programmes.

Published: Volume 05 • Issue 3 • December 2003 (pages: 13 - 22)

Title: Structured motivational interventions in methadone maintenance treatment

Authors: Kantchelov A., Vassilev G.

Summary: Improving the quality of services and increasing treatment effectiveness is quite a challenge in addiction treatment, including methadone maintenance. Besides adequate methadone dosing and length of treatment, there is an area that is fundamental but that does not yet seem to have been fully explored. It lies in the nature of the staff-client interaction and style used in meeting with clients. It is these factors that create a programme atmosphere and communicate deeper programme values

Published: Volume 05 • Issue 3 • December 2003 (pages: 22 - 36)

Title: Psychiatric severity and treatment response in methadone maintenance treatment programmes: New evidence

Authors: Pani P. P., Trogu E., Carboni G., Palla P., Loi A.

Summary: Recent studies have shown that the presence and severity of psychiatric comorbidity in opioid addicts enrolled in methadone maintenance programmes does not interfere with the outcome of treatment evaluated in terms of retention in treatment and heroin use. On this basis we sterted a cohort prospective study, in order to gather information on the impact of psychiatric severity on different outcome indicators of the treatment (retention, craving, use of heroin and cocaine, psychiatric status). The results obtained from the first 78 patients enrolled in the study show no significant differences, in terms of retention in treatment or of heroin amd cocaine use, between patients with high (44% of the cohort) and low (56% of the cohort) psychiatric severity. Regarding psychiatric status, almost all the psychopathological dimensions explored by SCL-90 show a significant reduction in symptoms during the course of the treatment, with a significantly higher improvement in patients with a severe psychopathology. Methadone dose tended to be higher in patients with high psychiatric severity. Moreover these patients had a significantly greater involvement in psychopharmacological treatments. The results of this study are consistent with those of previous ones showing that the severity of psychiatric comorbidity does not substantially alter the efficacy of maintenace methadone treatment

Published: Volume 05 • Issue 3 • December 2003 (pages: 37 - 42)

Title: Treatment of prisoners addicted to prohibited drugs in institutions for criminal law sanctions in Maribor, Slovenia

Authors: Pisec A.

Summary: In the penitentiary institutions of Maribor, over the seven-year period 1995-2002, 154 persons addicted to prohibited drugs were held in preventive custody, or served terms for administrative misconduct, or were being held after a conviction. Work with them was carried out in accordance with: (1) the Penal Law of the Republic of Slovenia - art. 66 on the obligatory medical treatment of alcoholics and drug addicts, (2) the Law on implementing the criminal law sanctions affecting the medical treatment of addicts to prohibited drugs, (3) regulations for the treatment of prisoners addicted to prohibited drugs. Before imprisonment 79 addicts were taking part in the methadone programme; in line with instructions, participation in the programme was ended within a month. All these addicts took part in classic medical detoxification, and in individual and group treatments. For these purposes a social welfare worker, a specialist pedagogist, a psychologist and psychiatrists were included in the team. A statistical review of imprisoned addicts showed that there were many more men (145) than women (9). Only a few prisoners were first-time offenders. Epidemiological results: (1) None of addicts examined were infected with the HIV virus. (2) 31 patients were infected with the hepatitis C virus. (3) In 31 cases no results were available (due to patients' refusal to be examined). (4) Comorbidity affected 60 patients (10 cases of psychosis, and 50 of personality disturbances). Work with imprisoned addicts is specific and difficult; it requires a great deal of knowledge and experience. We are guided by the idea that our task is to help these patients, while all the other data connected with them are irrelevant to us.

Published: Volume 05 • Issue 3 • December 2003 (pages: 43 - 52)

Title: Clinical picture and treatment of psycho-organic syndrome in drug addicts

Authors: Kozlov A. A., Rokhlina M. L., Tchistyakova L. A., Dvorina L. D.

Summary: Objective: To study the clinical picture and treatment of psycho-organic syndromes in drug addicts. Subjects and methods: 100 patients addicted to various drugs. Cerebrolysin was administered by intramuscular injection in 5 ml doses twice per day to 49 patients on the 14-20th day after the most recent drug use. Results: The clinical picture may be defined as “organic decline of the personality with desocialization”, or as a specific psycho-organic syndrome induced by drug consumption. We therefore considered the administration of the peptidergic substance Cerebrolysin potentially useful. Conclusion: Administration of cerebrolysin improves attention and concentration functions, makes intellectual processes more active, and promotes stable, positive emotions.

Published: Volume 06 • Issue 1 • April 2004 (pages: 5 - 18)

Title: Addressing violence in methadone maintenance treatment

Authors: Quigley P.

Summary: Violence is a core public health issue which is linked to substance misuse in complex and interactive ways. Qualitative data on 220 violent episodes was collected over a three year period from service users and staff at Dublin methadone clinics. Inductive analysis of the data led to a typology of violent events, which may help to enhance clinical and social responses to the problem.Witnessed clinic episodes were interpreted as consequences of disturbed individual states or traits, or in terms of immediate situational conflict. Client narratives were construed as illustrations of family violence, local feuds, delinquency, dealing, retribution and abuse. A variety of pertinent clinical and organisational solutions are put forward in the context of a necessary community development and social inclusion process.

Published: Volume 06 • Issue 1 • April 2004 (pages: 19 - 34)

Title: 'Vedette' study and 'Tracking' project: Their integration and preliminary results

Authors: Mollica R., Carleo P., Gatti R. C.

Summary: Since the end of 2000, our Department has managed two independent research activities. The first, the VEdeTTe Study, is a national multicentric cohort study which aims to evaluate the efficacy of treatment provided by outpatient units (called Servizi Tossicodipendenze, “Ser.T.” or SERTs) at national level. The second, Tracking Project, is a local form of research which was devised to “track” the careers of addicts and evaluate changes within therapeutic courses using ASI. As the Study and the Project had the same time frame, we thought it right that each should take account of the other, to yield a result capable of fulfilling the aims of both, and to exploit the potentialities of both research protocols. The preliminary results now available refer to a population consisting of subjects enrolled in 2001 and 2002, and this paper aims to investigate and describe any differences between the two main subgroups: cases of addiction to heroin and cocaine, where one or other was the primary drug abused.

Published: Volume 06 • Issue 1 • April 2004 (pages: 35 - 42)

Title: Methadone Treatment. Safe induction techniques

Authors: Payte T. J.

Summary: The motivation to develop a simple guideline for safe induction with methadone came largely from methadone-related deaths occuring during the induction phase of treatment. Clinical pearls for a safe induction are the following: 1) Very severe withdrawal signs/symptoms do not mean very high tolerance or the need for higher doses of methadone. 2) Consider use of instant opiate screens on admission with 2000 ng cut-off. 3) Document signs/symptoms of withdrawal with at least 2 objective signs. 4) Document daily assessment during induction includding basis for decisions to increase dose.

Published: Volume 06 • Issue 1 • April 2004 (pages: 43 - 52)

Title: Naltrexone as maintenance therapy for heroin addiction: Predictors of response

Authors: Maremmani I., Pacini M., Giuntoli G., Lovrecic M., Perugi G.

Summary: Naltrexone has been shown to have poor results on unselected populations of heroin addicts. Its use is mostly confined to detoxification-related procedures, whereas its long-term effects and properties have been largely neglected. The present study investigates the predictors of successful outcome in a population of 149 current heroin abusers selected as being opioid non-tolerant by a baseline naloxone test, and diagnosed as heroin addicts on the basis of DSM-IV criteria and undergoing long-term naltrexone treatment (naltrexone maintenance). Positive outcome is related to ongoing treatment, whereas negative outcome is due to treatment discontinuation through addictive relapse. Retained individuals are more likely to have no problems at work and to be psychosocially adjusted. Earlier substance users are those most likely to drop out. Global psychopathological impairment, with special reference to mood, aggressiveness and delusions are negatively related to treatment retention. Naltrexone maintenance appears to be suitable for a subgroup of heroin abusers whose clinical pictures combine a low level of addictive disease with the absence of major dysphoria, aggressive behaviour and psychosis.

Published: Volume 06 • Issue 2 • August 2004 (pages: 5 - 52)

Title: Craving in Opiate, Cocaine and Alcohol Addiction

Authors: Kreek M. J., Zhon Y., Schussman S.

Summary: In this overview, we have very briefly covered our basic clinical research studies, as well as a few of our molecular, neurobiological, and behavioural laboratory studies, each of which have given insights into the possible contributors to the neurobiological basis of craving and “drug hunger”. We have also proposed recently that specific medications might be directed at each of these disrupted components of physiology to achieve a “steady-state” and thus normalization of physiological function. We hypothesized years ago, and renew the hypothesis now ,with respect to long-acting opioid agonist treatment of heroin addiction, specifically and primarily methadone maintenance, but also more recently LAAM maintenance and bupernorphine-naloxone treatment, each by the oral (or sublingual) route, that these treatments may achieve normalization of disrupted functions and, at the same time, lead to a reduction of elimination of “drug hunger,” “drug craving,” drug-seeking behavior, and drug self-administration. Future studies, especially studies looking at the interface of genetic factors and environmental factors, combined, of course, with the profound drug-induced factors, may allow us to develop further insights into the biological substrates of craving, and thus enhance our capability of developing both behavioural and pharmacological early interventions, as well as treatments for those with chronic diseases of specific types (see Figure 32 and Figure 33).

Published: Volume 06 • Issue 2 • August 2004 (pages: 53 - 72)

Title: Clinical foundations for the use of methadone in jail

Authors: Maremmani I., Pacini M., Lovrecic M.

Summary: Interventions against drug addiction aim to achieve a satisfactory level of individual well-being, which does not vary despite different starting conditions. Spending time in jail is a common experience in the personal history of addicts; in response, the prison system should implement medical skills that have proven effective in ensuring behavioural control and health preservation for free individuals. Agonist maintenance by methadone or buprenorphine is feasible within prison walls, applying the same criteria that are adopted outside. Firstly, agonist drugs allow a safer relationship with the jailed addict. In addition, they improve the prospects for early release: therapies that started behind bars pave the way towards a life of freedom. Different schedules are suitable for different grades of addictive severity. Less severe patients may be forced out of an ill-chosen style of life as a free individual into an option of therapeutic parole. Hard-core addicts may benefit from the isolation of prison life, in so far as they are initiated and become stabilized on therapeutic regimens during custody. This solution will at least grant them a better quality of prison life. On this view, the prison system can play a crucial role in leading addicts towards therapy, mental health and social adjustment.

Published: Volume 06 • Issue 3 • December 2004 (pages: 5 - 16)

Title: Patient-treatment matching and opioid addicted patients: Past methods and future opportunities

Authors: Strain E. C.

Summary: Patient-treatment matching (PTM) is a proactive process in which individual characteristics of a patient are addressed by specific aspects of a treatment modality. While there is considerable interest in PTM for substance abuse disorders, there has been relatively little work showing its efficacy for addictions in general, and virtually no systematic work on PTM for persons with opioid dependence. This paper addresses three assumptions that underlie the idea of PTM: that meaningful subtypes of patients can be reliably identified, that distinguishably different types of treatment are available, and that those treatments can be provided reliably. Different approaches that are relevant to studying PTM are then briefly reviewed: the Addiction Severity Index, the Transtheoretical Model of Behaviour Change, the subtyping of patients, and the American Society of Addiction Medicine's Patient Placement Criteria. The paper concludes by outlining possible future directions for research on PTM, especially with respect to opioid dependence.

Published: Volume 06 • Issue 3 • December 2004 (pages: 17 - 26)

Title: Methadone patients' sexual dysfunctions: Clinical and treatment issues

Authors: Déglon J. J., Martin J. L., Imer

Summary: Opiates are known to cause loss of libido, erectile and ejaculatory dysfunctions among men, and lack of menstruation and sterility among women. Over the last 30 years, several research studies have shown low testosterone levels causing sexual dysfunction in many heroin addicts or patients treated with opiates (morphine and methadone). Unfortunately, only a few studies on the sexual dysfunctions of patients following a substitution treatment with methadone have become available. We must take these difficulties seriously, as they prevent the development of intimate affective relationships, so inhibiting the social rehabilitation process of these patients. This article provides an overview of recent research studies on the various causes of sexual dysfunctions for patients in substitution treatment, the benefits and risks associated with hormonal replacement therapies, and the value and limitations of bromocryptin prescription, while emphasizing the role of prolactin in sexual dysfunctions. Evaluations of several hundreds of men and women treated at the Phenix Foundation in Switzerland are presented. The sexual dysfunctions that these patients present with are defined by considering the many psychological, psychiatric and neurobiological factors involved. Based on the successful findings of a recent French study comprising the short-term prescription of Viagra, a new hypothesis is put forward on the possible natural increase of testosterone levels after comprehensive treatment involving testosterone level evaluation before and after Viagra prescription, psychosocial counselling and medical supervision. It is hoped that those of our patients who resume sexual activity after months of abstinence will naturally increase their levels of testosterone, thanks to the stimulation of the psyche and of the hypothalamus-hypophyso-testicular axis. The main advantages of this approach seem to lie in enhancing the social rehabilitation of our patients by helping them regain self-confidence and reducing the pressure to perform, along with the fact that patients can gradually quit taking the medication.

Published: Volume 06 • Issue 3 • December 2004 (pages: 27 - 32)

Title: Unreported double frequency of heroin addicts visiting psychiatric services and addiction treatment services

Authors: Lovrecic M., Lovrecic B., Dernovsek M. Z., Tavcar R., Maremmani I.

Summary: The aim of this chart review was to find out the extent of unreported double frequency (UDF) and characteristics of patients. A total of 37 patients with heroin addiction who were treated simultaneously in both services (Mental Health Service [MHS] and Centre for Prevention and Treatment of Illegal Drug Addiction [CPT]) in the last 10 years (the period during which the two services have coexisted) were identified. Patients were interviewed and case records were analyzed. Sociodemographic and clinical data were collected and the AbSo instrument was used. Factor analysis was used to identify clusters of symptoms reported by patients and models of drug prescription in patients receiving or not receiving methadone. Lastly we studied Pearson's correlation between identified symptomatological factors and identified models of drug prescription. In two thirds of our patients in the MHS, drug addiction was not recognized at first consultation. Patients tended to deny their drug-related problems and methadone maintenance. Depressive symptoms and anxiety were the features most commonly found in our sample, while psychotic symptoms were rare. There was poor cooperation between general psychiatric and addiction services, which led to addiction being underdiagnosed and withdrawal symptoms being mistreated.

Published: Volume 06 • Issue 3 • December 2004 (pages: 33 - 36)

Title: Evaluation of effectiveness of drug treatment programmes in Ukraine

Authors: Sergiy Dvoryak

Summary: Not available

Published: Volume 06 • Issue 3 • December 2004 (pages: 37 - 40)

Title: Bad patients or bad treatment?

Authors: Payte J. T.

Summary: Not available

Published: Volume 06 • Issue 3 • December 2004 (pages: 41 - 50)

Title: Opiate Dosage Adequacy Scale (O.D.A.S.): A clinical diagnostic tool as a guide to dosing decisions

Authors: Gonzales-Saiz F.

Summary: Not available

Published: Volume 07 • Issue 1 • March 2005 (pages: 7 - 18)

Title: Buprenorphine induction and stabilisation in the treatment of opiate dependence

Authors: Doran C., Holmes J., Ladewig D., Ling W.

Summary: Many early trials of buprenorphine in opiate dependence used fixed doses and slow induction protocols. However, more recent data show that subjects requiring higher doses need to be stabilised more rapidly. Analysis of ten trials suggests a relationship between days taken to reach a 6 mg buprenorphine tablet equivalent dose and retention of subjects at 4 weeks. Recent US studies show that dosage can be stepped up quickly, e.g. 8 mg on Day 1, 16 mg on Day 2. Maintenance dosage should then be adjusted to meet patients' clinical needs; fixed dose studies ignore the breadth of buprenorphine's effective dose range.

Published: Volume 07 • Issue 1 • March 2005 (pages: 19 - 30)

Title: Clinical significance of electroencephalographic abnormalities in heroin addicts: Systematic review

Authors: Polunina A. G., Davydov D. M., Briun E. A.

Summary: The present review is the result of a systematic attempt to collect and analyze all the available contemporary data on neurological and psychophysiological aspects of EEG changes in heroin addicts. These data offer valuable objective insights into clinically significant encephalopathic and/or disintegrative processes in these patients. Thirteen computer EEG studies published since 1995 have been analyzed. It can be concluded that the sensitivity of computer EEGs to heroin-induced brain alterations is comparable with other contemporary neuroimaging techniques. In any case, precise recommendations for their use in regular medical practice must await further extensive research in this field.

Published: Volume 07 • Issue 1 • March 2005 (pages: 31 - 38)

Title: Alcohol abuse in heroin addicts: An unfolding metabolic destiny

Authors: Pacini M., Mellini A., Attilia M. L., Ceccanti M., Maremmani I.

Summary: This paper deals with the issue of alcohol-abusing heroin addicts. On the basis of clinical and epidemiological findings, a view is presented which links the two kinds of abuse along a common metabolic pathway. Some data about the former history of opiate abuse in treatment-seeking alcoholics help to indicate which heroin-related features may influence the incidence and severity of alcohol abuse in heroin addicts. Observations point to alcohol abuse as one possible pathological outcome of the opioid metabolic impairment underlying heroin addiction. When alcohol is a surrogate for heroin, social adjustment improves, but the metabolic destiny does not change, and the medical outcome is worsened to some extent by the low chances of curing a possible actual alcoholism to come. Correctly handled agonist treatments are crucial in preventing that kind of negative outcome, whereas alcohol abuse as an opioid equivalent calls for greater attention, to allow adequate assessment of the effectiveness of treatment programmes for opiate addiction.

Published: Volume 07 • Issue 1 • March 2005 (pages: 39 - 46)

Title: Symptomatic treatment of opiate withdrawal syndrome by low-dose buprenorphine in an in-patient setting

Authors: Fuscone A., Correale M., Romualdo M., Bianchi W.

Summary: The present study aims to assess the effectiveness of buprenorphine treatment in countering predictable withdrawal from street opiates in 68 opiate-addicts who requested admission to an in-patient opiate detoxification facility. Buprenorphine was administered at flexible doses, on a patient-blind clinical basis. Withdrawal was assessed by scoring a range of symptoms at the start of treatment (T0) and three more times during treatment (T1-T3). The dropout rate was 14.7% and was not predicted by baseline clinical features. The average duration of treatment was 7.5 days. By then, buprenorphine had provided patients with quick-acting, stable protection against withdrawal symptoms and was well tolerated. Additional drugs were successfully resorted to when non-specific symptoms such as anxiety and insomnia were prominent. Buprenorphine proved effective in soothing withdrawal-related symptoms in a subgroup of mildly ill subjects. The short-term dropout in this population did not seem to be related to the severity of baseline withdrawal or to the absence of earlier improvement under buprenorphine.

Published: Volume 07 • Issue 1 • March 2005 (pages: 47 - 48)

Title: Open letter to physicians and other health care providers facing pain management during opioid agonist therapy with methadone

Authors: Payte J. T.

Summary: Not available

Published: Volume 07 • Issue 2 • June 2005 (pages: 5 - 10)

Title: Methadone maintenance treatment and mood disturbances: Pharmacological and psychological implications

Authors: Dyer K. R.

Summary: The rationale for methadone maintenance is to stabilise the pharmacological condition of illicit opioid users, thereby providing an opportunity to normalise health and social functioning. The extent to which methadone is effective for any given individual may be governed by the degree to which methadone prevents opioid withdrawal symptoms, in the absence of significant opioid adverse effects. Mood and anxiety disorders are common within opioid-dependent patients, and there is some evidence to suggest that these disorders may affect the response to treatment. This paper will describe the relationship between plasma (S)- and (R)- methadone concentration, opioid withdrawal, and state and trait mood disturbance. A series of studies have demonstrated that significant mood changes occur in response to changes in plasma methadone concentration, and that these mood changes are more pronounced in those who experience opioid withdrawal. Concentration-effect relationships suggest that relatively small changes in plasma concentration result in significant mood change. An important implication from this research is that consideration of individual differences in methadone pharmacokinetics is necessary for understanding the aetiology of observed mood disturbance among methadone dependent patients. Implications for the clinical management of methadone patients, including the assessment of, and response to, mood disorders and the implications for therapeutic drug monitoring within methadone maintenance programs will be discussed.

Published: Volume 07 • Issue 2 • June 2005 (pages: 11 - 18)

Title: Long-term treatment for patients with severe mental illness and substance abuse

Authors: Blix O., Eek U.

Summary: Drug and alcohol addiction is common among patients with severe mental illness. Those patients often fall between different treatment systems. Since 1994 a long-term treatment for patients with this kind of “Dual Diagnosis” has been going on in the city of Jonkoping, Sweden. It is a joint programme with staff both from the local social services and the psychiatric clinic. A team of six people, three social workers and three nurses with special education in psychiatry, are working with a group of at most 35-40 patients. A stepwise treatment lasts for a minimum of 3 years, after a model constructed and evaluated in the U.S. (Meuser and Drake, New Hampshire). The aim of the treatment is enduring retention leading to the stabilization of both problem areas. The treatment goals are set by each client. Great attention is given to training in social skills. Between 1994 and 2004, 82 patients in all were in the treatment programme. The results of the treatment programme are presented.

Published: Volume 07 • Issue 2 • June 2005 (pages: 19 - 24)

Title: Good practice, good results. Maintenance treatment outcomes in France

Authors: Coppel A.

Summary: In 2004, a public debate emerged on the misuse of, and trafficking in, prescribed drugs. Because of their positive outcomes, maintenance treatments were not officially questioned. A national evaluation showed that the decrease of 80% in fatal overdoses and of 67% in arrests for heroin use (1994-1999) were directly connected with treatment accessibility. This assessment resulted in a consensus among addiction and public health experts. These good results have not, however, been published by the mass media, and the general public still is unaware of them. Nor were the causes of these good results were not discussed among health professionals. They are not only due to the medications involved, but to good clinical practices. The first practitioners who started to prescribe maintenance treatment had followed extensive training, and were networking and building relationships of trust with their patients. Against the background of this public debate, a consensus conference on maintenance treatments organized in 2004 recommended that the prescribing GPs should be better trained, and that they should be included in professional networks. Although these recommendations gave priority to the improvement of clinical practices, the authorities have decided to implement control measures over patients. These measures might make access to treatment more difficult, and they fail to support the involvement of GPs and pharmacists. The effectiveness of substitution treatments could be affected.

Published: Volume 07 • Issue 2 • June 2005 (pages: 25 - 30)

Title: The endogenous cannabinoid system: Physiological modulation of neuronal activity

Authors: Marsicano G.

Summary: The endogenous cannabinoid system in the brain consists of the seven transmembrane cannabinoid receptor type 1, its endogenous lipid ligands (endocannabinoids) and the enzymatic machinery for their synthesis and degradation. By genetic, pharmacological, biochemical and behavioural approaches, our group has recently described several physiological functions of the endogenous cannabinoid system, such as processing of aversive memories, neuroprotection against excitotoxicity and regulation of energy balance. These and other results indicate that the endogenous cannabinoid system is centrally involved in many physiological functions and that pathological alterations in defect or in excess of its activity might participate in the progress of several diseases

Published: Volume 07 • Issue 2 • June 2005 (pages: 31 - 36)

Title: Substitution treatment in European prisons. A study of policies and practices of substitution treatment in prison in 18 European countries

Authors: Hennebel L. C., Stöver

Summary: The objective of this study was to examine policies in place for the provision of substitution treatment in prisons and existing practices in 18 European countries. The report presents findings per country through ‘country reports', together with ‘emerging issues' across the countries, which inform the recommendations made at the end.

Published: Volume 07 • Issue 2 • June 2005 (pages: 37 - 48)

Title: Medical meaning of psychosocial issues of heroin addiction

Authors: Pacini M., Maremmani I.

Summary: Drug addiction is often characterized by psychosocial highlights, so that it has been repeatedly depicted as a social disease, although to differing degrees. A variety of interventions have been proposed and applied as therapies, more on the basis of intentions than of scientific prospects of success: in fact, they all seem to share common roots in conceptions of addiction as being the outcome of a vicious social dynamic. The scientific vision of addiction as a medical issue allows a more reasonable evaluation of addiction-related social issues, both on pathophysiological and therapeutic grounds. To date, advisable first-line interventions for drug addiction have not been of a psychosocial kind. On the other hand, psychosocial markers have been crucial in assessing the effectiveness of pharmacological treatments since the very earliest stages of research in the field of methadone treatment. Furthermore, psychosocial adjustment and well-being should always be measured when newer approaches are tested, since they are crucial in allowing meaningful comparisons between treatment options. Lastly, a subgroup of heroin addicts, who suffer from severe psychosocial impairment, partly unrelated to addiction, should be offered psychosocial facilities as soon as they have been stabilized on an agonist treatment: predictably, their psychosocial well-being will not, as happens with others, follow the remission of drug abuse, but maintenance treatment will make them suitable for so-called pharmacologically assisted rehabilitation programmes.

Published: Volume 07 • Issue 3 • September 2005 (pages: 5 - 20)

Title: Psychotherapy for patients in methadone treatment

Authors: Bignamini E., Zazza S.

Summary: The management of methadone treatment requires the doctor to have a good level of relational and psychopathological competence. Drug addiction is a pathological condition, and may be defined as a “pleasure disorder” that comprises the following features: greed, compulsive mourning for the lost object, regrets for the fusional-heroic dimension. These features require psychotherapeutic treatment, which may be applied using the specific techniques developed by different schools (of psychodynamic, systemic relationship, behavioural-cognitive and group therapy).

Published: Volume 07 • Issue 3 • September 2005 (pages: 21 - 26)

Title: Buprenorphine high-dose, broad spectrum, long-term treatment: A new clinical approach to opiate alkaloid dependency

Authors: Di Petta G., Leonardi C.

Summary: In a large but neglected district north of Naples, Italy, the Department for Dependencies has adopted a new treatment strategy: high-dose sublingual buprenorphine tablets for broad-spectrum, long-term use against opiate dependency. The trial is still in progress. 650 patients in the study from three U.O.SER.T. branches were included and received long-term treatment with buprenorphine. At present, 600 patients remain in treatment. The following parameters were investigated: overdose, morphine in the urine, side-effects, social and occupational reintegration, compliance with psychotherapeutic and rehabilitational treatments and reduction in the costs of hospitalization. The results show how compliance with broad-spectrum, high-dose, long-term buprenorphine treatment proves beneficial both from a clinical viewpoint and from a socio-economic one. The data suggest that: buprenorphine is not only indicated for patients with mild-to-moderate drug dependency; patients receiving buprenorphine <16 mg may be at risk of relapse into heroin use or to dropping out, with a consequent need for re-initiation of treatments; high-dose, long-term buprenorphine was remarkably effective in terms of reducing withdrawal and craving, and maintaining patients in lasting programmes of psychosocial rehabilitation; high-dose buprenorphine offers a new innovative treatment strategy in the integrated approach to opiate dependency.

Published: Volume 07 • Issue 3 • September 2005 (pages: 27 - 32)

Title: Correlation between high methadone dose and methadone blood level in methadone maintenance treatment patients

Authors: Peles E., Bodner G., Adelson M.

Summary: Methadone dosage has been widely related to the degree of enduring opiate use and polyabuse while on methadone, lower dosages favouring partial rather than complete response and a worse outcome. Up to certain threshold, methadone blood levels seem to be directly related to oral dosages, thus supporting the clinical evidence of a methadone-induced, dose-dependent remission of addictive behaviour through a serological marker. In order to assess the clinical meaning of methadone blood levels, and its relationship to oral dosages, we performed an evaluation of 114 methadone treated subjects, who were stable on methadone dosages ranging from 40 to 290 mg (mean 171.7±50.8 mg). Lower methadone dosages correspond to lower blood levels and a higher rate of opiate abuse while on treatment. Non-opiate substance abuse characterized patients on higher methadone dosages, whose methadone blood levels were in fact higher. Cocaine abusers had higher methadone dose regardless of concurrent opioid abuse, while benzodiazepine abuse plays a role in respect to dosage only in those who do not abuse opioids. Blood testing also showed an inverse relationship between methadone dose and blood sodium, which warrants further investigation

Published: Volume 07 • Issue 3 • September 2005 (pages: 33 - 46)

Title: Addictive disorders, bipolar spectrum and the impulsive link: The psychopathology of a self-regenerating pathway

Authors: Maremmani I., Pacini M., Perugi G.

Summary: Impulsiveness is a typical feature of mood elation states, with a double link: on one hand, impulsive behaviour is favoured by manic states, on the other manic states are accompanied by a drive towards pleasurable objects and situations, which are repeatedly sought after, and may become prominent in the life of the individual. Mood elation does not bring with it its own antidotes, but, conversely, brings exposure to increasing levels of pro-manic stimulation, in a self-regenerating circuit. On epidemiological grounds, some observations can be cited: 1) impulse control disorders can be viewed as closely linked with bipolar disorders, especially when minor excitement (hypomania) and the whole bipolar spectrum are taken into account, beyond full-blown bipolar I patterns; 2) impulse control disorders tend to cluster, suggesting common grounds of pleasure-seeking and reward, regardless of the specific objects that are craved for in different periods or moments. Substance abuse can be read as one kind of impulse control disorder, linked to others and to the bipolar spectrum by a self-regenerating dynamic. Addiction is an autonomous disorder which can be seen as the extreme degree of an impulse control disorder, with paroxysmal craving and a self-maintaining or relapse-inducing course. Impulse control disorders, the bipolar spectrum and substance abuse also share some distinctive symptoms displayed during depressive states or during protracted abstinence, described under the name “hypophoria” and probably underlying the impairment of the brain-rewarding system.

Published: Volume 07 • Issue 3 • September 2005 (pages: 47 - 50)

Title: Bridging the preclinical - clinical gap

Authors: Nutt D. J., Lingford-Hughes A., Daglish M., Williams T., Taylor L., Wilson S., Davies S., Melichar J., Myles J.

Summary: Not available

Published: Volume 07 • Issue 3 • September 2005 (pages: 51 - 52)

Title: Mortality and retention of drug users in GP Shared Care in Glasgow

Authors: Gilhooly T.

Summary: Not available

Published: Volume 07 • Issue 3 • September 2005 (pages: 53 - 56)

Title: Working with the patient for optimal treatment outcomes in UK General Practice

Authors: Ford C., Oliver J., Whitehead B.

Summary: Not available

Published: Volume 07 • Issue 4 • December 2005 (pages: 5 - 22)

Title: Addiction and Pregnancy

Authors: Finnegan L., Amass L., Jones H., Kaltenbach K.

Summary: Addiction during pregnancy contributes to maternal and infant morbidity including pre-term deliveries, low birth weight, neonatal withdrawal, lengthy neonatal intensive care and infant mortality. Combined use of pharmacological and behavioral treatment approaches in managing pregnant opioid-dependent women has been shown to be beneficial for improving treatment retention and reducing maternal drug use. Clinicians should understand the complex biopsychosocial factors that make the treatment of opioid-dependent pregnant women a challenge as well as the principles and the differences in using methadone or buprenorphine combined with behavioral treatment. Researchers should consider continued studies on the use of methadone during pregnancy, relationship of maternal dose and neonatal abstinence, the differences between methadone and buprenorphine, and the impact of pharmacological options on patients and treatment providers.

Published: Volume 07 • Issue 4 • December 2005 (pages: 23 - 30)

Title: Primary care physicians and addiction treatment in Germany. Decentralization and take-home policy

Authors: Ulmer A.

Summary: Medical knowledge is not always discovered in universities and laboratories, before finally trickling down to primary care physicians. In some cases, the very opposite is true. Even in Germany, primary care physicians have sometimes been the first to develop new methods of treatment and introduce them in day-to-day medical practice. Unfortunately, the German medical system is unaccustomed to listening to their voice. As a result, new treatment methods introduced by this route meet with specific difficulties. Maintenance therapy for drug addicts was introduced in Germany in the 1980s, mainly by primary care physicians in the face of major resistance from the medical establishment. The need to take action was high, however, and primary care physicians were the professionals who felt this most keenly. Increasing numbers of primary care physicians started putting patients on maintenance therapy. Dihydrocodeine was the agent most frequently chosen, as methadone was prohibited until 1992. Responses were excellent for committed physicians who ensured that the necessary arrangements were in place. However, because of the lack of integration in established medical practice, unstructured prescription was rife, leading to new problems and culminating in a series of deaths. The official reaction was to tighten the regulations, with the consequence that most primary care physicians have given up. Maintenance is now predominantly offered by special maintenance centers, leading to a strong concentration of these specific patients. France and Croatia, but also other countries show us ways out of this dilemma. Decentralized, very liberal maintenance policies in France make maintenance easy and successful. We can learn, that a good support system for the practitioners helps to avoid quality problems, crucially, from the Croatian model.

Published: Volume 07 • Issue 4 • December 2005 (pages: 31 - 42)

Title: Psychopathological disorders in heroin addicts and administration of risperidone during rehabilitation

Authors: Kozlov A. A., Dorovskih I. V., Doljanskaia N. A., Buzina T. S., Polunina A. G.

Summary: The topic of the present study is the clinical picture of psychopathological symptoms during post-withdrawal periods in heroin addicts. Craving symptoms can be compared to productive psychopathological symptoms, and their intensity usually corresponds to the severity of depressive disorders in heroin ex-addicts. Risperidone is therefore a preferred choice for craving control when opiate maintenance therapy is unavailable (as it is currently in Russia). This antipsychotic showed its effectiveness and safety during prolonged anti-relapse therapy in the out-patient treatment of heroin addicts.

Published: Volume 07 • Issue 4 • December 2005 (pages: 43 - 48)

Title: Methadone reduces the need for antipsychotic and antimanic agents in heroin addicts hospitalized for manic and/or acute psychotic episodes

Authors: Pacini M., Maremmani I.

Summary: Clinicians are in agreement about the primary psychotropic properties of opiate drugs, but the issue of opioid abuse liability and physical dependence has hampered research. Despite this, the psychotropic properties of therapeutic opiates can be investigated indirectly in populations of dual diagnosis heroin abusers. We retrospectively evaluated the clinical files of 114 consecutive heroin addicts admitted for in-patient treatment of manic and/or acute psychotic episodes, in order to assess the relationship between methadone treatment during hospitalization and prescriptions at discharge. Regardless of the reasons for their hospitalization, subjects receiving increasing dosages of methadone were judged to be less in need of antimanic and antipsychotic drugs at discharge. These results support the idea that methadone has quick-acting anti-dysphoric and anti-impulsive properties which apply to a wide range of psychiatric disorders.

Published: Volume 07 • Issue 4 • December 2005 (pages: 49 - 58)

Title: Methadone serum concentration and its relationship to methadone dose revisited

Authors: Okruhlica L., Valentova J., Devinsky F., Formakova S., Klempova D.

Summary: The study sample included 64 patients, who were divided into two subgroups on the basis of their daily methadone dose: ´Group 1´: 29 patients with doses up to 80 mg; ´Group 2´: 35 patients with doses above 80 mg. The overall correlation in the whole group was: r = 0.570. A strong correlation was found between dose and serum concentration in ‘Group 1': r = 0.799. Non-significant correlation close to zero was found in ‘Group 2'. Our findings suggest that the linear relationship between methadone dose and its serum concentration in lower doses cannot be extrapolated to higher doses.

Published: Volume 07 • Issue 4 • December 2005 (pages: 59 - 66)

Title: Medical and social factors determining early poly-drug dependence

Authors: Chernobrovkina T. V., Igor A. Nikiforov I. A.

Summary: Adolescent narcotism has grown into an epidemic in Russia. Younger drug experimenters seem to run a higher risk of habitual involvement in drug use as a lifestyle, which also makes them liable to develop addictive diseases through enduring exposure to drugs. Moreover, polyabuse seems to be the rule among younger addicts, which increases the likelihood that physicians will have to deal with multiple addictive pictures, destined to a poor outcome and pervasive disruption. Upbringing, environmental ties and opportunities, economic status and family-related lifestyle may play a crucial role in supporting or discouraging a sensation-seeking lifestyle, although personality factors come first in establishing a risk disposition. In any case, on preventive grounds, the identification of stereotypes in drug user populations may offer a helpful means of impeding or reversing the transition from experimental drug use to habitual drug use and then addiction. The administration of a 20-item psychosocial questionnaire to a sample of 150 subjects aged between 7 and 18 helped us to ascertain the prevalence of social problems and drug use trends in a younger risk population. The handling of pleasure-seeking drives and needs by environmental facilities may reduce youngsters' interest in substance use and provide them with other kinds of practical, spiritual and pleasurable habits.

Published: Volume 08 • Issue 1 • March 2006 (pages: 5 - 10)

Title: Necessity of a world federation of health organizations providing opiate agonist therapy for heroin addicts

Authors: Parrino M.

Summary: Not available

Published: Volume 08 • Issue 1 • March 2006 (pages: 11 - 24)

Title: Heroin dependence in the Russian Federation: the current situation

Authors: Kozlov A. A., Perelygin V. V., Rohlina M. L., Vyshinsky K. V.

Summary: This article reviews the current situation surrounding heroin addiction in the Russian Federation; it describes the epidemic patterns associated with that addiction, including their negative impact and complications (HIV, hepatitis, asocial behaviour, mortality). The need to search further for effective integrated approaches to prevention, treatment and rehabilitation is demonstrated with reference to the attitudes of progressive scientists, to the historical experience of Russian addictive psychiatry and to the recommendations of the WHO. The proposal is made that there should be an ongoing search for a differentiated approach and for appropriate criteria to be adopted in integrated treatments of HIV infection and other socially significant consequences of drug addiction; these will call for discussions on substitution therapy.

Published: Volume 08 • Issue 1 • March 2006 (pages: 25 - 30)

Title: No intrauterine growth retardation in babies of mothers stabilized on methadone before conception and throughout their pregnancies

Authors: Klempova D., Okruhlica L.

Summary: The aim of the present study is to explore the maturity of neonates of women who had conceived while being stabilized on methadone and who remained stabilized throughout their pregnancies. The sample comprised ten women and their neonates. All the neonates were eutrophic and nine of them were full-term. Mean birth weight of the neonates was 3,193 g. None of the measures of maturity differed from the data for the general population. The results obtained do not indicate any negative effect of methadone alone on neonatal maturity.

Published: Volume 08 • Issue 1 • March 2006 (pages: 31 - 48)

Title: Effectiveness of buprenorphine in double diagnosed patients. Buprenorphine as psychothropic drug

Authors: Maremmani I., Pacini M., Pani P. P.

Summary: Opiate drugs were first proposed for the treatment of dysphoric syndromes, depression and psychoses many years ago. Even so, the usefulness of these compounds in psychiatry is supported by only a small corpus of data. The reasons given for the restrictions placed on opiate use are based on prejudice rather than scientific evidence. Buprenorphine, with its unique pharmacological profile, has proved to possess antidepressant, anti-dysphoric and antipsychotic properties in small groups of psychiatric patients. Moreover, it may turn out to be the opiate of choice in subjects affected by lower severity addiction coupled with dysthymic disorders, anxiety disorders and personality disorders. The best dosages appear to be those that ensure a combination of k-antagonism with high levels of μ-mediated stimulation.

Published: Volume 08 • Issue 2 • June 2006 (pages: 5 - 22)

Title: Say “Yes” to Methadone and Buprenorphine in Russian Federation

Authors: Maremmani I., Pacini M., Pani P. P., Parrino M.

Summary: The medical community has determined that narcotic addiction is a chronic and relapsing medical disorder, which is effectively treated with medications. The success rate of patients, who are treated with medications, such as methadone and buprenorphine, when combined with other needed treatment services, improves the health of the patient. Methadone and buprenorphine are the most exhaustively studied medications for the treatment of any disease. More than 40 years of research and clinical practice have repeatedly demonstrated its efficacy in millions of patients throughout the world. An objective observer might argue that it is irresponsible not to use such medications to treat narcotic addiction in an age of HIV infection, hepatitis-C and other developing co-morbidities

Published: Volume 08 • Issue 2 • June 2006 (pages: 23 - 35)

Title: Knowledge and attitudes of drug treatment professionals towards HIV prevention and care activities in the Russian Federation

Authors: Dolzhanskaya1 N. A., Bouzina T. S., Kozlov A. A., Sarang A.

Summary: Illicit drug use and HIV has spread rapidly in Russia, with 75% of HIV cases attributed to heroin and opiate IDU. The integration of drug treatment and HIV services would ensure access to HIV prevention and treatment for IDUs, but so far this has not happened. A series of interviews and focus groups reveals the attitudes of drug treatment specialists to the risks run by their patients, together with those specialists' knowledge of the issues involved; these data make clear the opportunities that exist to integrate HIV services. We recommend better training in HIV issues such as principles of HIV counselling, harm reduction and substitution treatment. Measures to ensure access to HIV information and care within drug treatment settings and better research on these issues are an important priority.

Published: Volume 08 • Issue 2 • June 2006 (pages: 37 - 46)

Title: A Low Value Voucher Contingency Management Programme with Israeli Methadone Maintained Patients – A Pilot Evaluation Study

Authors: Lawental E., Eshkol D.

Summary: Purpose: This study evaluated, for the first time, the effectiveness of a voucher-based contingency management programme (CMP) with a population of methadone-maintained patients outside the U.S.A. The study reported was carried out at the Haifa Drug Abuse Treatment Centre in Israel. The population studied differed culturally from previously studied groups in the U.S.A. Vouchers were given to patients upon providing a urine test that was negative for illicit drug use. With the accumulation of three consecutive vouchers subjects could redeem one for one take home dose. After the accumulation of five or more consecutive vouchers subjects were able to redeem two for two consecutive take-home doses. Method: Two groups of subjects were evaluated in this study. In the first group, subjects (n = 35) treated prior to the initiation of the CMP were included. These subjects provided 455 urine samples in the three months prior to the CMP. In the second group, subjects (n = 41) treated after initiation of the CMP were included. A three-month period was allowed for the Centre to adjust to the new CMP. Subjects in the “post” group provided 554 urine samples in the three months following this period. No statistically significant differences were noted between the groups with reference to their pre-treatment characteristics and the length of time subjects stayed in treatment. Results: The post CMP group showed an improvement in providing samples free of illicit substance abuse. An improvement of 36.3% was noted. The post group also had 47.1% more stable-on-methadone subjects. Conclusions: This study supports the claim that such a CMP may be effective in reducing illicit drug abuse in the Israeli methadone-maintained patient population. As the sample of this study is relatively small and no attempt was made to identify a specific group of Israeli patients that may benefit even more from this type or other types of CMP, additional studies are needed.

Published: Volume 08 • Issue 2 • June 2006 (pages: 47 - 49)

Title: Treatment for hepatitis C in jailhouses is doable and successful: definitive data of first national French study (POPHEC)

Authors: Remy A. J., Serraf L., Galinier A., Hedouin V., Gosset D., Wagner P.

Summary: Background: A French survey of 85 jailhouses in 2000 yielded disappointing results on the diagnosis and treatment of hepatitis C (HCV) in inmates: serology was available for 2/3 of the patients, but only 36% had undergone liver biopsies (LB) and only 4% had been treated. LB access was identified as an obstacle to therapy. This prospective study (POPHEC) was designed to increase treatment access in this population. Methods: 37 medical units in French jailhouses participated. Patients were all to be treated with a combination of pegylated interferon alpha 2b and ribavirin. LBs were optional. Biochemical, virological and clinical data were collected. Therapy and data collection continued for patients who were transferred. In cases where final data were unavailable, patients were classified as non-responders. Results: As of 1st June 2004, 200 patients were analysed: 94% were male, mean age 37 years, contamination route IVDU in 78%, transfusion in 3%. The genotype was 1a, 1b, 3a and 4 in 28%, 11%, 36% and 7%, respectively; 12% were also infected with HIV; 37% were treated with methadone or buprenorphine. The average viral load was 1227689 IU/mL; 33% had LB before treatment, with a mean Metavir score of A1.8 F1.73. The mean treatment duration ranged between 4 months in patients with early termination due to non-medical reasons and 7 months for patients who completed therapy; 95 patients (47.5%) experienced a complete sustained response). Conclusion: treatment for HCV in jailhouses is feasible and sucessful; the limitations placed on indications for LBs, as recommended by the 2002 French consensus conference, apply specifically to the inmate population and facilitate access to HCV therapy, besides helping initiatives such as POPHEC

Published: Volume 08 • Issue 2 • June 2006 (pages: 51 - 54)

Title: Is heroin addiction related to a dysfunctional processing of reward and hedonism in the brain? Insights from neuroimaging studies

Authors: Martin-Soelch C.

Summary: The functioning of reward in drug addicts is a major issue both in terms of pathophysiology and in a rehabilitative view. We used a PET imaging device to assess the hedonic functioning of methadone maintained heroin addicts, compared to control subjects, by two modalities: 1) the elicitation of interest by anticipated monetary reward; 2) the neuroimaging correlates of visually elicited pleasure. In heroin addicts fewer brain regions showed activated during tasks implying known monetary reward in comparison to tasks without any reward. On the other hand, the processing of subjectively pleasant videoclips resorted to different brain pathways in heroin addicts. Heroin addicts seem to show a lower level of anticipatory sensitivity to monetary reward, whereas the topography of pleasure-feeling seems to be different from normal subjects'. Such results show a different reward-seeking and reward-feeling status of methadone maintained heroin addicts, although it is to be clarified whether such a status was also forerunning heroin use, or developed as a correlate of addiction.

Published: Volume 08 • Issue 3 • September 2006 (pages: 7 - 12)

Title: Forty years of Methadone Maintenance Treatment around the world: past, present and future

Authors: Maremmani I.

Summary: Not available

Published: Volume 08 • Issue 3 • September 2006 (pages: 7 - 12)

Title: Methadone and Treatment Quality. The EFQM Excellence Model

Authors: Flego A.

Summary: In the technologically advanced world, providers of products and services have been dealing with the problem of quality, of how to assess its level, and of how to improve it continuously and systematically for many years. Therefore, this aspect cannot be eluded when scientifically planning and practically organizing a methadone treatment program. The treatment with methadone, although it is safe and relatively easier than others, is still at the centre of a great controversy. This is mainly due to the fact that the controversy lies in the basic reasons of the treatment with methadone rather than in the effectiveness of this treatment. The search for quality is a never-ending, dynamic process, and excellence itself is not definitive. It is a circular process that has to progressively improve the performances but also to defend itself from the natural entropy of not-managed situations (it has to continually introduce “negative entropy”). This process has to continually take into consideration innovations and new knowledges or ‘scientific evidence'.

Published: Volume 08 • Issue 3 • September 2006 (pages: 37 - 48)

Title: Treatment of chronic hepatitis C virus infection in intravenous drug addicts: State-of-the-Art

Authors: Guadagnino V., Trotta M. P., For the Nocchiero Study Group

Summary: Injection drug users (IDUs) are the largest group of people infected with the hepatitis C virus, and the group among whom most new infections occur. Treatingchronic hepatitis C in IDUs is important at an individual level and from a public health perspective. Treatment with a combination of pegylated interferon and ribavirin eradicates the virus in a high percentage of patients depending on the HCV genotype. Unfortunately, HCV-positive IDUs are rarely offered this treatment because of their assumed lower compliance with treatment, psychiatriccomorbidities, social discomfort and the risk of reinfection. However, there is increasing evidence that IDUs treated for HCV infection can achieve a sustained virological response comparable to that of non-IDUs. It has also been shown that drug addicts with HCV infection can benefit from anti-HCV treatment if it is given within the framework of a multidisciplinary standardized model of care. In this scenario, prospective clinical trials are warranted to establish new guidelines for the treatment of HCV infection in patients with drug dependence.

Published: Volume 08 • Issue 4 • December 2006 (pages: 5 - 8)

Title: Combating the Stigma: Discarding the Label “Substitution Treatment” in Favour of “Behaviour-Normalization Treatment”

Authors: Maremmani I., Pacini M.

Summary: Not available

Published: Volume 08 • Issue 4 • December 2006 (pages: 9 - 28)

Title: In the Service of Patients: The Legacy of Dr. Dole

Authors: Joseph H., Woods J. S.

Summary: The underlying theme in Dr, Vincent P. Dole's work is the effect of metabolism on behavior. This led to ground breaking investigations at The Rockefeller University in electrophoresis, lipids, obesity, addiction, and the development of methadone maintenance in 1964 with his late wife, Dr. Marie E. Nyswander. Dr. Mary Jeanne Kreek, a research resident in his laboratory in 1964, is now continuing addiction research as a professor at Rockefeller. Dole developed methadone detoxification in the New York City jail system and office based methadone medical maintenance with Nyswander. His major concern was to resolve the stigma that methadone patients encounter.

Published: Volume 08 • Issue 4 • December 2006 (pages: 29 - 40)

Title: Injecting Buprenorphine Tablets: A Manageable Risk

Authors: Reisinger M.

Summary: Buprenorphine for the treatment of heroin addicts was launched on the French market in February 1996. Ten years on, more than 85,000 patients are undergoing this treatment and most reports are positive. However, it has been observed that a certain proportion of patients are using buprenorphine inappropriately. Instead of taking buprenorphine sublingually, as prescribed, these users crush tablets to inject them3. This practice of injection also involves individuals not undergoing this treatment. The same problem of buprenorphine diversion and injection has been observed in several other countries, like England, Scotland, Ireland, New Zealand, Australia, Finland and the Czech Republic. Given the reported substantial benefits of buprenorphine for individuals and for public health generally, it is important to analyse the problem of buprenorphine injection to get a better understanding of the origins of this problem, its incidence, consequences, causes and remedies.

Published: Volume 08 • Issue 4 • December 2006 (pages: 42 - 52)

Title: QTc Prolongation in Methadone Maintenance: Fact and Fiction

Authors: Schmittner J., Krantz M. J.

Summary: Methadone is an effective treatment for opioid dependence- and, until recently, was viewed as a medication without cardiac properties. High-dose therapy has been linked to prolongation of the rate-corrected QT interval (QTc) and torsade de pointes (TdP), a form of ventricular tachycardia requiring QTc prolongation. To date, only one prospective study has demonstrated a modest increase in QTc with methadone. Arrhythmia risk is related to the magnitude of the QTc change from baseline. Clinicians should be aware of methadone's potential cardiovascular effects and weigh the benefit-to-risk ratio for each patient, based upon individual risk for arrhythmia.

Published: Volume 08 • Issue 4 • December 2006 (pages: 53 - 64)

Title: Methadone: Is It Enough?

Authors: Gossop M.

Summary: This paper looks at the applications of methadone in day-to-day clinical practice. It reviews the evidence of effectiveness, including those areas in which the outcomes of methadone treatment are less satisfactory. Although the majority of patients respond well to methadone maintenance, about one in four tends not to respond well to treatment. An important question is how to achieve a better understanding of the reasons why patients respond or fail to respond to methadone treatment. The paper considers some ways in which methadone treatments could be strengthened.

Published: Volume 09 • Issue 1 • March 2007 (pages: 5 - 24)

Title: Effects of Opioid Pharmacotherapy on Psychomotor and Cognitive Performance: A Review of Human Laboratory Studies of Methadone and Buprenorphine

Authors: Mintzer M. Z.

Summary: Opioid pharmacotherapy can provide the stability necessary to initiate lifestyle changes, obtain steady employment and function in society. Thus, a critical question is the extent to which pharmacotherapy is associated with impairment in psychomotor and cognitive performance that might affect functioning. In this article, I review human laboratory studies of the effects of the most common opioid pharmacotherapies, methadone and buprenorphine, on psychomotor and cognitive performance (both observational group comparison and experimental drug administration studies) and the effects of withdrawal from opioid pharmacotherapy on performance. I then outline some recommendations for further study in this area.

Published: Volume 09 • Issue 1 • March 2007 (pages: 25 - 34)

Title: The Vincent P. Dole Research and Treatment Institute for Opiate Dependence: An Integrated Biopsychosocial Model for the Treatment of Methadone Maintained Patients

Authors: Curet E., Beeder A. B., Joseph H., Alexander K., Schamisso C., Rodriguez H.

Summary: This paper will provide an overview of an integrated biopsychosocial treatment model utilized at the Vincent P. Dole Research and Treatment Institute for Opiate Disorders of the Weill Cornell Medical College, Department of Public Health, and the New York Presbyterian Hospital, to provide treatment services to a population of multi-diagnosed opiate addicted patients. The Institute consists of two methadone clinics that employs a multidisciplinary staff and provides treatment services to young adults (Adolescent Development Program) and to older adults (Adult Services Clinic) who are multi-diagnosed with substance abuse and chronic psychiatric and medical illnesses.

Published: Volume 09 • Issue 1 • March 2007 (pages: 35 - 44)

Title: Opioid Substitution with Methadone and Buprenorphine: Sexual Dysfunction as a Side Effect of Therapy

Authors: Brown R. T., Zueldorff M.

Summary: Opioid substitution is the most widespread and well-researched treatment modality for opioid dependence. Methadone and buprenorphine are currently the most commonly used pharmacotherapeutic agents. Sexual dysfunction has been reported as an adverse effect of opioids including methadone and buprenorphine. The current article describes proposed mechanisms for sexual dysfunction as an adverse effect of methadone and buprenorphine, summarizes research conducted on subjects on these agents, and explores appropriate evaluation and intervention in the management of the types of sexual dysfunction most commonly encountered during opioid substitution treatment (libido, erectile, and orgasm dysfunction).

Published: Volume 09 • Issue 1 • March 2007 (pages: 45 - 54)

Title: Paxil (Paroxetine) in Complex Therapy in Heroin Addicts

Authors: Rokhlina M., Kitkina T., Gubanov G.

Summary: The efficiency of Paroxetine was studied in 27 males with heroin addiction (average age: 26.2 years, average disease duration: 3.4 years) undergoing detoxification. After 3-4 days of paroxetine (initial dose 20 mg/day, maximum dose 40 mg/day) the first improvement of affective symptoms were noticed. By the 14th day of treatment, affective discomfort had been arrested in most cases. On the whole paroxetine can be considered an effective medicine for contrasting affective discomfort of heroin addicts in the post-withdrawal stage, as long as agonist compounds are not available.

Published: Volume 09 • Issue 1 • March 2007 (pages: 55 - 76)

Title: Use of Sodium Gamma-Hydroxybutyrate (GHB) in Alcoholic Heroin Addicts and Polydrug-Abusers

Authors: Maremmani I., Pacini M.

Summary: Sodium gamma-hydroxybutyrate (GHB) in one of the most effective options available for the treatment of hard-core alcoholism in maintenance programmes that aim to achieve relapse prevention and rehabilitation. Polysubstance abuse and multiple addiction have become quite common in alcoholic youths and former heroin addicts receiving inadequate or no specific treatment. In approaching these categories, GHB is usually neglected, on the basis of the idea that its abuse potential must be amplified in abuse-prone individuals. However, the normalizing effects of anticraving treatment on the behaviour of heroin addicts may make GHB a suitable remedy for the heroin-alcohol polyabuse picture. The same cannot be said of cocaine abusers, due to the lack of anticraving treatments possessing major, reliable effectiveness. After reviewing the data in the literature on the use of GHB in alcoholics and other kinds of abusers, we describe 13 cases of alcohol-abusing heroin addicts, in which GHB proved to possess some effectiveness, even if there were major limitations regarding compliance and completeness of response.

Published: Volume 09 • Issue 2 • June 2007 (pages: 5 - 10)

Title: Can Heroin Maintenance Treatment Be Called a Therapy?

Authors: Guelfi G. P., Cibin M., Pani P. P., Maremmani I., For the Board of Directors of Italian Society of Addiction Medicine

Summary: Heroin administration may be reasonably accounted for in order to handle the cases of patients who proved refractory to methadone, despite repeated attempts and the employment of enhancement techniques to favour retention and rehabilitative processes. In most countries this is not the case, since standard effective treatments are often neglected or applied with unjustified limitations resulting in hampered effectiveness. As a consequence, effective treatment is far from being actually available to all those who apply for it, let alone those who may benefit from it. The first step to empower the addiction care system is to spread and enhance resources to grant patients with correct and powerful application of effective techniques, methadone/buprenorphine maintenance being regarded as the gold and first-line standard for the average addict. If that will ever be the case, as we hope, we would need to provide patients identified as refractory with a salvage option, along the concept of harm reduction. In any other context, the introduction of heroin administration programs would rather reduce the benefit than the harm

Published: Volume 09 • Issue 2 • June 2007 (pages: 11 - 16)

Title: Buprenorphine for Dual Dependency: Cocaine, Alcohol and Opiates

Authors: Gardner T., Kosten T.

Summary: Dual-drug dependency is common in Europe and America and represents a complex management and treatment challenge. Most heroin addicts abuse stimulants or alcohol in addition to opiates. Cocaine pharmacotherapy remains a challenge, but there has been some success with Buprenorphine, Disulfiram, Modafinil and GABA agonists. A promising cocaine vaccine is also under development. Triple-dependency with alcohol or benzodiazepines is also common and can lead to serious dependence requiring detoxification. In addition to regular monitoring following alcohol detoxification, relapse prevention pharmacotherapy is essential. The following review will briefly describe concurrent-drug abuse with cocaine and opiates as well as describe current pharmacotherapies for multi-drug dependence. In addition, we will briefly discuss the implications for combining behavioral therapies with medications to improve treatment efficacy.

Published: Volume 09 • Issue 2 • June 2007 (pages: 17 - 26)

Title: Brain Disintegration in Heroin Addicts: The Natural Course of the Disease and the Effects of Methadone Treatment

Authors: Polunina A. G., Davydov D. M., Kozlov A.

Summary: The present review aims to clear up the issue of the neurological processes underlying the personality changes induced by chronic opioid use. The effects of methadone treatment on brain functions have been analyzed, too. Brain disintegration becomes evident very soon after an onset of chronic heroin abuse and continues throughout the period of drug consumption. A considerable proportion of opioid addicts are characterized by conspicuous neuropsychological deficits, which preclude the maintenance of complete opioid abstinence in this patient subgroup. At present, there are no data to testify that the effects of methadone maintenance on brain functions exceed the adverse neurological effects of chronic heroin use.

Published: Volume 09 • Issue 2 • June 2007 (pages: 27 - 38)

Title: Voucher-Based Reinforcement Therapy for Drug-Dependent Pregnant Women

Authors: Heil S. H., Linares Scott T. J.

Summary: Opioid and other drug abuse during pregnancy is a leading preventable cause of fetal and neonatal morbidity and mortality. Given the limited availability of safe and effective pharmacotherapies for this population, additional interventions that address drug use and other behaviors are sorely needed. One of the most robust interventions for increasing drug abstinence is voucher-based reinforcement therapy (VBRT). The present report reviews the growing literature on VBRT interventions to promote opioid and other drug abstinence in pregnant substance abusers. Overall, results suggest that VBRT interventions can foster drug abstinence and other therapeutic behaviors in this special population.

Published: Volume 09 • Issue 2 • June 2007 (pages: 39 - 46)

Title: Pharmacokinetic and Pharmacogenetic Factors Influencing Methadone Plasma Levels

Authors: Crettol S., Eap C. B.

Summary: Methadone is widely used as a maintenance treatment for opiate addiction. Methadone plasma levels vary widely for a given dose, so contributing to interindividual variability in response to methadone maintenance treatment. Until recently, the relative in vivo involvement of various cytochrome P450 (CYP) isoforms in methadone pharmacokinetics had been unclear. A recent large-scale pharmacogenetic study with patients in methadone maintenance treatment has now demonstrated that CYP3A4 and CYP2B6 are the major cytochrome P450 isoforms with a major involvement in methadone metabolism, while CYP2D6 only contributes to a minor extent. In addition, P-glycoprotein, a transmembrane efflux protein, is also involved in methadone kinetics.

Published: Volume 09 • Issue 2 • June 2007 (pages: 47 - 54)

Title: Providing Comprehensive Treatment in Medication Assisted Opioid Treatment: The Development of Needs Based Treatment at a Medical School Sponsored Program

Authors: Marion I. J., Burke D.

Summary: Not Available

Published: Volume 09 • Issue 2 • June 2007 (pages: 55 - 64)

Title: Dihydrocodeine Treatment of Alcohol Addicts with Previous Opiate Addiction — Case Reports

Authors: Ulmer A., Mueller M., Frietsch B.

Summary: Objective: In papers already presented at conferences we were able to report that a successful maintenance therapy for alcohol addicts is possible with Dihydrocodeine (DHC). Here we report the case histories of 9 serious alcohol addicts; eight of these were former opiate addicts and the ninth a former non-addicted heroin user. Methods: We describe here all nine of our former heroin users who have more recently been treated with DHC because of a serious alcohol addiction. They had all distanced themselves for several years from their earlier phases of heroin addiction. All these patients had received professional counselling and, with one exception, had experienced professional addiction treatment. We prescribed DHC very cautiously and normally avoided exceeding the dosage of 320 mg daily, a much lower dosage than would have been needed for opiate substitution; higher dosages were prescribed to only two patients in this group. Results: All these patients substantially reduced their alcohol consumption; this led to a clear general improvement. Two patients stopped drinking altogether, the first over a period of 1.5 years at the time of writing, and the second over a period of nearly 3 years; both report an unrestricted feeling of well-being. One has, meanwhile, also completed his DHC-intake treatment. A third patient showing a similar improvement, who now drinks only very occasionally, does not seem to need absolute alcohol abstinence. In most of the patients the improvement was not sustained or absolutely irreproachable. One patient with a severe phasic depression committed suicide after years of clear improvement. Other patients showed an only transient improvement in their GGT, despite having reported nearly complete alcohol reduction and a drastic improvement in their anxiety and panic attacks, or they experienced a gradual relapse back to their original level of alcohol consumption. Two patients refused to undergo a regular DHC therapy as prescribed by us, and switched back to heroin or alcohol consumption. Conclusions: In 7 out of 9 patients a clear improvement in the situation was achieved by prescribing DHC. These seven patients substantially reduced their alcohol intake; in two cases drinking was completely eliminated. But one suicide, one heroin relapse and two apparently definitive alcohol relapses, in addition to other problems, show that we are unable to present DHC as offering all patients an easily won treatment success

Published: Volume 09 • Issue 3 • September 2007 (pages: 5 - 8)

Title: Addiction Treatment: When Will Medical Principles Matter?

Authors: Pacini M., Maremmani I.

Summary: Not available

Published: Volume 09 • Issue 3 • September 2007 (pages: 9 - 20)

Title: New Approaches in the Treatment of Opioid Dependency During Pregnancy

Authors: Kaltenbach K., Jones H., Fischer G., Selby P.

Summary: Although the treatment of opioid dependence during pregnancy has received considerable attention over the past 40 years, most approaches have been based on retrospective, observational and/or clinical studies rather than well controlled clinical trials. An exciting new period appears to be emerging in which rigorous empirical data will provide recommendations for optimal treatment approaches for both the opioid dependent pregnant woman and her child.

Published: Volume 09 • Issue 3 • September 2007 (pages: 21 - 30)

Title: Clinical Features of Heroin Dependence Onset in Young Women

Authors: Blagov L. N.

Summary: Important clinical mechanisms leading to opiate (heroin) addiction in young female patients have been investigated using a clinical-psychopathological method. The aim of this study is a better understanding of how integration takes place between the main factors involved in the onset and initial dynamics of general syndromes involving chemical dependence: pattern of intoxication, withdrawal syndrome, craving, personality degradation. Our clinical definitions have focused on describing the symptomatology and analysing which factors count the most in determining dependence. Distinctions have been drawn between the main onset mechanisms of heroin dependence in young females. They have been divided into: inductive, hedonistic, neurotic and mixed inductive-neurotic. Each mechanism is characterized by intrinsic clinical traits and symptoms, which comprise both premorbid personality and environmental factors. Comments are provided on the clinical dynamics of opioid dependence in its early stages, as these emerge in young female patients.

Published: Volume 09 • Issue 3 • September 2007 (pages: 31 - 40)

Title: Supporting GP's in Improving Substitute Prescribing for Opiate Users in UK General Practice

Authors: Ford C.

Summary: UK General Practice is now undertaking an increasing role in drug treatment but it hasn't always been that way. Over the previous 20-30 years, much of the drug treatment in the UK has been poor with little involvement of General Practice. From the mid 90s there was the beginning of government support for general practice to be involved in this area of work. Many developments have occurred which have try to address the barriers and provide support such as 1) A network of support and training; 2) An annual conference, a newsletter and web site; 3) The RCGP Certificate course and 4) Writing of guidance's specifically for care in general practice. All these measures have begun to change the face of drug treatment in the UK from general practice undertaking less than 5% to now about 30% and still rising.

Published: Volume 09 • Issue 3 • September 2007 (pages: 41 - 50)

Title: Mortality Among Opiate Abusers in Stockholm: A Longitudinal Study

Authors: Stenbacka M., Leifman A., Romelsjö A.

Summary: Background. Earlier studies have shown that opiate abuse is associated with an increased risk of developing a negative lifestyle, and also with high mortality and morbidity in young people. Many studies on mortality among drug users are based on clinical samples with short follow-up periods. In this study we were able to follow a more general cohort of opiate abusers with reference to mortality and morbidity during a 37-year follow-up period. The aims were to analyse mortality in a large cohort of opiate abusers during a follow-up period as long as 37 years. Material and methods: The study is based on a cohort of opiate abusers selected in Stockholm in 1967. They were recruited by using a case finding method, with data based on reports from authorities, hospitals, prisons, schools, and so on. A total of 817 people (647 men and 170 women) reported opiate abuse alone (Op) or in combination, either with central stimulants (Op+Cs) or alcohol (Op+Alc). The cohort was followed up in the Cause of Death and Inpatient-care Registers, until 2003 and 2004, respectively. Results. A total of 477 (58.4%) opiate abusers (392 men and 85 women) died during the follow-up period. The average age of death was higher for the men in the cohort (48.1 years) than for the women (42.9 years). The average age at death in Stockholm County was 71.7 for men and 76.3 for women in 1967 and 77.8 and 82.3 in 2003. Irrespective of drug use (Op, Op + Cs and Op+Alcohol use), a common cause of death among the youngest (15-34 years) was accidents (41%, 35%, and 11%) followed by suicide. After adjusting to take account of age and gender in the general population in Stockholm County, the standard mortality ratio (SMR) among the whole group was 4.38 (95% CI 4.0-4.78); it was 5.79 (95%CI 4.56-7.02) for the women and 3.45(95% CI 3.11-3.79) for the men. Conclusion. The female addicts were at a considerably higher mortality risk than the men and at death they were younger. Accidents and suicide, especially among young people, are two causes of death which might have been prevented. This is crucial in supplying information useful to preventive efforts.

Published: Volume 09 • Issue 3 • September 2007 (pages: 51 - 56)

Title: Methadone Treatment in the Criminal Mental Hospital of Montelupo Fiorentino, Tuscany, Italy

Authors: Lamanna F.

Summary: Not Available

Published: Volume 09 • Issue 4 • December 2007 (pages: 5 - 8)

Title: The Need For Scientifically Based Ethical Principles In Dealing With Drug-addicted Persons

Authors: Pacini M., Maremmani I.

Summary: Not available

Published: Volume 09 • Issue 4 • December 2007 (pages: 9 - 20)

Title: Maintenance: How Long ? Experiences from a German Practice

Authors: Ulmer A., Muller M., Frietsch B.

Summary: Objective: Classical addiction treatments comprise detoxification therapies and in, some cases, inpatient therapies in special clinics. This kind of treatment is so firmly established that society, many professionals and even many addicts think it should be possible to cure addiction diseases within a few months. This is why, maintenance therapies are believed to be disease-prolonging. The prescribers are often asked how long they plan to treat their patients. Methods: For 17 years now, we have been observing the evolution of > 350 addicted patients in our practice with the help of diagrams, leading to an overview of what we have seen, rather than to statistical analyses. Results: The impression is absolutely clear: addiction diseases are chronic, life-accompanying diseases. Patients who are able to overcome the symptomatic phase of this kind of disease forever, within months or only a few years, are rare and, in most cases, are among those less seriously affected. Even our 'best', and most presentable patients need ten and more years of treatment for a lasting stabilization even when they are already stable. Other patients who have not been stable over a long period of time, usually need much longer. Conclusions: When treating addicted patients, we must have plenty of patience. The overwhelming majority need therapy for many years, often for the rest of their lives. We should always look forward, and never give up. The prognosis for most of the patients is hopeful. Lasting improvement has been seen in at least a majority of our patients.

Published: Volume 09 • Issue 4 • December 2007 (pages: 21 - 30)

Title: Agonist Opioid Treatment in Prisons

Authors: Kastelic A., Kostnapfel-Rihtar T.

Summary: It is estimated that approximately one third of prison inmates can be considered opiate-dependent, and that many more are experienced drug users. In several prisons, this includes up to three quarters of the inmate population. Prisons are extremely high-risk environments for HIV transmission because of overcrowding, poor nutrition, limited access, continued illicit drug use (“unhygienic relapses”) and unprotected sex. As to recidivism among substance abusing prisoners, between 70 and 98 % of those who have been imprisoned for drug-related crimes, but did not receive treatment during their imprisonment, undergo a relapse during the twelve months following their release. The recently published position paper WHO, UNODC and UNAIDS (2004) on agonist opioid maintenance therapy concludes that providing agonist opioid maintenance therapy in treating opioid dependence is an effective strategy for preventing HIV/AIDS, and that it should be considered for implementation as soon as possible in communities at risk from HIV infection. IDUs who do not enter treatment are up to six times more likely to become infected with HIV than injectors who enter and remain in treatment. The death rate of people with opioid dependence in methadone maintenance treatment is between one third and one quarter the rate for those not in treatment. The health services for individuals in prisons or correction houses should have standards as high as those provided outside the correctional system.

Published: Volume 09 • Issue 4 • December 2007 (pages: 31 - 50)

Title: The Need For Patient Education. Opinions And Attitudes On Heroin Addiction: Changes In Italy Over Ten Year (1995-2005)

Authors: Quilici C., Pacini M., Maremmani I.

Summary: Objective: that of making clear the level of neuroscientific knowledge and the cultural prejudices that call for targeted psychoeducational interventions in treating heroin dependence. Methods: after a time-interval of 10 years, and within the same socio-cultural environment, standardized methods have been used to map out the attitudes of groups of drug-addicted subjects undergoing treatment at local addiction treatment units (“SerT”) or in Therapeutic Communities (n=60), of young people at risk (n=30) and of subjects drawn from the general population (n=20). Results: our results show a poor, little-changed level of scientific knowledge and of the frequency of misconceptions about heroin-addiction in the recent past (1995-2005), along with a significant deterioration in the general population. The areas that most clearly reveal a need for psychoeducational interventions prove to be those linked with knowledge about the disease, with the attitudes of drug-addicts towards the onset of their addiction, with knowledge about the available therapeutic resources, with risks to health associated with drug-taking and with the choice of the most appropriate person to be in charge of therapeutic programs. Conclusions: nowadays, more than ever before, there is a need in Italy for an intensive psychoeducational program to be planned, to cover all the environments involved (social and health care structures, schools, therapeutic communities, and so on), and for this program to be clear and precisely targeted in its contents. Practical implications: major effort should be addressed towards the improvement of patients' insight and professionals' cultural attitudes, which appear to be stay in spite of rational awareness of therapeutic results or the understanding of scientific knowledge.

Published: Volume 09 • Issue 4 • December 2007 (pages: 51 - 54)

Title: Motivational Interviewing: Linking Systems and Dancing with Clients

Authors: Bes R.

Summary: Not Available

Published: Volume 10 • Issue 1 • March 2008 (pages: 5 - 12)

Title: Sexual Behaviour of Heroin Addicts In Treatment

Authors: Brajević-Gizdić I., Pletikosa M.

Summary: Addicts are a high risk group for diseases transmissible sexually or through the blood. Their pathological behaviour caused by addiction makes it a priority to collect information about the sexual conduct of addicts, especially those who are trying to cure themselves. It is important to get results about how they assess the risks related to certain kinds of behaviour and how they see the need to be educated about the issue. The aim of this study is to determine the sexual behaviour patterns of heroin addicts who have already begun treatment, while getting insights into how they assess the risks associated with being sexually active, and whether they need to be informed about the whole issue. According to the survey, heroin addicts displayed an uncritical attitude towards the risk assessment of their sexual behaviour and failed to understand that they need to be informed about protection.

Published: Volume 10 • Issue 1 • March 2008 (pages: 13 - 18)

Title: First Experience of Opioid Therapy with Buprenorphine in Ukraine

Authors: Dvoryak S., Grishayeva I.

Summary: Ukraine is the country that has the highest rate of HIV/AIDS among IDUs in Europe. The development of opioid maintenance treatment for opioid users is an important public health issue.The earliest utilization of buprenorphine for OMT was made in 2004-5, within the framework of the UNDP Applied Human Rights Project. It was accompanied by research which was a part of the WHO Collaborative Study on Opioid Treatment of Opioid Dependence and HIV/AIDS. There were 67 opioid drug users under observation. This was a prospective observational study with assessments at baseline, and at 3- and 6-month follow-ups. All assessments refer to the period of one month prior to interview. The main aims of outcome evaluation were to explore changes in the following domains: health status and well-being of individuals in opioid treatment; community/social benefits and also programme performance. Improvements in the main indicators were documented after 6 months of treatment. The retention level was 66% and the mean buprenorphine dose was about 8 mg/day. The main conclusion is that buprenorphine treatment is effective in the context of Ukrainian social conditions.

Published: Volume 10 • Issue 1 • March 2008 (pages: 19 - 24)

Title: Administration of Nalbuphine to Heroin Addicts. Feasibility and Short-Term Effects

Authors: Voronkov M., Ocheret D., Bondarenko S., Yu Y. I., Koren S.

Summary: Kappa opioid agonists attenuate some of the neurochemical and behavioural effects of opiates and are under consideration as potential treatments for opiate dependence. We have shown that mixed kappa-agonist mu-antagonist nalbuphine (0.25 mpk im b.i.d.) was effective in reducing opiate consumption in 29 patients with a broad range of ages (29.4±6.4 years) and with a long history of substance abuse (9.3 ±3.6 years). Administration of nalbuphine for at least 14 days, up to at most 6 months, on an outpatient basis, led to a dramatic fall in the consumption of heroin and other totally illicit substances, along with a decline in criminal behaviour, as well as a higher level of retention of patients in the study, but also to improvements in patients' quality of life. Nalbuphine was safe, effective and highly compatible with the traditional therapy used to combat opiate addiction in Russia. Nalbuphine can also be used to stabilize HIV-positive patients. The study showed that both the current Russian medical infrastructure and medical professionals themselves could successfully contribute to the long-term agonist-antagonist treatment of patients with opiate addiction. We believe that our study warrants the further investigation of nalbuphine in treating opiate addiction.

Published: Volume 10 • Issue 1 • March 2008 (pages: 25 - 38)

Title: Evidence of Reliability and Validity of the Opiate Dosage Adequacy Scale (ODAS) in a Sample of Methadone Maintenance Patients

Authors: González-Saiz F., Rojas O. L., Gómez R. B., Acedos I. B., Martínez J. G., Collantes M. A. G., Fernández A. L., Serum Methadone Levels Study Group

Summary: Introduction: The testing and adjusting of methadone dosing is a clinical procedure that must be individualized to meet the needs of each patient. So far no evidence has been published of a tool capable of providing a global measurement of dose adequacy. For this reason, we have devised the Opiate Dosage Adequacy Scale (ODAS), which is intended as a means of implementing a theoretical construct called ‘dose adequacy'. Aim: To provide evidence of the reliability and validity of the ODAS. Methods: The study was carried out on a total of 300 patients on MMT, randomly selected from 10 public out-patient drug abuse treatment centres. We used ODAS, Addiction Severity Index (ASI), Outcomes Clinical Impression Form (OCIF) and laboratory tests (serum methadone levels, serum EDDP levels, serum a-1 acid glycoproteins levels [AAG] and urinanalysis). Results: Internal consistency for the ODAS was acceptable (a Cronbach = 0.70). Very high inter-rater reliability was found across items (kappa values between 0.95 and 1). The factor analysis yielded a four factor structure exactly coinciding with the dimensions of the ‘dose adequacy' construct proposed a priori (‘opiate withdrawal syndrome' ‘craving' ‘overmedication' and ‘drug use'. As far as construct validity is concerned, methadone dose adequacy as measured by the ODAS was correlated with clinical stabilization variables (heroin use, OCIF, ASI), while neither the methadone dose nor SML values correlated significantly with these variables. Conclusions: This study provides sufficient evidence for the reliability and validity of the ODAS as a tool for measuring methadone dose adequacy. The results of the construct validity test support the hypothesis put forward by several authors that an individualized clinical assessment of methadone dose adequacy is better able to account for a patient's condition than either the methadone dose or the patient's serum level.

Published: Volume 10 • Issue 1 • March 2008 (pages: 39 - 46)

Title: Improvement in the Quality of Live in Heroin Addicts: Differences Between Methadone and Buprenorphine Treatment

Authors: Maremmani I., Pani P. P., Popovic D., Pacini M., Deltito J., Perugi G.

Summary: The main goals of opioid treatment in heroin addiction is to eliminate or reduce the use of heroin and other substances of abuse, to promote patients' social rehabilitation and to improve their quality of life. The purpose of this study is to evaluate the efficacy of buprenorphine and methadone on the quality of life of patients. These subjects were sampled on the basis of the same severity of illness and the same impairment of quality of life at the start of treatment. 50 patients (41 male and 9 female) in buprenorphine treatment and 83 patients (63 males and 20 females) in methadone treatment, were evaluated regarding their retention in treatment, the use of substances, their clinical improvement and their quality of life over a one year period. In markedly ill patients buprenorphine and methadone both successfully and similarly reduce substance abuse and the severity of illness. Patients treated with buprenorphine show a better improvement of quality of life especially regarding improvements in jobs, leisure activities, income and self-acceptance. We conclude that Buprenorphine is a good choice for markedly ill patients with severe impairment in their quality of life parameters.

Published: Volume 10 • Issue 1 • March 2008 (pages: 47 - 54)

Title: Methadone: A Fast and Powerful Anti-anxiety, Anti-depressant and Anti-psychotic Treatment

Authors: Deglon J. J., Wark E.

Summary: Not Available

Published: Volume 10 • Issue 1 • March 2008 (pages: 55 - 56)

Title: Explaining Agonist Treatment Through Movie Language: The Interesting Allegory of ‘Videodrome'

Authors: Pacini M.

Summary: Not Available

Published: Volume 10 • Issue 2 • June 2008 (pages: 5 - 10)

Title: Evaluation of therapeutic alternatives to imprisonment for drug-dependent offenders. Findings of a comparative european multi-country study

Authors: Uchtenhagen A., Stevens A., Berto D., Frick U., Hunt N., Kerschl V., Mcsweeney T., Puppo I., Santamaria A., Schaaf S., Steffan E., Gegenhuber B., Turnbull P., Werdenich W.

Summary: A multi-country, multi-site comparative research study has documented the feasibility of recruiting drug-dependent individuals receiving treatment as an alternative to imprisonment (‘quasi-compulsory' treatment, in the setting of an experimental group), while comparing them with those receiving treatment in the same therapeutic institutions, on a voluntary basis (control group). The study combined qualitative and quantitative methods in describing the evolution and outcome of each case after 6, 12 and 18 months in treatment. 845 probands were recruited from 9 sites in 5 countries (Austria, Germany, Italy, UK, Switzerland), 429 in the experimental and 416 in the comparison group. Data were collected using a standardized instrument set and following a joint protocol that allowed for the testing of a number of pre-established hypotheses. Significant reductions in drug use and delinquent behaviour, together with improvements in social integration and health, were found in both groups. Higher rates of perceived external pressure to stay in treatment in the experimental group did not affect motivation of these patients as regards improvement and retention in the study. It can be concluded that the availability of treatment alternatives to imprisonment for drug dependence are a valuable policy option, under various different conditions, but that this option is open to further improvement.

Published: Volume 10 • Issue 2 • June 2008 (pages: 11 - 20)

Title: Motivational interventions for Methadone-Treated patients

Authors: Kantchelov A.

Summary: Implementing a motivational approach in MMT acts as a powerful resource in influencing in a positive way the dominant programme atmosphere, staff-client interactions, quality of services and programme functioning as a whole. There are various ways in which motivational interventions can be successfully applied in MMT. The evidence to date is very encouraging in suggesting that even brief interventions can enhance client motivation and trigger significant improvement and change. The use of these promising methods in the future will depend on the creativity of clinicians and researchers in adopting, adapting and evaluating motivational interventions to make them more widely and effectively implemented in MMT clinical practice for the good of our clients.

Published: Volume 10 • Issue 2 • June 2008 (pages: 21 - 26)

Title: Health care utilization and morbidity associated with Methadone and Buprenorphine Treatment

Authors: Bell J., Butler B.

Summary: Background: Methadone and buprenorphine treatment reduce the high mortality associated with heroin addiction, but even in-treatment, Standardised Mortality Rates are high. Aim: This study investigates the nature of morbidity associated with methadone and buprenorphine treatment, and investigates predictors of health care utilization among people in a variety of treatment settings. Methods: Collation of data from earlier studies, and from published reports. Findings: In a recent study of an entry cohort, the SMR was 5.52 [4.62, 5.65]; suicide and overdose accounted for 2/3 of the mortality, but allowing for this, mortality rates remain elevated. Cancer, heart disease and respiratory disease were the three major contributors to mortality. Taken in conjunction with a recent study of medical co-morbidity, this suggests that alcohol, tobacco and other drug use represent the major factors contributing to serious illness in treated opioid addicts. In addition, side-effects of treatment may themselves contribute to some morbidity. Lack of access to health care does not appear to be a contributing factor, as opioid users consult doctors (other than their methadone doctors) at rates far higher than the general population. Predictors of doctor attendance “outside” doctors were psychological distress, and benzodiazepine use. Adjusting for these factors, we found evidence that quality of methadone treatment was a significant predictor of doctor attendance, with better clinical care being associated with less outside doctor attendance. Conclusion: There is a paradox; heroin users have significant physical illness, but their attendance for health care tends to be driven by psychological distress, and can be improved by good care within treatment programs. The priority in addressing health problems of stabilised heroin users is dealing with alcohol and tobacco problems.

Published: Volume 10 • Issue 2 • June 2008 (pages: 27 - 38)

Title: GPs' office based Metadone Maintenance Treatment in Trieste, Italy.Therapeutic efficacy and predictors of clinical response

Authors: Michelazzi A., Vecchiet F., Leprini R., Popovic D., Deltito J., Maremmani I.

Summary: Objective: To evaluate the effectiveness of methadone treatment carried out by General Practitioners (GPs) and to identify response treatment factors. Methods: 33 subjects with heroin addiction according to the DSM-IV-R criteria , 25 males and 8 females with an average age of 26 ± 6 years, were placed in an observational protocol with average duration of 429 ± 273 days. Retention rate, substance use, overall clinical improvement, social adaptation, quality of life and psychopathologic symptoms were used as outcome measures. In order to assess predictors of treatment response dropout and non-dropout subjects were compared at baseline. Results: At the end of the observational period, 6 patients (18.2%) had a positive outcome, 8 (24.2%) negative outcome, while 19 (57.6%) were still in treatment with a cumulative retention of 60% at the end of the third year of observation. In 25 non-dropout patients baseline-endpoint improvement results were statistically significant for substance use, global clinical evaluation, psychological, social and occupational functioning, and craving. They also showed improvement in all of investigated psychopathological and quality of life dimensions. There were no significant side effects associated with their treatment. Patients with higher severity of illness, with problematic relationships with spouse/partner, difficulty with socialization and organization of leisure, with an altered mental state at beginning of treatment, subjects with dual diagnosis (especially bipolar disorder), with greater severity of obsessive-compulsive symptoms, interpersonal sensitivity, depression, violence, with greater severity of psychopathological symptoms, with the largest number of problematic areas as regarding the quality of life, patients with a low dose of methadone given for treatment were considered most at risk for abandoning treatment. Conclusions: Methadone treatment carried out by General Practitioners appears safe and effective, especially in less severe patients treated with adequate doses, without severe psychopathology, without dual diagnoses (particularly bipolar disorder) and with quality of life impairment only in limited areas.

Published: Volume 10 • Issue 2 • June 2008 (pages: 39 - 40)

Title: Use of Sertraline in depressed methadone maintenance patients

Authors: Trajanovska A. S., Popovska O. S.

Summary: Not Available

Published: Volume 10 • Issue 3 • September 2008 (pages: 5 - 12)

Title: When a New Drug Promotes the Integration of Treatment Modalities: Suboxone and Harm Reduction

Authors: Maremmani I.

Summary: In medicine, the introduction of a new drug is often associated with an overall enhanced understanding of the clinical issues that originally stimulated its own development. Sometimes newer drugs must be introduced to counter the improper use of existing drugs. In this paper, we discuss some concepts regarding the pharmacotherapy of heroin addiction (regarding blocking dosages and stabilization dosages), the advantages and disadvantages of opioid agonists in the pharmacotherapy of heroin addiction, the role of motivation for harm reduction strategies, the difficulties of methadone, buprenorphine, naltrexone and naloxone use in harm reduction strategies, and the possible use of buprenorphine-naloxone combination in harm reduction strategies. A buprenorphine-naloxone combination is not only a clinical improvement over pre-existing treatments, but it also represents a good example of a drug designed to limit the misuse of another resulting in the integration of different modalities of intervention, previously believed to be in opposition.

Published: Volume 10 • Issue 3 • September 2008 (pages: 13 - 24)

Title: Pseudo-Addiction: The Illustrative Case of Howard Hughes

Authors: Tennant F.

Summary: While the need for chronic pain treatment is evident by epidemiologic surveys from many countries, countless persons continue needless suffering due to lack of pain treatment. One is a bias against opioid drugs, and the false belief that persons who take opioids are “addicts”. Modern definitions essentially relegate the term “addict” to persons who take opioids for non-pain purposes. The term “pseudo-addiction” is now the term properly used for those persons who seek pain relief by patronizing a variety of sources to obtain opioids because they lack a regular, medical source of treatment with opioids. Perhaps the most famous “pseudo-addict” was Howard Hughes. He was involved in a plane crash in 1946 and suffered severe chronic pain as a result of facial and neck fractures and third degree burns of the upper torso. His subsequent post-trauma neuropathies are now commonly referred to as Reflex Sympathetic Dystrophy. They were so severe that he often could not brush his teeth, comb his hair, shave, or wear clothes or shoes. He survived 30 years taking about 200 mg equivalent of morphine a day for pain control. At this time the author is treating a cohort of severe, chronic pain patients who have taken high, daily opioid dosages for 20 to 30 years. As did Howard Hughes, these patients lead high quality, productive lives despite high dose opioid treatment. Severe, chronic pain, per se, and unrelated to its underlying cause, has life shortening and debilitating complications that are caused by uncontrolled electrical conduction, excess sympathetic discharge in the autonomic nervous systems, and excess pituitary-adrenal hormone secretions. Pseudo-addicts are easy to clinically differentiate from bonafide opioid addicts and treatment facilities should differentiate between the two. We need a world wide humane movement to provide life-time, opioid, medical management for persons afflicted with severe, chronic pain that can only be controlled by opioid drugs.

Published: Volume 10 • Issue 3 • September 2008 (pages: 25 - 32)

Title: The Under-Treatment of Pain: A Global Problem. An Educational Approach

Authors: Buttfield I.

Summary: In order to undertake comprehensive pain treatment, acute and chronic, all prescribers are required to understand opioid medication, and to appreciate the phenomenon of addiction. Throughout the world there is a major concern with under treatment of pain. This paper aims to assist health professionals in their efforts to treat patients' pain effectively. It also outlines medications available for use, typical patient situations and strategies for intervention to relieve pain. Barriers to pain treatment are reviewed, in both developed and developing nations.

Published: Volume 10 • Issue 3 • September 2008 (pages: 33 - 36)

Title: Finnish Experience With Buprenorphine-Naloxone Combination (Suboxone®): Survey Evaluations With Intravenous Drug Users

Authors: Simojoki K., Alho A.

Summary: Finland, with a population of around 5.5 million, has four years of prescribing a buprenorphine-naloxone combination product (bup/nx) under its belt, and it already has the most bup/nx experience within Europe. Our data show that the decision to transfer patients from buprenorphine to bup/nx more than halved the street value of an 8 mg tablet, in a country where buprenorphine had previously been the most widely intravenously-abused drug. Patients are now maintained on an average daily dose of 16 mg bup/nx and, reassuringly, buprenorphine misuse is decreasing. Most importantly, the pre-buprenorphine heroin mortality figures have all but vanished: from 63 deaths in 2000, in the last few years Finland has seen heroin claim just 0 - 4 lives per annum.

Published: Volume 10 • Issue 3 • September 2008 (pages: 37 - 40)

Title: Fifteen Years of Office-Based Prescribing in Croatia. Attitudes, Obstacles and Outcomes.

Authors: Ivancic A.

Summary: Not available

Published: Volume 10 • Issue 4 • December 2008 (pages: 5 - 18)

Title: Buprenorphine-Naloxone Versus Methadone Maintenance Therapy: A Randomised Double-Blind Trial With Opioid-Dependent Patients

Authors: Kamien J. B., Branstetter S. A., Amass L.

Summary: This is the first randomised study comparing buprenorphine-naloxone with methadone for maintenance treatment of opioid dependence. A 17-week, double-blind, double-dummy trial of daily dosing compared buprenorphine-naloxone (8/2 mg and 16/4 mg) with methadone (45 mg and 90 mg) in 268 participants. The percentage of opioid-free urine samples over time did not differ by drug or dosage. The percentage of patients with ≥12 consecutive opioid-negative urine samples did not differ by drug and was significantly greater for patients receiving higher doses of either agent. Induction success, compliance, nonopioid drug use, retention and Addiction Severity Index scores did not differ among groups. Buprenorphine-naloxone is a viable alternative to methadone in clinical practice.

Published: Volume 10 • Issue 4 • December 2008 (pages: 19 - 28)

Title: Predictors for Non-Relapsing Status in Methadone-Maintained Heroin Addicts. A Long-Term Perspective Study

Authors: Maremmani I., Pacini M., Lamanna F., Pani P. P., Trogu M., Perugi G., Deltito J., Gerra G.

Summary: Despite the established effectiveness of Methadone Maintenance Therapy (MMT), specific evidence regarding factors influencing the prognosis of enrolled patients is quite limited. This study aims to ascertain which patient- or treatment-related features, assessed in a standardized way at the beginning of the program, do have an influence on whom is retained for long-term compliance with retention in treatment. 129 patients (94 male and 35 female) were treated in a methadone maintenance treatment program for 6 years on average. Retention in treatment was compared (survival analysis and Leu-Desu statistics) among groups of patients selected on the basis of socio-demographic and clinical variables. The variables that showed statistically significant differences (p<0.05) for an association regarding retention rate were included in separate logistic backward regression analyses comprising outcomes as dependent variables. Results show that dual diagnosis, defined by concurrent psychiatric disorders in evidence before the onset of heroin use, is the strongest negative predictor of relapse throughout a six year's average observation period, regardless of other clinical and socio demographic variables. Such a finding should be read in the context of a high-threshold setting, and accounts only for those patients, who had been retained in treatment over the first year

Published: Volume 10 • Issue 4 • December 2008 (pages: 29 - 32)

Title: Unintentional and Intentional Injuries Due to Opiate Abuse

Authors: Stenbacka M.

Summary: Alcohol and drug abuse runs a generally higher risk of fatal and non-fatal injury risk. But the overall injury pattern in relation to opiate abuse is not well known. Aim. The aim of the study is to analyse intentional and unintentional injuries –in the forms of accidents and suicides, as reported in the case histories of opiate abusers compared to the general population in Stockholm. Method: The analyses are based on a cohort of 1700 drug abusers identified in 1967 and followed until 2003 and 2005 with respect to causes of death, and inpatient care stays. Results: The results show that 817 (48%) subjects took opiate as their primary drug and nearly one third of these had died due to an intentional or an unintentional injury. Nearly 60 percent of the opiate abusers had been treated, at least once, in hospital for an injury. On average, the total cohort had been treated in hospital for an injury 1.6 times (range, 0-40 times), while the opiate abusers who had been treated in hospital for a drug-related diagnosis at least once had, on average, also been treated for an injury diagnosis 2.8 times (0-20 times) during the follow-up period. Conclusion: Societal support and injury prevention need to be improved in this vulnerable group.

Published: Volume 10 • Issue 4 • December 2008 (pages: 33 - 38)

Title: Scientific Evidence and Practical Experience with Methadone-Assisted Withdrawal of Heroin-Dependent Pregnant Patients

Authors: Jones H.

Summary: Opioid dependence during pregnancy is a complex multi-faceted medical challenge that, if untreated, places the mother and child at risk for life threatening consequences. While methadone maintenance is the accepted standard of care for opioid dependent patients who are pregnant, there are limited circumstances when this life saving medication may not be an immediate option. Thus, this paper first highlights the data supporting the current USA clinical guidelines regarding medication-assisted withdrawal during pregnancy in opioid-dependent patients. Next, the results of a retrospective study comparing the maternal and neonatal consequences of methadone-assisted withdrawal to methadone maintenance in pregnant opioid-dependent patients are summarized. Given the generally poorer maternal outcomes of the medication-assisted withdrawal patients, these data provide renewed and current support for methadone-maintenance as the first-line treatment approach for opioid-dependent pregnant women.

Published: Volume 10 • Issue 4 • December 2008 (pages: 39 - 44)

Title: Opioid Therapy and Restoration of the Immune Function in Heroin-Addicted Patients

Authors: Somaini L., Giaroni C., Gerra G.

Summary: There are several reports suggesting that opioid compounds may influence the immune response. Studies carried out in experimental animals and in humans have shown that both innate and acquired immunity are significantly affected by opioids. From a molecular viewpoint, opioids behave like cytokines, modulating the immune response by interacting with their receptors both in the central nervous system and in the periphery. One of the main features of opioid-mediated modulation of the immune function is the development of immunosuppression, which has been documented in injecting heroin abusers. Over the last few years, however, evidence has been provided to suggest that various opioid drugs may have distinctive effects on the immune function. Data obtained from animal studies have demonstrated, for instance, that long-acting opioids, such as methadone and buprenorphine, are devoid of any intrinsic immunosuppressive activity. In this connection, the hypothesis, which was first put forward some years ago, that the normalization of altered cellular immunity can, in injecting heroin abusers, be achieved through long-term methadone or buprenorphine treatment, has been positively re-evaluated in recent times. Our group has recently investigated the immune response in heroin-addicted patients currently under methadone or buprenorphine maintenance treatment, comparing them with untreated heroin addicts and healthy controls. In agreement with the data obtained by other groups, our study has provided evidence confirming the ‘immunoprotective' effect of long-acting opioid drugs. From a pathophysiological viewpoint, the ability of opioids to modulate the immune function may have some bearing on the development of the infectious diseases that are often associated with drug abuse. The high percentage of infections among injecting drug users is partly related to injection methods and life-style practices, but it is now accepted that heroin-induced immunosuppression may contribute as a co-factor in the contraction of several microbial and viral infections, such as Hepatitis C virus (HCV) infection. Conversely, in view of the ‘immunoprotective' action of some opioids, such as buprenorphine, it has now been proposed that the administration of these latter compounds may improve the outcome of chronic HCV virus infections.

Published: Volume 10 • Issue 4 • December 2008 (pages: 45 - 48)

Title: Major Policy and Clinical Developments in the Use of Methadone and Buprenorphine Treatment in the U.S.

Authors: Parrino M. W.

Summary: Not Available

Published: Volume 11 • Issue 1 • March 2009 (pages: 5 - 14)

Title: Treatment of Opioid Dependence and ADHD/ADD with Opioid Maintenance and Central Stimulants

Authors: Blix O., Dalteg A., Nilsson P.

Summary: Since January 2005 Medically Assisted Rehabilitation of opiate addicts (MAR) is a regular treatment supported by the National Board of Health and Welfare in Sweden. Treatment facilities are now open in most parts of Sweden. At the addiction medicine unit in Jönköping, high dose buprenorphine has been used since 1999, and methadone was added in 2005, when the previously separate regulations for the use of those two substances were merged in the present regulations. ADHD and ADD, together with OCD, are relatively common disorders among drug addicts. Since 2004 we have diagnosed over 150 patients with these disorders at the addiction medicine unit. By November 2007, treatment with long-acting methylphenidate or modafinil had been initiated in 85 subjects. Of those 85, 12 had also met the criteria for opioid substitution. This paper will discuss our experiences with the combined treatment with opioids and central stimulants, as administered to those drug addicts. In this naturalistic study, all 12 subjects (1 female), mean age 38 (range 20 to 51) were evaluated before starting Central Stimulant (CS) treatment with clinical interviews, self-assessments and formal computerized tests (EuroCog). The ambition is to follow each patient's development through the use of drug tests, interviews (subjects and relatives/significant others), and a retest to evaluate the outcome of the combined treatment.

Published: Volume 11 • Issue 1 • March 2009 (pages: 15 - 22)

Title: Dihydrocodeine for the Treatment of Alcohol Dependence

Authors: Ulmer A., Müller M., Frietsch B.

Summary: Objective: In most cases, alcohol dependence shows a profile similar to that of many chronic diseases, but no effective basic treatment comparable to that adopted with the other illnesses has been established up to now. In particular, patients with repeated relapses, despite a broad range of therapeutic approaches, and patients who are unable to attain what is essentially a state of abstinence from alcohol, continued to need a basic medication. Methods: Convinced by a few specialized colleagues who reported successful treatments of alcohol addicts with Dihydrocodeine (DHC) and by a first own patient of ours who showed a complete reduction of his severe alcohol craving when given Codeine-based pain medication, we went on to treat as many as 77 (M/F: 55/22) heavily alcohol-addicted patients with DHC, beginning in 1997. Right from the start, the data were documented meticulously. We present a retrospective analysis of this documentation here. Results: The patients had a history of a total of 1060 medically assisted detoxifications and specialized therapies. The 4 year-retention rate was 26.1%, including 6.5% of treatments that had a successful outcome. In our 12-step scale on clinical impressions, we noticed a significant improvement from a mean of 3.5 to 6.7. The demand for medically assisted detoxifications in patients who had at most 2 years left was reduced by 63%. Mean GGT improved from 201.1 U/l at baseline to 57 U/l after 4 years. The MCV value also showed a significant improvement. Mean GGT of patients with additional chronic hepatitis C improved from 198.3 U/l at baseline to 86.4 U/l after 1 year. Conclusions: Our data are preliminary, and these are practice-generated results, which are far from reflecting the whole potential of this new approach. Between 10 and 20% of these patients recorded no good effects from DHC. In around half of the patients the treatment was abandoned for several reasons, in some cases because of the anxiety caused by the pioneering nature of this non-established therapy: a treatment with partly overcautious dosages. But in about 25% of the patients, DHC was an almost perfect medication, sometimes even crucially better than all previous approaches, even in absolutely desperate cases. A lot of regular studies are needed, comparing different substances, settings, dosages and clarifying the cause and pathomechanism of the effects. This should be done because it seems that we are standing at a gateway leading into immense new opportunities. In the long run the breakthrough will be a question of the right mixture of scientific investigation, well-structured implementation with sufficient control, but also, and this may be most important factor, enough trust in our patients and the prescribing doctors. On a long-term basis there will be no success without a structure that supports and reassures, but also represents, this trust.

Published: Volume 11 • Issue 1 • March 2009 (pages: 23 - 30)

Title: Use and Abuse of High-Dose Buprenorphine (HDB) Obtained Without a Prescription: a French Survey

Authors: Courty P.

Summary: Objectives: To gain information on the profile of patients using High-Dose Buprenorphine in France without a medical prescription. Methods: This was a naturalistic survey on 27 survey sites (n=298) comprising three different groups: people who had always obtained their HDB without a prescription, people who had obtained HDB both with and without a prescription over the previous month and an intermediary group who had previously obtained it on prescription, but not over the course of the previous month. Results: In terms of treatment and supervision objectives, significant differences were found between the group of patients who were under the supervision of a doctor and those who continued to obtain HDB without any prescription. Discussion: Medical supervision is a central factor in treatment. Conclusion: Treatment education for patients, medical training for prescribers, and pharmaceutical form appear to be means that need to be developed simultaneously to optimize the treatment.

Published: Volume 11 • Issue 1 • March 2009 (pages: 31 - 34)

Title: A 10-Year Evaluation of Chronic Pain Patients Treated with Opioids

Authors: Tennant F.

Summary: Over the past 15 years laws and guidelines have been widely promulgated to allow physicians to prescribe opioids for severe, chronic pain patients who have non-malignant conditions. To date little is known about the outcomes of long-term opioid pain therapy. Reported here is an evaluation of 24 patients with non-malignant conditions who have been in continual opioid treatment for at least 10 years. Data collected indicates that some chronic pain patients greatly benefit from long-term opioid therapy. Almost all (22 of 24: 91.7%) patients report that their pain has permanently decreased over time, and the great majority (20 of 24: 83.3%) believe that opioids continue to relieve their pain as well as when treatment was initiated. All patients report they can now do a variety of activities and physical functions they could not do prior to opioid therapy. The major complications of opioid therapy detected to date are hormonal abnormalities which can be easily managed with replacement therapy.

Published: Volume 11 • Issue 1 • March 2009 (pages: 35 - 40)

Title: Psychotherapeutic Experiences with Methadone Maintained Patients in the Framework of Multidisciplinary Clinical Institution

Authors: Todorov O.

Summary: This communication presents a number of theoretical and clinical formulations that belong to a psychodynamic framework specifically constructed to foster the understanding and treatment of drug addiction. I find this framework useful not merely for the purpose of conceptualizing drug addiction as a clinical category, but also in explaining the complex experiences involved in the therapeutic process to people suffering from that condition. Contemporary psychoanalytic tradition sees drug addiction as an unsuccessful attempt to ward off the unbearable and unmanageable effects through self-medication, but also, more importantly, as a massive disorder originating in early interactions with significant others, resulting in a fragmentation of the self that prompts the individual to self-injury, constant traumatic experiences and a paradoxical fear/pain/pleasure relationship with the drug via addictive fantasies. All of this, enacted in everyday life and in therapeutic sessions, evokes complex emotional experiences on the part of patients, therapists and whole institutions. Relieving, bearing, getting to understand and, crucially, modifying these experiences is seen to be the task at stake in the therapeutic encounter. The final part of the article reflects on some of the advantages for the psychotherapeutic work that derive from methadone maintenance treatment and well-organized team work within a specialized clinic.

Published: Volume 11 • Issue 1 • March 2009 (pages: 41 - 42)

Title: Preferences for Buprenorphine/Naloxone (Suboxone®) and Buprenorphine (Subutex®) in Patients Receiving Buprenorphine Maintenance Therapy in France: A Prospective, Multicentre Study

Authors: Daulouède J.-P., Caer Y., Galland P., Villeger P., Brunelle E., Bachellier J., Piquet J.-M., Harbonnier J., Leglise Y., Courty P.

Summary: Not Available

Published: Volume 11 • Issue 1 • March 2009 (pages: 43 - 46)

Title: Coordinating Methadone Treatment Providers and Policymakers: Lessons Learned Over 30 Years

Authors: Parrino M. W.

Summary: Not Available

Published: Volume 11 • Issue 1 • March 2009 (pages: 47 - 48)

Title: En Route to 90% Retention. ‘Active Rehabilitation' in Central Norway

Authors: Nordstrand B.

Summary: Not Available

Published: Volume 11 • Issue 2 • June 2009 (pages: 5 - 8)

Title: Swedish Use and Misuse of the Dole & Nyswander Treatment

Authors: Gunne L.

Summary: For 23 years (1966-1989) Sweden had a National Methadone Maintenance treatment of opioid addicts, delivering 70-80 % vocationally rehabilitated patients, taxpaying citizens, with no drug abuse and a great reduction in mortality rates. This treatment was changed in 1990 into a short-term methadone program, resulting in numerous discharges for disciplinary reasons, a high mortality rate among the newly discharged and poor rehabilitation results. Politically, the short-term treatment is called “restrictive”, which is regarded as commendable by the Swedish mass media

Published: Volume 11 • Issue 2 • June 2009 (pages: 9 - 20)

Title: Methadone-treated Patients After Switching to Buprenorphine in Residential Therapeutic Communities: An Addiction-specific Assessment of Quality of Life

Authors: González-Saiz F., Gómez R. B., Bilbao Acedos I., Lozano Rojas O., Gutiérrez Ortega J.

Summary: Background: evaluating the addiction-related quality of life of a sample of opiate-dependent patients in treatment with buprenorphine in therapeutic communities after a switch from methadone. Design and participants: observational (descriptive), open longitudinal prospective study (‘before-after' design); a non-probabilistic consecutive sampling procedure was used. After their admission to five therapeutic communities, a sample of patients in treatment with methadone switched to buprenorphine induction (SubutexR). When considered appropriate, a gradual reduction in buprenorphine dose was begun, so as to bring it down to 0 mg within 16 weeks. The patients met DSM-IV-TR criteria for Opiate Dependence, were adults and had signed an informed consent release. All the patients were evaluated at three times; baseline assessment (Mo), after one month of treatment (M1) and after three months (M2). The study protocol was approved by the Andalusian Regional Committee for Clinical Trials, and was conducted in accordance with the Declaration of Helsinki. Measurements: The Objective Opiate Withdrawal Scale (OOWS), the Subjective Opiate Withdrawal Scale (SOWS), the Health Related Quality of Life for Drug Abusers Test (HRQoLDA Test), the General Health Questionnaire (GHQ-28), the Opiate Treatment Index (OTI) and the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). Results: A total of 119 patients met the selection criteria. Of these, 46 subjects transferred from methadone to buprenorphine, while the remaining 73 decided to stay on their methadone maintenance treatment. A statistically significant increase was observed in scores on the quality of life scale after one month of treatment with buprenorphine (from 0.62 to 0.99; p<0.05) and at three months (from 0.43 to 0.77; p<0.05). One month after the start of treatment, statistically significant improvements were observed in “general state of health” (from 10.7 to 4.3; p<0.05), in “severity of dependence” (11.7 to 4.1; p<0.05) and in “psychological adjustment” (from 7.5 to 3.7; p<0.05). At the three-month assessment, statistically significant differences were again observed in the same variables, except for “psychological adjustment”. Conclusions: the patients who were in treatment with methadone after their admission to a therapeutic community and switched to buprenorphine were able to experience ongoing improvement in their quality of life.

Published: Volume 11 • Issue 2 • June 2009 (pages: 21 - 30)

Title: Clinical trial on the use of olanzapine in reducing the consumption of cocaine in Methadone Maintenance Programmes

Authors: Vázquez M. L., Castillo I. I., Jiménez-Lerma J. M., Beldarrain J. A. H., Gutiérrez-Fraile M.

Summary: The consumption of cocaine among people included in Methadone Maintenance Therapy (MMT) is a widely identified phenomenon, but clinical experience and the literature have highlighted the difficulty of finding an effective pharmacological alternative for cocaine abusers. The aim of this study was to assess the use of olanzapine as a therapy for reducing the use of cocaine in MMT while implementing a more controlled design. A randomized clinical trial has been applied to 60 subjects assigned to three MMT programmes. The independent variable was treatment with olanzapine at three dose levels (0, 5 and 10 mg/day), with three treatment groups being formed; they comprised 20, 21 and 19 subjects, respectively. The outcome variable was the percentage of positive urine tests for cocaine consumption, as estimated by means of urine monitoring using immunoassay, during the first three months after the start of treatment. For the data analysis, MANOVA and the hierarchical regression model were used. The mean proportion of previous cocaine consumption was 25.8% (S.D.= 26.4; range 0‑100), with no differences between the treatment groups (F(2,57) = 0.167; p= 0.845). Hierarchical regression analysis showed a significant model in final step (F(5,54)= 8.61; p ≤ 0.001), with an explained variance of 44.3% (R2= 0.443). The semi-partial correlation coefficients (rs-m) indicated significant effects on the variables: methadone dose (rs-m= ‑0.229), previous cocaine consumption (rs-m= 0.345) and treatment with 5 mg/day (rs-m= ‑0.469) and 10 mg/day (rs-m= ‑0.514) of olanzapine. The mean proportion of positive control results in the untreated subjects was 21%, whereas, in the patients receiving olanzapine therapy, it was 8.8% in those taking a dose of 5 mg/day and 9.5% in those on a dose of 10 mg/day. The prior consumption of cocaine is shown to be a risk predictor for subsequent consumption, whereas an increase in the dose of methadone or treatment with olanzapine both show a protective effect. Specifically, the 10 mg dose of olanzapine, when followed by the 5 mg dose shows the highest degree of explained variance in post-treatment cocaine consumption, after checking the effects induced by the remaining variables.

Published: Volume 11 • Issue 2 • June 2009 (pages: 31 - 40)

Title: Voices of Experience: Attitudes and Opinions of Recipients of Unsupervised Injectable Opiate Treatment in the Northwest of England

Authors: Orgel M., Wilson A., Leavey R., Sell L., Zador D.

Summary: Aims and Methods: To describe the views and experiences of drug users receiving unsupervised injectable opiate treatment (IOT) for opiate addiction, the most common current form of injectable treatment in the UK. Semi-structured interviews were completed by 29 IOT recipients from two Community Drug Teams in northwest England. Findings: Attitudes of most respondents were positive with personal and social benefits: reduction or cessation of illicit drug use; health gains; more “normal” lifestyle; reduced criminal activity. IOT recipients were not a homogeneous group and had different needs and goals. Conclusions: Individuals valued the stability IOT had brought to their lives. The treatment challenge is how to maintain stability without allowing drift into inertia. Much of the IOT debate has been led by service providers and academics. IOT recipient views have been neglected and this study adds a new voice.

Published: Volume 11 • Issue 2 • June 2009 (pages: 41 - 46)

Title: Substitution Therapy. A New Problem of Biomedical Ethics and Medical Law

Authors: Mendelevich V. D.

Summary: Substitution maintenance therapy can be judged from different perspectives focused on its medical, legal, social, economic and ethical aspects. A subject that attracts special attention is the ethical side of substitution therapy. In the opinion of the opponents of substitution maintenance therapy, there are several key ethical problems that make this therapy immoral. From our point of view, it is unethical to refuse a patient this kind of help (substitution therapy). Substitution therapy for opioid dependence should be seen as the most ethical and humane of all methods. The absence of substitution therapy in the Russian Federation puts Russian patients in an awkward position.

Published: Volume 11 • Issue 2 • June 2009 (pages: 47 - 58)

Title: New Approaches in the Treatment of Opioid Dependency During the Pregnancy

Authors: Finnegan L., Winklbaur B., Fischer G., May O., Welle-Strand G.

Summary: Not Available

Published: Volume 11 • Issue 2 • June 2009 (pages: 59 - 62)

Title: QTc Interval Screening. American Association for the Treatment of Opioid Dependance (AATOD) Policy and Guidance Statement

Authors: Parrino M., Aatod Board of Directors

Summary: Not Available

Published: Volume 11 • Issue 3 • September 2009 (pages: 5 - 10)

Title: Methadone Treatment in Italy in the Third Millennium: Continuing Fear of Treatment

Authors: Maremmani I.

Summary: Not Available

Published: Volume 11 • Issue 3 • September 2009 (pages: 11 - 28)

Title: Pharmacology and Neurochemistry of Methadone

Authors: Vendramin A., Sciacchitano A. M.

Summary: Contrary to what might be thought initially, the pharmacology of methadone is only partly known, and current research continues to investigate into its distinctive aspects. Clinical evidence provides key guidance to pharmacological research on the opiate system; on the other hand, evolving expectations from therapeutic drugs or putative agents for addiction treatment provide a key incentive to the broadening of pharmacological knowledge. Apart from the classic description of receptorial opioid agonism, narcotic blockade and tolerance/withdrawal dynamics, some crucial issues need to be clarified in a comprehensive way. For instance, studies have proved the importance of metabolic polymorphism in treatment planning and offered interpretations of apparent resistance to normal dosages, so authorizing the employment of high dosages on a sound pharmacological basis. Also, dosages should not be regarded as stable through time, especially in the first few months, and clinicians may schedule dose variations that take into account such expected variations while pursuing stabilization. Methadone's action profile in the central nervous system is not exclusively based on opioid receptors, and a thorough knowledge of its 'collateral' effects may explain its beneficial action against specific psychopathological abnormalities. The role of the inactive enantiomer in the context of racemous methadone's tolerability and action profile has also been outlined. Lastly, some of the therapeutic effects of methadone endure without being neutralized by the emergence of tolerance; one of these is its crucial anticraving property. In order to clarify this issue, the mechanisms of cell membrane endocytosis and signal transduction have been illustrated and compared between different opiates.

Published: Volume 11 • Issue 3 • September 2009 (pages: 29 - 34)

Title: Cannabis and Premonitory Symptoms of Schizophrenia: What Is the Time Sequence?

Authors: Vernex N., Dagher G., Touzeau D.

Summary: Nowadays, cannabis is the most widely used illegal drug in France. Epidemiological studies have shown that in schizophrenic patients the risk of developing cannabis dependence is six times what it is in the general population. However, debates on the real chronology of the appearance of psychiatric disorders and addictive cannabis behaviour are ongoing. The aim of this article is to try to find out how best to interpret the association of cannabis and premonitory symptoms through a review of the literature. Some recent longitudinal studies suggest a potential role for pre-existing troubles, taking the view that cannabis would only aggravate them and turn them into schizophrenic symptoms. By contrast, other studies propose a causal linkage as well as a dose-effect relationship between cannabis consumption and the appearance of schizophrenia. Conclusion: The methodology of these studies limits the possibility of a reverse causality. In addition, it must be noted that some research teams excluded from their cohort subjects who presented psychiatric disorders at entrance. Cannabis appears to be a risk factor for psychotic disorders, because it interacts with a pre-existing vulnerability. Neuroimagery research will make it possible to clarify the common cerebral mechanisms of cannabis and schizophrenia.

Published: Volume 11 • Issue 3 • September 2009 (pages: 35 - 38)

Title: Alcoholics With a History of Heroin Consumption: Clinical Features and Chronology of Substance Abuse

Authors: Ceccanti M., Vitali M.

Summary: In our clinical experience, when alcohol is used as a surrogate for heroin, social adjustment improves, although the metabolic destiny does not change, and the medical outcome is worsened to some extent by alcoholism itself. Alcohol abusers with a history of heroin use engage in alcohol use in a more intensive way. Alcohol consumption is higher right from the start, and reaches higher maximum levels, whereas heroin use dwindles, in some cases to extinction. The results of our studies support the hypothesis that alcohol replaces opiate craving in former heroin consumers who break away from heroin, and often become alcohol abusers or at least increase their use of alcohol.

Published: Volume 11 • Issue 3 • September 2009 (pages: 39 - 40)

Title: Opioid Dependence and Quality of Life: Changes in the Heroin Epidemic

Authors: Domingo-Salvany A.

Summary: Not Available

Published: Volume 11 • Issue 3 • September 2009 (pages: 41 - 44)

Title: Predictors for Non-Relapsing in Methadone- and Buprenorphine-maintained Heroin Addicts: A Comparative Study

Authors: Maremmani I., Pacini M., Lamanna F., Maremmani A. G. I., Pani P. P., Perugi G., Gerra G.

Summary: Not Available

Published: Volume 11 • Issue 3 • September 2009 (pages: 45 - 48)

Title: Echoing the Patient's Lack of Insight: A Role We Must Avoid Playing

Authors: Pacini M.

Summary: Not Available

Published: Volume 11 • Issue 4 • December 2009 (pages: 5 - 10)

Title: QT Interval

Authors: Caldarola P., Cuonzo M.

Summary: The electrocardiogram records the electrical activity of the heart, the depolarization and repolarization of the atria and ventricles. Deflections are all shown by the single features of the electrocardiogram: the P wave, the QRS complex, the T wave, the U wave, the PR interval and the QT. The QT interval represents the entire electrical activity of the left ventricle: it begins with the onset of ventricular depolarization (start of the Q wave) and is completed when ventricular repolarization ends (at the end of the T wave). Measurement of the QT interval is important because of the useful information it provides on the electrical activity of the heart; the length of the interval depends on various pathophysiological conditions, changes in electrolyte concentration, and the pharmacological action of toxic substances.

Published: Volume 11 • Issue 4 • December 2009 (pages: 11 - 20)

Title: Psychoactive Drugs and Prolongation of the QT Interval

Authors: Deruvo G., Vendramin A., Di Sciascio G.

Summary: The links between psychiatry and cardiology that are pertinent to potential cardiovascular risks associated with the use of psychotropic drugs, especially antipsychotics, cannot be viewed as entirely new. In Italy, however, an important innovation was made when, on 28 February 2007, the Italian Medicines Agency (AIFA), issued a directive laying down provisions for the amendment of the printed papers that accompany various medicines, including haloperidol; that initiative has revived the relevance of the whole question. In particular, contraindications to the use of these drugs have been redefined. The primary ones are now listed as acute myocardial infarction, decompensated heart failure, arrhythmias treated with antiarrhythmic drugs belonging to special classes, the prolongation of the QT interval corrected for heart rate (QTc), the family history for arrhythmia or torsades de pointes, hypokalaemia and the concomitant use of drugs that prolong the QTc.

Published: Volume 11 • Issue 4 • December 2009 (pages: 21 - 28)

Title: Opioid Treatment and “Long-QT Syndrome (LQTS)”: a Critical Review of the Literature

Authors: Pacini M., Maremmani A. G. I., Dell' Osso L., Maremmani I.

Summary: The present review aims at perusing the available literature about QT-related cardiac safety during methadone treatment. On the whole, case reports, either single or multiple, do not seem a reasonable bases to draw conclusions about the weight of any putative risk factor for QT prolongation. On the other hand, systematic studies allow making some statements about the extension and weight of QT prolongation during methadone maintenance treatment for heroin addiction. No major concern about cardiac safety of methadone itself in the average addict seems to stand. Conditions at higher risk of multiple and polydrug treatments deserve some greater surveillance. No rationale for a dose-ceiling stands in a risk/benefit perspective.

Published: Volume 11 • Issue 4 • December 2009 (pages: 29 - 34)

Title: Management of Cardiac Risk during Methadone Treatment: Focus on the QT Interval

Authors: Pani P. P.

Summary: In recent years, methadone, along with various other drugs, has been implicated in the lengthening of the QT interval of the electrocardiogram (ECG) and in the onset of potentially fatal arrhythmias. The risk of prolonged QT in methadone-maintained subjects is estimated at between 2-4%, while the risks of torsades de pointes or sudden death are extremely low. Despite the diversities reported, the guidelines available to date indicate the need to implement preventive measures based on ECG screening. The impact of these recommendations is, however, limited by the lack of a comparative risk/benefit assessment of specific procedures.

Published: Volume 11 • Issue 4 • December 2009 (pages: 35 - 40)

Title: Cardiovascular Complications of Cocaine Use

Authors: Gambarana C.

Summary: As cocaine use has become prevalent, an increasing number of reports of cocaine-associated morbidity and mortality, largely because of central nervous system and cardiovascular toxicity, appeared. Cardiovascular toxicity is broad, and it may also lead to neurological, psychiatric and other organ-specific symptoms. Cocaine may induce myocardial ischemia by increasing myocardial oxygen demand while simultaneously decreasing myocardial oxygen supply. Most of the cardiovascular toxic effects elicited by cocaine are likely related to its ability to selectively bind to the L-type calcium channels and the potassium channels that modulate the Ikr current. In addition, cocaine may promote intracoronary thrombosis in the absence of coronary atherosclerosis. This article briefly reviews the current knowledge regarding the cardiovascular effects of cocaine, providing insight into some of the underpinning mechanisms.

Published: Volume 12 • Issue 1 • March 2010 (pages: 5 - 16)

Title: Evaluation of Opioid-Dependent Prisoners in Oral Opioid Maintenance Therapy

Authors: Metz V., Matzenauer C., Kammerer K., Winklbaur B., Ebner N., Radler D., Fischer G.

Summary: Background: Opioid maintenance treatment is available in prison in many countries, but without a specific methodology or homogeneity. The aim of our study was to investigate characteristics and differences among opioid-dependent prisoners in an Austrian penitentiary. Methods: Structured assessments were obtained from 57 (78.1%) of 73 opioid-maintained prisoners on their demographic data, imprisonment terms, health status and quality of life. Results: From 1996 until 2007, the number of opioid-maintained detainees increased by 444%. Prisoners treated with methadone had significantly more convictions (p=0.036) and a longer duration of polydrug abuse (p=0.093) and opioid consumption (p=0.05) than patients maintained on slow-release morphine. Conclusions: There is a strong need for a diversification of opioid maintenance treatments, as well as the development of a specific methodology for the use of therapeutic opioids in prison.

Published: Volume 12 • Issue 1 • March 2010 (pages: 17 - 24)

Title: Dose Determination in Dual Diagnosed Heroin Addicts during Methadone Treatment

Authors: Maremmani I., Pacini M., Canoniero S., Deltito J., Maremmani A. G. I., Tagliamonte A.

Summary: Ninety-nine consecutive responders to treatment for heroin addiction (54 with one or more Axis I psychiatric diagnosis (DD-patients), and 45 without psychiatric comorbidity (NDD-patients), were monitored prospectively (20 months on average, min.1, max. 51), in order to achieve some useful clinical information pertaining to effective methadone dose determination for double diagnosed heroin addicts. First day and first month dosages do not differ between the two groups. Stabilization dosages are higher in DD patients than in NDD patients. The time to reach stabilization phase is longer in DD patients than in NDD patients. Tapering of methadone follows a similar trend in both groups. DD patients need more attention from clinicians, especially when stabilization dosage has to be established.

Published: Volume 12 • Issue 1 • March 2010 (pages: 25 - 32)

Title: Urine Labelling Marker System for Drug Testing Improves Patient Compliance

Authors: Simojoki K., Alho A.

Summary: Urine drug testing plays an important role in substance abuse treatments. When strictly controlled, as it often is, urine sampling creates a humiliating situation and ties up resources. A new sample labelling method has been developed to make supervision unnecessary. This innovation is achieved by labelling the urine with polyethylene glycols. In this study, 57 patients who required urine sampling were randomized into two groups, the traditional supervised (TS) group and the new marker (NM) group. The urine test return rate was 98.3% in the NM group and 100% in the TS group. Attempts to manipulate the urine samples were discovered in 2% of the NM group and 0% of the TS group. Most patients preferred the NM testing method. The personnel too preferred the NM system, and estimated that it reduced their workload dedicated to drug screening by 50%. We conclude that the NM method is more acceptable to patients and personnel, and may increase compliance as a result.

Published: Volume 12 • Issue 1 • March 2010 (pages: 33 - 36)

Title: Quality of Life As a Means of Assessing Outcome in Opioid Dependence Treatment [Letter]

Authors: Torrens M.

Summary: Not available

Published: Volume 12 • Issue 1 • March 2010 (pages: 37 - 40)

Title: Why There Has Been an Excess of Overdoses in Norway Since 1990? [Letter]

Authors: Haraldsen M.

Summary: Not available

Published: Volume 12 • Issue 2 • June 2010 (pages: 5 - 8)

Title: Addiction: Challenging the dual diagnosis construct

Authors: Pani P. P.

Summary: Not Available

Published: Volume 12 • Issue 2 • June 2010 (pages: 9 - 18)

Title: Adherence and social antecedents in relation to outcome in Methadone Maintenance Treatment (MMT)

Authors: Gronbladh L., Öhlund L. S.

Summary: Numerous reports of the effectiveness of methadone in reducing opiate use as well as mortality, criminality, prostitution and the risk for HIV-infection have been published during the last forty years. However, poor adherence to treatment, continuing drug use and increasing rate of premature termination may lead to less than optimal outcome results or in too many cases death. The aim of this paper is to investigate which of the background variables, collected at the admission procedure, that can be used to tell which type of patient will adhere to the treatment regime and succeed or who will fail and who either need special considerations or ought not to be accepted for a methadone treatment (MMT). As much as 86 percent of the compliers in this study did benefit from the treatment and were rated as medium to very much improved according to CGI-I. The group not improved or worse had significantly more background problems such as school problems, a history of non-opioid abuse, many non-MMT treatment episodes, low age at drug debut and opioid debut than the group much or very much improved. Those moderately improved is usually situated somewhere in between the others.

Published: Volume 12 • Issue 2 • June 2010 (pages: 19 - 24)

Title: Additional take-home dosages

Authors: Rupnik J. C.

Summary: Objectives: The objective of the study was to analyse the practice of giving take-home dosages of opioid medications to patients with reference to the reasons for and the quantity of the medications given as additional or extra take-home dosages. Methods: All the patients were checked regarding the kind of medication, urine samples, reasons for extra take-home dosages and their quantity. Results: Of the 150 patients selected for the group in the programme, 27 needed one or more extra take-home dosages in 2007. 10 (11*) of those patients had negative urine samples for all illicit drugs and never used alcohol at any stage of the year of the study. 7 patients used marijuana, benzodiazepines or alcohol only once or just occasionally in that year. 10 patients used other illicit drugs or used alcohol and benzodiazepines more often. Among the reasons for extra take-home dosages, hard physical work was listed 7 times, vomiting because of the bad taste of the medication 3 times, difficulties in intiating medical therapy after entering the programme 3 times, vomiting as a part of illness twice and lowering the dosage too quickly twice. Other reasons were listed once each. Altogether, the percentage of the overall quantity of medications received by patients during the year as extra take-home dosages was: 0.47% for methadone, 0.75% for buprenorphine and 0.10% for SR morphine. Conclusions: Reviewing the fairly good results of treatment at the centre, therapeutic decisions to give additional take-home dosages to the patients have proved to be reasonable and usually correct. Throughout this study a continual therapeutic wish to achieve a better understanding of opioid addiction as just one among other chronic diseases has been made evident.

Published: Volume 12 • Issue 2 • June 2010 (pages: 25 - 28)

Title: From methadone to buprenorphine or back to methadone. The Croatian experience

Authors: Ivancic A.

Summary: In Croatia maintenance treatment is made widely available through a network of GP offices that covers the whole of the country. More then 50% of all GPs in Croatia have at least one patient in MT. Methadone was the only opioid agonist used for over a decade, but this changed when buprenorphine was introduced 4 years ago. There is little difference in the regimen for the prescription and provision of the two medications: both are free of charge and are prescribed by GPs; in addition, there are no restrictions on the dose to be used or on ‘take home' policy. The decision on which medication will be used is based exclusively on the clinical assessment and patient-doctor agreement. The example of Croatia gives an opportunity to compare the acceptance of this medication by patients and doctors in situations of equal availability.

Published: Volume 12 • Issue 2 • June 2010 (pages: 29 - 36)

Title: Methadone treatment for pregnant heroin addicted women

Authors: Finnegan L., Pacini M., Maremmani I.

Summary: A review of methadone-related issues and the approach to heroin addicted patients is presented with the aim to clarify what is practiced by the establishment of anti-craving treatment and what is expected within a history of addiction. A series of clinical situations occurring throughout pregnancy to early child development are described, and the etiological hypothesis discussed. Moreover, some methodological considerations are described in order to better understand some ambiguity about the effectiveness and harmlessness of methadone treatment, particularly with regard to neonatal opiate withdrawal. Limitations to the outcome of pregnancies in heroin addicted women seems to be due to misconceptions about methadone toxicity and neonatal damage, which may lead to the mishandling of methadone as a therapeutic modality, especially with regard to maintenance at effective dosages.

Published: Volume 12 • Issue 2 • June 2010 (pages: 37 - 40)

Title: What is the right dosage for our patients?

Authors: Ulmer A.

Summary: Not Available

Published: Volume 12 • Issue 3 • September 2010 (pages: 5 - 8)

Title: Psychological performance and sedation following injectable opioid administration

Authors: Forzisi L., Mitchell T. B., Bond A., Lintzeris N., Spofforth N., Strang J.

Summary: Injectable opioid treatment (IOT) can be an effective strategy for heroin users who respond poorly to treatment with oral methadone, but its safety profile is yet to be fully characterised. This study assessed the risks of sedation and impaired psychological performance in 13 IOT patients following injection of their regular dose of heroin (n=7) or methadone (n=6). Measures of psychological performance (digit symbol substitution task, DSST; cancellation task, CT) and sedation (visual analogue scale, VAS) were taken at baseline and 15, 30 and 60 minutes post-injection. Comparisons were made between the methadone and heroin groups, with reference to data collected in control groups maintained on oral methadone or sublingual buprenorphine. Results indicated that performance and sedation did not change significantly in the hour after injection. However, patients prescribed injectable heroin or injectable methadone showed significantly worse psychological performance at the time of peak effect compared to patients prescribed oral methadone or buprenorphine. These findings suggest that further research is required to characterise possible psychological performance deficit in IOT patients.

Published: Volume 12 • Issue 3 • September 2010 (pages: 9 - 19)

Title: Treatment practices and perceived challenges for European physicians treating opioid dependence

Authors: Bacha J., Reast S., Pearlstone A.

Summary: This survey investigated the current practices and challenges of physicians treating opioid dependence in Germany, France, Italy and the UK. Doses favoured in Europe appeared to conflict with recommended best practice, with low mean methadone and buprenorphine maintenance doses reported (44.3 and 9.5 mg, respectively). Mean time to buprenorphine maintenance doses was longer than recommended at 14.4 days. Respondents also rated diversion and misuse management as their most difficult challenge in treating opioid dependence. These data suggest that prescribing practices are likely to increase this problem, as well as impeding treatment success by decreasing compliance and retention.

Published: Volume 12 • Issue 3 • September 2010 (pages: 21 - 30)

Title: Clinical foundations for the use of methadone in patients with infectious diseases

Authors: Somaini L., Pacini M., Maremmani I.

Summary: The immune system is an organization of cells and molecules with specialized roles in defending against infection. Communication between the central nervous and the immune system lies at the hart of the neuroimmune axis. There are several data indicating that opioids drugs may influence the immune system. One of the main features of opioid induced alteration of immune function is the development of immunosuppression. However, evidence has been provided to suggest that different opioids drugs may have distinctive effects on the immune system. Methadone is a widely used synthetic 3,3-diphenylpropylamine opioid which primarily acts at the μ opioid receptor. Its most common use is in the therapy for opioid dependence. Besides to their therapeutic efficacy, opioids can produce several well known adverse events, and, as has recently been recognized, can positively interfere with the immune response. Infact, data obtain from animal and human studies have demonstrated that long acting opioids drugs such as methadone is devoid of any intrinsic immunosuppressive activity. This effect may partly depend on the ability of methadone to restore the HPA axis function, that is altered in heroin dependent patient, or by the long-lasting activation of opioid receptors both in the central nervous system and on immune competent cells. HIV and HCV infections are the most frequent infectious disease seen in drugs users. Opioids may facilitate the outbreak of infections through marked immunomodulating effects on the immune respsoses against a virus. The enrolment of heroin patient in MMT programs represents a particularly effective measure for the prevention of HCV and HIV virus transmission and the immunorestoring properties of methadone are particularly relevant in the treatment of concurrent infectious such as HCV frequently associated with heroin addiction. It is evident that the possibility to reach an adequate control of addiction and of concomitant infectious diseases choosing either immunosuppressive drugs or drugs characterized by immunoneutral or immunostimulating effects could represent an important point to be considered in the future in opioid therapy.

Published: Volume 12 • Issue 3 • September 2010 (pages: 33 - 38)

Title: Bioethical preferences of supporters and opponents of agonist opioid therapy in Russia

Authors: Mendelevich V.

Summary: Not available

Published: Volume 12 • Issue 3 • September 2010 (pages: 39 - 40)

Title: The pleasure constant

Authors: Softic J.

Summary: Not available

Published: Volume 12 • Issue 4 • December 2010 (pages: 5 - 16)

Title: Psychiatric comorbidity in substitution treatment of opioid-dependent patients in primary care: Prevalence and impact on clinical features

Authors: Lieb M., Wittchen H. U., Palm U., Apelt S. M., Siegert J., Soyka M.

Summary: Although elevated rates of psychiatric comorbidity in drug-dependent patients in methadone maintenance treatment are known, differences in comorbidity, maintenance medications, provider settings and somatic morbidities often remain unclear. Here, the prevalence and impact of comorbidity is described in a large, nationally representative sample of substitution patients with a cross-sectional naturalistic study in German buprenorphine or methadone substitution patients. Over two thirds of both the males and females were diagnosed by their physician as having a psychiatric diagnosis other than substance dependence. Depressive and anxiety disorders were the most common diagnoses. Men recorded higher rates for schizophrenic disorders, sleep disorders and antisocial personality disorder, while a higher percentage of women had a borderline personality disorder.

Published: Volume 12 • Issue 4 • December 2010 (pages: 17 - 22)

Title: Methadone maintenance therapy and feto-maternal outcomes of pregnancy

Authors: Igboekwu J., Wolff K.

Summary: We studied a cohort of pregnant opioid dependent women (n = 30) on methadone maintenance therapy aiming to identify obstetrics, neonatal and pregnancy outcomes and characteristics including the level of antenatal contact and its effect. There were statistical significant associations between birth weight and use of illicit drug and between use of illicit drugs and gestational age (crack use and length of labour r2 =.57 and r2 = .012. P = 0.05; Cocaine use and type of delivery r2 = .515 and r2 = .006. P = 0.05; Birth weight and length of gestation r2 .429 and r2 = .041. p= 0.05).

Published: Volume 12 • Issue 4 • December 2010 (pages: 23 - 32)

Title: On opioid receptors

Authors: Vendramin A., Sciacchitano A.

Summary: The system of opioid receptors is characterized by a high level of complexity and has received much attention from scientists all over the world. The aim of this article is to describe the present, updated situation regarding scientific knowledge on the subject. Each opioid receptor is distributed in CNS in a distinctive way. Some regions (striate body and dorsal horns of spinal medulla) indicate the three receptor types, although not necessarily in the same neurons. Conversely, other regions, such as the thalamic nucleus for µ or the claustrum for k, show various sites for a single type of receptor. Each receptor is involved in functions that are implemented along different paths and extensions. At present, it seems clear that the role of each receptor in mediating biological actions or physiological effects needs to be deepened using methodologies that differ from the classic ones. It can now be predicted that molecular cloning, re-combining DNA, antisense holigonucleotides, knockout and knockdown techniques will soon make it possible to understand many of the problems which make this system so ‘complicated'.

Published: Volume 12 • Issue 4 • December 2010 (pages: 33 - 40)

Title: Psychotherapeutic management of heroin-addicted patients. Psychopathological, relational and organizing aspects

Authors: Bignamini E.

Summary: Addiction is a pathological condition which is still only partly understood. the complexity of reality exceeds our capacity to elaborate and synthesize the information that is currently available, so compelling us to operations of simplification, in order to become operative. In this exposition I will discuss how, starting from a view of addiction as a pathology of relationships, and from a pragmatic vision of the available therapeutic techniques as tools of intervention rather than interpretive theories of realty, is it possible and necessary to evaluate the psychotherapeutic approach.

Published: Volume 12 • Issue 4 • December 2010 (pages: 41 - 48)

Title: Treating heroin addicts. Blocking dosages and stimulation-stabilization of opioidergic system

Authors: Pacini M., Maremmani A. G. I., Rovai L., Rugani F., Maremmani I.

Summary: The paper that follows is an attempt to conceptualize a clinically based classification of treatments for heroin addiction. In fact, a distinction is drawn in classifying treatments between those that are antagonists and those that are agonists; the latter can be further subdivided into full and partial. On this view, the effectiveness of full agonists cannot be displayed as dependent on a key antagonist action, originally described as an ‘opioid blockade' and regarded as the main therapeutic mechanism available against addiction. On the other hand, the differences in levels of effectiveness between antagonists and full agonists cannot be understood either in terms of the presence of absence of antagonism, or as opposing two radically different mechanisms of action (it remains true that they both produce an opioid blockade). In proceeding further, the authors propose the concept of optimal antagonism, which is centred around the original ‘opioid blockade' mechanism and also accounts for agonist potency providing a direct anticraving effect and aversive effects. Also, acquired tolerance to opiates does function as a drawback deriving from abrupt treatment termination or steep reduction, so as to favour stability of the anticraving coverage. In practice, optimal antagonism is a concept that helps to define the gold standard of retention, clinical response and rehabilitative potential. Naltrexone only provides patients with antagonism, which does not appear to be the crucial feature of the ‘narcotic blockade' originally described for full agonists, since levels of global effectiveness differ markedly. The balance between the level of narcotic blockade and other properties corresponds to the level of global effectiveness of a treatment regimen, which eventually explains why complete blockade brings poorer results in the absence of other anticraving actions. Methadone and buprenorphine appear to provide optimal antagonism; in other words, they offer patients opioid blockade combined with tolerance to euphoria and direct anticraving action.

Published: Volume 12 • Issue 4 • December 2010 (pages: 49 - 52)

Title: It is time for a responsible administration of gamma hydroxybutyrate and methadone

Authors: Caputo F.

Summary: Not Available

Published: Volume 12 • Issue 4 • December 2010 (pages: 53 - 56)

Title: Opiate maintenance treatment in primary health care in Germany

Authors: Ullmann R.

Summary: Not Available

Published: Volume 13 • Issue 1 • March 2011 (pages: 5 - 10)

Title: Tobacco smoking prevalence in a large sample of heroin users accessing rehabilitation

Authors: Pajusco B., Boschini A., Chiamulera C., Begnini M., Smacchia C., Lugoboni F.

Summary: Although there is a large amount of anecdotal evidence about the association between heroin abuse and tobacco smoking, there have been only a few epidemiological studies. The present report is a cross-sectional survey on tobacco smoking in heroin users. The sample included 10,530 drug users accessing the Comunità di San Patrignano during the time period 1st January 1980 to 1st May 2007. Heroin-addicted subjects (n = 10,181) were not receiving any type of substitution or detoxification therapy. Tobacco smoking prevalence in the heroin-addicted group was 99.2% (10,095 out of 10,181 subjects). In the large sample of heroin users observed in the present study, this confirms the anecdotal report that most heroin users are smokers.

Published: Volume 13 • Issue 1 • March 2011 (pages: 11 - 14)

Title: Housing and employment situation, body mass index and dietary habits of heroin addicts in methadone maintenance treatment

Authors: Alves D., Costa A. F., Custódio D., Natário L., Ferro-Lebres V., Andrade F.

Summary: Forty-nine heroin addicts in methadone maintenance treatment were evaluated with the aim of studying the anthropometric, nutritional and sociodemographic characteristics of these individuals. The BMI of heroin addicts who live with their spouse/partner is significantly higher compared with other housing situations. Most of the heroin addicts evaluated do not consume the minimum servings of fruits, vegetables and grains recommended by the food pyramid, and their consumption of sweets is high. This study reinforced the need for intervention programmes specifically designed to correct the poor nutritional status and diet of drug users, while considering this to be a major public health issue.

Published: Volume 13 • Issue 1 • March 2011 (pages: 15 - 20)

Title: Effect of valproate on benzodiazepine withdrawal severity in opioid-dependent subjects: a pilot study

Authors: Vorma H., Katila H.

Summary: This study aimed to determine whether valproate is effective in treating benzodiazepine withdrawal symptoms in subjects receiving opioid maintenance treatment. Thirty patients were randomly selected for benzodiazepine discontinuation with or without valproate. Twenty-eight subjects completed the treatment. No serious adverse events were reported. After randomization, the baseline median diazepam-equivalent doses were 60 mg in the valproate group and 30 mg in the control group. No statistically significant differences were found between the weekly mean withdrawal scores of the two groups; even so, we believe that valproate may be useful in treating benzodiazepine withdrawal in opioid-dependent subjects. More studies are needed to confirm this.

Published: Volume 13 • Issue 1 • March 2011 (pages: 21 - 28)

Title: Opioid addiction complicated by alcoholism (in young men)

Authors: Blagov L. N., Kurgak D. I.

Summary: A clinical run of addictive diseases shows a variety of trends. One of these is an amplification of the clinical picture, with the appearance of new structural components whose dynamic psychopathological characteristics tend to increase in severity. It is important here to look at addictive problems not only as constituting a dependence syndrome, but as an ongoing, ever-varying clinical reality, showing the distinctive traits of a specific psychopathological process that comprises post-toxic problems, including combinations of personality disorders and their environmental predisposition. So, opioid addiction complicated by alcoholism can be seen as a prime example of how consistent patterns can be found in the clinically dynamic aspects of addictive diseases. A clinical description of these patterns based on reported cases to be investigated throughout a lifelong period of illness is a step to be taken towards a better understanding of addictive pathology as a severe medical problem.

Published: Volume 13 • Issue 1 • March 2011 (pages: 29 - 34)

Title: Dual Diagnosis (Comorbidity): A growing diagnostic and treatment issue in the psychiatric and substance use programmes in the Republic of Macedonia

Authors: Tulevski I. G.

Summary: The purpose of this paper is to describe several existing problems encountered in the management of dual diagnosis (DD) in the psychiatric and drug treatment institutions in Macedonia. The term DD or comorbidity refers to the co-occurrence of at least one mental and behavioural disorder due to psychoactive substance use with another psychiatric disorder in the same individual. These ‘dual' subjects present greater severity from both the clinical and social perspectives than those who have only one type of psychiatric disorder. The cost to the health system for those with DD is significantly higher than it is for someone with a single psychiatric disorder. This presents a significant challenge with respect to the identification, prevention and management of people with DD. According to the 2004 Report by the EMCDDA, the prevalence of DD in treatment settings in various EU countries ranged between 22% and 96%. In the Day Hospital for the Prevention and Treatment of Drug Dependencies in Kisela Voda, Skopje in an 8-year period, 1995-2002, 9.8% – 49 out of a group of 500 heroin users – were diagnosed as ‘dual' patients. The unmet need for treatment of people with DD is considerable. People with DD often found themselves in the gap between the relevant services, namely between the Day Hospital in Kisela Voda, and the Psychiatric Hospital in Skopje, or, less frequently, in prison. In Macedonia guidance regarding the best practice for the treatment of individuals with DD is not available. Access to services for people with DD diagnosis is restricted. They are under-diagnosed and receive very little treatment. The present Author has stressed the need for increasing the capacity of the health care system in Macedonia to meet the needs of people with DD. Further research is needed to establish the prevalence of DD, and to improve the diagnosis, treatment and social rehabilitation of people with DD.

Published: Volume 13 • Issue 1 • March 2011 (pages: 35 - 36)

Title: Does cannabis have therapeutic benefits for withdrawing opioid addicts?

Authors: Peloquin M., Peters L. R., Mclarnon M. E., Barrett S. P.

Summary: Not available

Published: Volume 13 • Issue 1 • March 2011 (pages: 37 - 40)

Title: Is it time for new studies on the level of insight in heroin addicts to promote compliance with methadone treatment?

Authors: Rovai L., Maremmani A. G. I.

Summary: Not available

Published: Volume 13 • Issue 2 • June 2011 (pages: 5 - 40)

Title: Basics on Addiction: a training package for medical practitioners or psychiatrists who treat opioid dependence

Authors: Maremmani I., Pacini M., Pani P. P., On Behalf of the 'Basics on Addiction Group'

Summary: Opioid dependence is a chronic, relapsing brain disease that causes major medical, social and economic problems to both the individual and society. This seminar is intended to be a useful training resource to aid healthcare professionals – in particular, physicians who prescribe opioid pharmacotherapies – in assessing and treating opioid-dependent individuals. Herein we describe the neurobiological basis of the condition; recommended approaches to patient assessment and monitoring; and the main principles and strategies underlying medically assisted approaches to treatment, including the pharmacology and clinical application of methadone, buprenorphine and buprenorphine–naloxone.

Published: Volume 13 • Issue 3 • September 2011 (pages: 5 - 16)

Title: Therapeutic management and comorbidities in opiate-dependent patients undergoing a replacement therapy programme in Spain: the PROTEUS study

Authors: Roncero C., Fuste G., Barral C., Rodríguez-Cintas L., Martínez-Luna N., Eiroa-Orosa F. J., Casas M., On Behalf of the Proteus Study Investigators

Summary: The aim of this study was to comprehensively describe the clinical comorbidities, concomitant treatments and the current therapeutic management of opiate-dependent patients undergoing a replacement therapy programme(RTP). This is an observational, cross-sectional, multicentre, epidemiological study conducted in 74 healthcare centres for drug users. Patients were diagnosed with Opiate Dependence (OD), and enrolled in a RTP in Spain (N=624). Most patients were men (84%); they received methadone (94%) at a mean dose of 61.52mg/day during the maintenance phase, orally (95%) with take-home doses (76%). High rates of infectious (59%) and psychiatric comorbidities (67%) were found. Patients infected by HIV, HCV or coinfected by HIV/HCV were given significantly higher methadone doses (p<0.0001).

Published: Volume 13 • Issue 3 • September 2011 (pages: 17 - 26)

Title: Life events (loss and traumatic) and emotional responses to them in heroin-dependent patients before and after the dependence age of onset

Authors: Rugani F., Maremmani A. G. I., Rovai L., Mautone S., Perugi P., Pani P. P., Dell'osso L., Maremmani I.

Summary: Epidemiological data show frequent associations between post-traumatic stress disorder (PTSD) and substance use disorders. In this study we assessed the life events (loss events and potentially traumatic events) of 82 heroin-dependent patients before and after the dependence age of onset (DAO) and their emotional, physical and cognitive responses to these events, within a trauma and loss spectrum. We also assessed personality traits at risk for Post-Traumatic Stress Disorder (PTSD). In passing from the before-DAO to the after-DAO period, 97.6% of patients continued to experience life events, 82.9% loss events and 91.5% potentially traumatic events. The life events most frequently rated as the most important by patients are “death of a close friend or relative”, “divorce” and “being neglected or abandoned”. Sexual abuse seems to be present, but with a lower percentage. Criminal behaviours become very common after DAO. “Grief reactions” to loss events increase after DAO, as well as “reactions to the most important event”, “re-experiencing”, “avoidance and numbing”, “maladaptive coping” and “arousal”. After DAO, we found an increase in all the emotional, physical and cognitive behaviours typically reported in PTSD patients. This increase in the intensity of emotive reactions during a drug addiction history seems to configure a sort of PTSD spectrum resulting from the addictive process. At a therapeutic level it would be appropriate to consider this higher emotional reactivity in patients as being due to loss events and potentially traumatic events, so as to allow the optimization of therapeutic resources when these life events occur.

Published: Volume 13 • Issue 3 • September 2011 (pages: 27 - 38)

Title: A comparison of the drug use patterns, measures of needs and quality of life of methadone maintained patients using and not using cocaine

Authors: Ducray K., Byrne P., Burke C., Smyth B. P.

Summary: Cocaine use on methadone maintenance treatment (MMT) is believed to complicate clinical outcomes. This study aimed to determine whether cocaine users on MMT require distinct services by virtue of their differential drug use, needs and quality of life relative to non- cocaine users. A cross sectional survey of 108 adults attending a Dublin opioid treatment service was conducted. The urine toxicology screens, Camberwell Assessment of Need Short Appraisal Schedules and WHO Quality of Life- Bref responses of respondents defined as either cocaine users or non- cocaine users were compared. Whilst cocaine use on MMT was not significantly associated with adverse measures of need or quality of life, it was linked to significantly greater heroin use and to more frequent injecting.

Published: Volume 13 • Issue 3 • September 2011 (pages: 39 - 48)

Title: Sociodemographic and clinical differences among deceased and surviving cohort members of opioid maintenance therapy

Authors: Lovrečič B., Šemerl J. S., Tavčar R., Maremmani I.

Summary: This study aimed to analyse the differences found among surviving and deceased heroin addicts in opioid maintenance treatment in the years 2004-2006 in Slovenia in terms of their sociodemographic and clinical characteristics. 3,950 heroin addicts entered our retrospective cohort study; of these, 69 had died by the end of the study. Mean age as recorded at entry into treatment was significantly higher among those who had died by the end of the study than among survivors. Men and those who had undergone more than one treatment died significantly more frequently than women and those in their first treatment. In addition, those who were unemployed or had had fewer years of education proved to be more likely to die. Heroin was the main drug in both groups; among its users death rates were significantly higher than among those taking other widely used addictive drugs. This is the first cohort study that has taken the step of recording indirect deaths. Further studies are now needed to acquire a better understanding of the phenomenon.

Published: Volume 13 • Issue 4 • December 2011 (pages: 5 - 12)

Title: Self-reported differences in side-effects for 110 heroin addicts during opioid addiction and during methadone treatment

Authors: Grönbladh L., Öhlund L. S.

Summary: Although methadone maintenance treatment (MMT) has been shown to be effective, poor compliance is always a threat. It has often been pointed out that one variable that inevitably reduces adherence to treatment regimes is the negative side-effects of the treatment. This study examines seventeen known side-effects in a sample of 110 former opiate addicts consecutively admitted to methadone maintenance treatment. Self-reported side-effects were collected through a questionnaire. Despite the considerable increase, from 23 to 74% of the sample, in the proportion that reported individual side-effects between the period of opiate use and that of methadone treatment, the overall result was a significant decrease in eleven symptoms, no change in four and a substantial increase in only two. In some individuals a symptom that is liable to be problematic actually does become problematic, while the same symptom becomes less frequent in the group as a whole. Weight gain is the symptom that increases most in the whole group and needs to be constantly monitored. Other side-effects that remain high and need to be kept under review in clinical practice are nervousness, decreased libido, daytime drowsiness, constipation and perspiration.

Published: Volume 13 • Issue 4 • December 2011 (pages: 13 - 20)

Title: Latent suicidality in heroin addicts

Authors: Budiša D., Gavrilov-Jerković V., Dickov A., Vučković N., Mitrović D., Svilokos S.

Summary: According to the transactional analysis (TA) theory of personality development and the development of psychopathology, any behaviour that indirectly or directly threatens someone's physical integrity could be a manifestation of the 'Don't exist' injunction and the script decision to die young. A 'don't exist' injunction is defined as a parental message that challenges a child's right to live, and that can be sent directly or indirectly, verbally or nonverbally, intentionally or unintentionally. An (early) script decision is defined as a compromise between the various authentic needs and requirements of the environment. The theoretical assumption on which this work is based is that a mentioned injunction and script decision to die young could be present in the population of heroin addicts, considering their continuous and repeated self-destructive behaviours and, typically, short lifetimes. The main objective of this work was to check the assumption that the 'Don't exist' injunction and the script decision to die young are theoretical concepts that are available for measurement through questionnaires and have the potential to discriminate heroin addicts from non-clinical examinees. The general research method that was selected was non-experimental, correlation research; the sample consisted of 50 heroin addicts and 50 non-clinical examinees. Its results confirm the hypothesis that both measured theoretical concepts have the potential to discriminate heroin addicts from non-clinical examinees. Heroin addicts have, to a statistically significant degree, a more strongly marked “Don't exist” injunction, together with the script decision to die young. This finding may be related to the theoretical assumptions of several authors in the TA – assumptions which include the concept that psychoactive substances allow a person to implement the script decision to die young.

Published: Volume 13 • Issue 4 • December 2011 (pages: 21 - 26)

Title: Patients who use alcohol during MMT receive lower doses of methadone, show fewer positive urine analyses for opioids, and suffer from PTSD more frequently

Authors: Softić J., Awad H.

Summary: The objectives of the study were to identify the prevalence of alcohol use, to find out differences in sociodemographic characteristics, the frequency of PTSD, percentages of invalid war veterans, the average methadone dose and number of positive urine analyses on opioids among patients undergoing methadone substitution treatment who use alcohol from those who abstain. We found that 42 (25.77 %) out of 163 participants had an AUDIT score > 7, indicating alcohol use. The two groups did not differ in terms of sex, age, education, employment, marital status or percentages of war veterans. The statistically significant differences recorded were: lower average dose of methadone, fewer positive urine analyses for opioids and a higher incidence of PTSD among the patients undergoing methadone substitution treatment who were using alcohol. Conclusions: The patients who use alcohol have a lower average dose of methadone, fewer positive urine analyses for opioids and a more frequent presence of PTSD. The risks arising from alcohol abuse and possible PTSD in these patients call for greater attention in everyday practice.

Published: Volume 13 • Issue 4 • December 2011 (pages: 27 - 34)

Title: Further evidence of no relationship between anxiety-depressive mental status and dual diagnosis in heroin addicts entering treatment

Authors: Lovrecic M., Lovrecic B., Rovai L., Rugani F., Maremmani A. G. I., Maremmani I.

Summary: Psychiatric symptoms are generally the rule among heroin addicts requesting treatment, and are not always the expression of an associated mental disorder. In a previous study we investigated the mental status of 1,090 Italian heroin addicts at the beginning of treatment, and its relationship to relevant demographic and clinical data through the use of standardized instruments. We concluded that the presence of depressive–anxious symptomatology in the clinical presentation appears to be unrelated to ‘dual diagnosis'. In this study we tried to replicate our previously reported study in a sample of 591 Slovenian heroin addicts (462 males and 129 females aged between 18 and 52). The results showed that psychomotor excitement was the most frequent psychiatric symptom among Slovenian heroin addicts looking for treatment; it was linked with a lower severity of drug addiction history. By contrast, the presence of depressive features in the clinical presentation of Slovenian heroin addicts appears to be a reliable indicator of general addiction severity. Psychomotor excitement and psychosis, but not depression, predict the presence of an actual dual diagnosis, in agreement with our previous study and providing further support for the view that it is important for clinicians to be able to identify major as well as minor psychomotor excitement and psychotic symptoms in heroin addicts presenting for treatment.

Published: Volume 13 • Issue 4 • December 2011 (pages: 35 - 38)

Title: Requiring stabilized heroin addicts to stop successfull agonist opioid treatment before liver transplantation can shift patients over a cross-acting (alcohol) substance abuse

Authors: Piz L., Maremmani A. G. I., Rugani F., Pacini M., Rovai L., Dell'osso L., Maremmani I.

Summary: Methadone Maintenance Treatment patients are significantly under-represented in most liver transplant programmes, but the number of patients receiving agonist opioid treatment (AOT) is increasing, and few data are available at the moment when patients are selected for surgery. We present a case in which an Italian patient affected by heroin dependence and successfully treated with AOT had to stop opioid medical treatment to be able to enter a liver transplantation programme. He successfully discontinued AOT, received a liver transplant and continued not to abstain from heroin in the post-transplant period. Unfortunately, he engaged in alcohol use, so shifting over into another cross-acting substance abuse disorder, and endangering his newly restored liver functions. He was a non-responder to alcohol abuse treatment and, while he was abstaining from alcohol, he reported a craving for heroin. We reintroduced opioid agonist treatment, so obtaining a non-relapsing condition regarding heroin and a significant patient recovery on alcohol abuse, with a complete liver function normalization. We suggest that successful agonist opioid treatment should be continued even when transplantation is needed, not only to avoid the risk of relapse into heroin use, but also to avoid the risk that the patient may shift over into another substance abuse disorder (in this case, alcoholism). The shift from heroin to alcohol also means the transition from a highly curable disease, as heroin addiction is, to one that is hard to cure, as alcoholism is, which implies a greater risk to endangering the new liver function with respect to the continuation of AOT.

Published: Volume 13 • Issue 4 • December 2011 (pages: 39 - 40)

Title: Suboxone® switch data: A regional experience

Authors: Leonardi C.

Summary: Not available

Published: Volume 13 • Issue 4 • December 2011 (pages: 41 - 46)

Title: What concept of ‘spectrum' is useful in addiction medicine?

Authors: Rovai L., Rugani F., Bacciardi S., Maremmani A. G. I.

Summary: Not available

Published: Volume 14 • Issue 1 • March 2012 (pages: 5 - 10)

Title: How should Methadone- and Buprenorphine-Treatment be organized and regulated? A comparison of two systems in the context of an Europad-conference in Brussels

Authors: Ulmer A., Lamy D., Reisinger M., Haraldsen M., Maremmani I., Newman R.

Summary: Opiate Agonist Treatment (OAT-providing) physicians and pharmacists from the southwest region of Germany and the Wallonian part of Belgium came together with international experts to compare their two different sets of OAT regulations. Both countries mostly rely on methadone, but with an increasing use of buprenorphine, besides a much less frequent recourse to other opioids. German OAT is rather strictly regulated. The aim of these regulations was to ensure quality. That effect is, however, questionable. The regulations make it difficult and legally dangerous to provide OAT. Physicians and patients suffer from these regulations. Most doctors avoid getting involved. No successors are available. The future scenario will be OAT provision at only a few clinics, with a large array of controls and with a customary setting of crowds of addicted people. The Belgian system runs without these regulations. The consequence is not greater chaos, but a much more normal integration of patients into normal medical practice and into society itself. The take-home message of the conference held under the auspices of EUROPAD was that most special regulations point in the wrong direction, and lead into a costly dead end. The whole treatment procedure works better and much more effectively if we treat the patients as normally as possible, with nothing more complicated than normal diligence. Connection with a good support system, networking, regular education and periodic evaluation of how the system functions - all these factors go to constitute a guarantee of the best possible outcome for patients.

Published: Volume 14 • Issue 1 • March 2012 (pages: 11 - 22)

Title: Heroin addicts' psychopathological subtypes. Correlations with the natural history of illness

Authors: Maremmani A. G. I., Rovai L., Pani P. P., Maremmani I.

Summary: By recently using an exploratory factor analysis of the 90 items in the SCL-90, we identified a five-factor solution for 1055 heroin addicts who answered that questionnaire at treatment entry. On the basis of the highest z-scores obtained on these factors, subjects can be assigned to 5 mutually exclusive groups labelled “worthlessness and being trapped”, “somatization”, “sensitivity-psychoticism”, “panic anxiety”, and “violence-suicide”. In this study we correlated the distribution within these groups of 455 heroin addicts The patients belonging to the “worthlessness and being trapped” group had the highest average age and were those who, most frequently, had a white-collar job. Those belonging to the “somatization” group were less frequently at their first treatment, more frequently reported sleep disturbances and less frequently referred to their use of hallucinogens. The leading distinctive feature of those in the “sensitivity-psychoticism” group was that they were the youngest. Patients belonging to the “panic anxiety” group less frequently reported major problems with their love life, sleep disturbances, and more frequently referred to their use of CNS stimulants. The features of being more excitable and violent brought with them the highest likelihood of belonging to the “violence-suicide” group. These differences were independent of the presence of dual diagnosis. These data support the hypothesis that heroin has as its foundation a specific psychopathology.

Published: Volume 14 • Issue 1 • March 2012 (pages: 23 - 34)

Title: Profile of an Addict or Beyond the Addiction Mask

Authors: Knežević Tasić J., Šapić R., Valkanou M.

Summary: The main purpose of this study was to examine if there is anything that could be correctly described as the “profile of an addict”, and whether certain personality disorders occur with a higher frequency in substance abuse patients in Serbia today. The other question investigated in this study is how the presence of psychopathology can be evaluated in individuals who have developed addiction compared with those who have not. In addition, factors such as emotional relationships and education have been examined. The sample selected for this inquiry included 79 participants - 42 addicts, and 37 individuals making up a control group. Personality disorders were assessed by applying the Millon Multiaxial Clinical Inventory III (MCMI III), together with a specially constructed data sheet. Canonical discriminant analysis was used to present the model best able to generate distinct personality features that strongly predict drug abuse and determine the essence of an addiction personality profile. Canonical discriminant analysis was also used to explore differences in the presence of psychopathological features between the two groups. A chi-squared analysis examined the differences in emotional status and level of education between groups. Significant differences were found between the general population and the substance abuse group in terms of the presence of personality disorders and the level of the pathology presented. Individuals who have developed an Antisocial, a Borderline, a Depressive or a Dependent personal style are those most prone to substance abuse, whereas individuals who have adopted a Histrionic or Compulsive Personality style are those least likely to develop addiction. The study found that addiction is firmly attached to the presence of major Depression, PTSD and Dysthymia. Another significant difference in the levels of pathology between the two groups was documented, in a way that showed that the addiction group had a significantly higher overall level of pathology.

Published: Volume 14 • Issue 1 • March 2012 (pages: 35 - 44)

Title: Factors associated with discharge against medical advice from an alcohol and drug inpatient detoxification unit in Barcelona during 1993-2006

Authors: Gilchrist G., Langohr K., Fonseca F., Muga R., Torrens M.

Summary: Records from 1,228 consecutively admitted patients (74.5% male) to an inpatient detoxification unit in Barcelona between 1993 and 2006 were examined to determine factors associated with discharge against medical advice (AMA). 21.5% of admissions were discharged AMA. In multiple logistic regression and compared with patients who were medically discharged, those discharged AMA were younger, more likely to be dependent on heroin, other opiates, cocaine or psychostimulants, or to be experiencing reduction or elimination methadone maintenance therapy [reference category: alcohol]. The provision of assistance to clinicians in identifying the patients who are most at risk of leaving inpatient detoxification AMA will enhance their ability to motivate such patients to stay in treatment.

Published: Volume 14 • Issue 1 • March 2012 (pages: 45 - 58)

Title: A compartmental model for the pharmacokinetics of heroin and its metabolites in man.

Authors: Urso R., Montefrancesco G., Rigato M.

Summary: A compartmental model was used to describe the pharmacokinetics of heroin, 6-monoacetylmorphine, morphine and glucuronides. The parameters of the model were estimated by pooling the observations collected and published in various studies, and were used to predict the effect of a reduced rate of glucuronidation and renal excretion on the plasma profile of morphine and its glucuronides after single and multiple administrations of morphine. Simulations were performed by assuming that some rate constants were representative of the rates of morphine glucuronidation and renal excretion. The results showed that renal impairment may produce more extensive drug accumulation during multiple dose treatments than an impaired morphine metabolism (leading to as much as a tenfold increase in the plasma levels of morphine after a 90% reduction of renal clearance). This happens because enterohepatic recycling takes place fast enough to allow morphine to stay in equilibrium with its glucuronides in blood, while the pool of morphine and morphine-glucuronides is only slowly cleared by the kidneys.

Published: Volume 14 • Issue 1 • March 2012 (pages: 59 - 64)

Title: The state of the art regarding heroin addicts in prisons in Slovenia during the period from 1990 to 2008

Authors: Lovrecic M., Lovrecic B.

Summary: Not available

Published: Volume 14 • Issue 1 • March 2012 (pages: 65 - 72)

Title: Clinical assessment of opiate induction: The Opiate Dosage Adequacy Scale Induction Form (O.D.A.S.-IF)

Authors: González-Saiz F., Velo Camacho D.

Summary: Not available

Published: Volume 14 • Issue 2 • June 2012 (pages: 5 - 18)

Title: Ethnicity and drug addiction. A comparison between Italian and Slovenian heroin addicts

Authors: Lovrecic B., Lovrecic M., Rovai L., Rugani F., Bacciardi S., Dell'Osso L., Maremmani A. G. I., Maremmani I.

Summary: We aimed to study the impact of ethnicity on the clinical addiction history of heroin addicts belonging to two closely interrelated racial groups (213 Italian and 591 Slovenian) characterized by different cultural, historical and political features. The results of this study show that ethnicity tends to influence the clinical addiction history of Italian and Slovenian heroin addicts. Italians are, more frequently, stable users or else are involved in the revolving door stage, or are diagnosed more frequently as ‘dual diagnosis'. Slovenians are, more frequently, bipolar and polyabuser patients with a daily use of heroin, showing only minor social adjustment. These differences appear to be largely mediated by the various organizations providing medical services for addiction treatment in Italy and in Slovenia.

Published: Volume 14 • Issue 2 • June 2012 (pages: 19 - 34)

Title: The Opiate Treatment Index (OTI) clinical interview: New evidence of reliability and validity

Authors: González-Saiz F., García-Valderrama T.

Summary: The Opiate Treatment Index (OTI) is a semistructured clinical interview designed by Shane Darke et al., to measure self-reported treatment outcomes of opioid users. It consists of six independent outcome domains. The domains chosen to reflect the dimensions of treatment outcomes were: Drug use, HIV Risk-taking Behaviour, Social Functioning, Criminality, Health, and Psychological Adjustment. The aim of this work is to analyze the internal structure and reliability of the Spanish version of this instrument, as well as to contribute evidence of its concurrent validity with regard to measures of global functioning such as the Global Assessment of Functioning Scale (GAF) of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The study was carried out with a total sample of 105 patients with substance dependence who were being treated in two centres for drug addictions. Test-retest and inter-rater reliability were both very high (with mean intraclass correlation coefficient [ICC] values for the two scores of .89 and .88, respectively). The internal consistency values were generally moderately high, and similar to those observed by other authors in comparable studies. Principal component analysis (PCA) of each one of the OTI scales reveals structures made up of several factors. The differences between this and other studies and the practical applications of this well-known instrument are discussed.

Published: Volume 14 • Issue 2 • June 2012 (pages: 35 - 48)

Title: The Effects of Psychopathology and Personality on the Substance Abuse in the Twelve-Step Treatment Program Abstainers, Opiate Substance Abusers and Normally Sample

Authors: Khodarahimi S., Branch E.

Summary: The purpose of this study was to examine the effects of psychopathology and personality on opiate substance abuse, and also to investigate the roles of marital status, income, educational level, and familial history of drug abuse and family size, as well as ethnicity, in determining substance abuse. There were 150 young adult male participants divided into three groups; these comprised twelve-step treatment programme abstainers, opiate addicts and normal individuals, respectively. A demographic questionnaire, the SCL-90-R, and the NEO PI-R were used in this study. The study data demonstrated significantly positive and negative correlations between the Neuroticism and Extraversion dimensions of personality and all indices of psychopathology. Patients with opiate use had significantly higher levels of psychopathology than the other two groups. The twelve-step self-treatment programme significantly lowered psychopathology in patients with opiate abuse. In addition, normal individuals had a significantly lower level of Neuroticism and higher levels of Openness to Experience, Agreeableness and Conscientiousness than either opiates abusers or abstainers. Lastly, the results of the study indicated the effects of familial history of substance abuse and family size on prospective drug abuse.

Published: Volume 14 • Issue 2 • June 2012 (pages: 49 - 56)

Title: Maladaptive behaviours after catastrophic events: the contribute of a “spectrum” approach to post traumatic stress disorders

Authors: Dell'Osso L., Carmassi C., Stratta P., Rossi A.

Summary: Not Available

Published: Volume 14 • Issue 2 • June 2012 (pages: 57 - 58)

Title: Reduction of psychotic symptoms during the use of exogenous opiates

Authors: Ros Cucurull E., Miquel L., Quesada Franco M., Brugue M. C.

Summary: Not available

Published: Volume 14 • Issue 2 • June 2012 (pages: 59 - 62)

Title: Clinic and social aspects of unlawful activities of persons with psychoactive substance dependence

Authors: Klimenko T., Kozlov A., Bukhanovsky A.

Summary: Not available

Published: Volume 14 • Issue 3 • September 2012 (pages: 5 - 70)

Title: Assessing the current state of opioid-dependence treatment across Europe: methodology of the European Quality Audit of Opioid Treatment (EQUATOR) project

Authors: Fischer G., Stöver H.

Summary: Opioid-dependence treatment varies between countries despite the underlying condition being similar. The European Quality Audit of Opioid Treatment (EQUATOR) project utilised a survey design in 10 European countries to characterise the treatment of opioid dependence from the perspective of treating physicians, patients in treatment, and opioid users currently outside the medication-assisted treatment system. The survey covered topics including treatment goals; knowledge about and experience of treatment; drug use, misuse and diversion; employment; and prison experience. EQUATOR provides the opportunity to generate important new insights to guide treatment policy and practice. This article presents a detailed overview of the study methodology.

Published: Volume 14 • Issue 3 • September 2012 (pages: 71 - 76)

Title: Is Substance Use disorder with comorbid adult Attention Deficit Hyperactivity Disorder and Bipolar Disorder a distinct clinical phenothype?

Authors: Ceraudo G., Toni C., Vannucchi G., Rizzato S., Casalini F., Dell'osso L., Maremmani I., Perugi G.

Summary: Objectives: Comorbidity between substance use disorder (SUD) and attention deficit hyperactivity disorder (ADHD) in adulthood has been reported in epidemiological and clinical samples. With the aim of assessing the impact of comorbid ADHD, we have investigated the prevalence, clinical and epidemiological features associated with that comorbidity in a sample of adult patients diagnosed with SUD. Methods: A total of 109 outpatients (aged 18-65 years) with SUD (high prevalence of heroin addicts) were included. All patients were screened using the Adult ADHD Self-report Scale (ASRS) and the Diagnostic, Clinical and Therapeutic Checklist (DCTC), a semi-structured interview developed for the exploration of the criteria of major Axis I and Axis II diagnoses, according to DSM-IV criteria. The DCTC also includes the Clinical Global Impression Bipolar (CGI-BP) scale, Global Assessment of Functioning (GAF) scale and the Sheehan Disability Scale (SDS). Results: Twenty patients out of 109 (18.35%) fulfilled both DSM-IV and ASRS criteria for ADHD. No significant differences were observed between ADHD and non-ADHD patients in age, sex, marital status, employment, education or type(s) of substance used. ADHD patients showed a higher prevalence of Bipolar Disorder (80% vs 43.2%, chi-square = 8.84, p=.003) and of current manic or mixed episode at the time of observation (40% vs 16.9%, chi-square=3.29, p=.027) than Non-No-ADHD patients. No significant difference between ADHD and non-ADHD patients were observed in terms of prevalence of comorbid Anxiety Disorders and Impulse Control Disorders. “Treatment resistance” (15% vs 3.4%, chi-square= 4.25, p=.039) and “irritability” (35% vs 15.7%, chi-square=3.90, p=.048) in response to previous treatment with antidepressants were more frequently reported by ADHD than by non-ADHD patients. Conclusion: In patients with SUD (with high prevalence of heroin addicted patients) the presence of comorbid adult ADHD influences a patient's course, prognosis and therapeutic management. Patients with SUD and adult ADHD present high rates of comorbid BD. Patients with ADHD, SUD and BD seems to be a distinct phenotype characterized by early onset and mood instability. Further research is needed to confirm our findings, and the clinical and therapeutic implications of SUD-ADHD-BD comorbidity.

Published: Volume 14 • Issue 3 • September 2012 (pages: 77 - 88)

Title: Economic Evaluation of Opioid Substitution Treatment in Greece

Authors: Geitona M., Carayanni V., Petratos P.

Summary: We performed an economic evaluation of opioid substitution treatment (OST) in Greece using data from the Greek Organization Against Drugs (OKANA). Cost minimization analysis predicted that buprenorphine monotherapy is more costly than buprenorphine-naloxone therapy. Analyses of cost effectiveness demonstrated that buprenorphine-naloxone was the dominant therapy in terms of mortality avoidance and completion of treatment. Furthermore, compared with methadone, buprenorphine-naloxone reduced the mean cost by 49%; it raised the percentage of participants who completed their treatment ~1.5-fold and reduced the percentage of deaths ~2.5-fold. Budget impact analysis demonstrated that switching to buprenorphine-naloxone treatment would result in significant savings, cut the length of waiting lists, and allow greater access to OST in Greece.

Published: Volume 14 • Issue 3 • September 2012 (pages: 89 - 100)

Title: The journey into injecting heroin use

Authors: Barry D., Syed H., Smyth B. P.

Summary: Drug injection carries with it many risks and it is therefore important to understand its origins. We interviewed 104 young opioid users with median age of 22 years. The median age of first opioid use was 16 years, this being heroin chasing in 91% of cases. Friends or sexual partners played an important role in both initial introduction to opiates and in the switch to injecting. Curiosity was the most important factor in first heroin use and the second most important factor, after escalating tolerance, in influencing the decision to first inject.

Published: Volume 14 • Issue 3 • September 2012 (pages: 101 - 110)

Title: Cognitive behavioural coping skills therapy in cocaine using methadone maintained patients: a pilot randomised controlled trial

Authors: Darker C. D., Sweeney B., El Hassan H., Kelly A., Smyth B. P., Barry J.

Summary: A pilot randomised controlled trial to test the effectiveness of delivering cognitive behavioural coping skills (CBCS) to reduce cocaine usage in methadone maintained patients. Recruitment was stopped after forty-five patients were recruited into the study, with twenty-two randomised to TAU and twenty-three randomised to CBCS. CBCS group significantly reduced their cocaine powder usage compared to the TAU group (DiD = -6.65, p<0.03). There was a significant reduction in both cocaine powder (DiD = -7.66, p<0.002) and crack cocaine (DiD = -4.88, p<0.04) between baseline and follow-up across both groups. However, urine toxicology results indicate a slightly larger drop in the percentage positive urines (relative to baseline) occured in the TAU group. Attendance at counselling sessions was very low, with the average attendance at CBCS sessions being 25% and 13% at TAU sessions. For those participants who did attend for counselling, there was a marked decline in the proportion of cocaine positive urines (during treatment and again at week 52).

Published: Volume 14 • Issue 4 • December 2012 (pages: 5 - 6)

Title: Foreword — EQUATOR publication series

Authors: Maremmani I.

Summary: Not available

Published: Volume 14 • Issue 4 • December 2012 (pages: 7 - 22)

Title: The profile of patients, out-of-treatment users and treating physicians involved in opioid maintenance treatment in Europe

Authors: Goulão J., Stöver H.

Summary: Opioid users often cycle in and out of opioid maintenance treatment (OMT), consistent with opioid dependence being a chronic, relapsing condition. Results from the European Quality Audit of Opioid Treatment (EQUATOR), the largest analysis of OMT undertaken in Europe to date, revealed similar demographic profiles for patients in OMT and out-of-treatment opioid users (most of whom have been in OMT previously). Demographic profiles appeared relatively consistent across all 10 participating countries. Overall, EQUATOR data suggest that the healthcare setting for OMT is far more varied than the demographics of the OMT patient population, supporting the idea that variability in treatment outcomes is unlikely to be related to the clinical characteristics of patients but rather to other ‘environmental' factors.

Published: Volume 14 • Issue 4 • December 2012 (pages: 23 - 38)

Title: Quality of Care Provided to Patients Receiving Opioid Maintenance Treatment in Europe: Results from the EQUATOR analysis

Authors: Dale-Perera A., Goulão J., Stöver H.

Summary: Patients receiving treatment for opioid dependence are prone to relapse into illicit drug use, risking significant harms to themselves and to society. The European Quality Audit of Opioid Treatment (EQUATOR) analysis assessed aspects of opioid maintenance treatment (OMT) delivery and the quality of care offered to patients undergoing OMT across 10 European countries. Findings suggest quality of care may be improved by: ensuring patients and physicians discuss the range of available treatment options, achieving the appropriate balance between control and patient flexibility, reducing the likelihood of misuse and diversion, and providing appropriate psychosocial care in conjunction with pharmacotherapy.

Published: Volume 14 • Issue 4 • December 2012 (pages: 39 - 50)

Title: Outcomes of opioid-dependence treatment across Europe: identifying opportunities for improvement

Authors: Fischer G., Nava F., Stöver H.

Summary: TeThe European Quality Audit of Opioid Treatment (EQUATOR) analysis suggests that current systems of opioid-dependence treatment in Europe may be failing to achieve optimal outcomes in a substantial subset of patients. In general, opioid-dependent patients report high rates of cycling in and out of opioid maintenance treatment (OMT), past misuse or diversion of their medication, and continued on-top heroin use despite being prescribed OMT. Building on evidence from this analysis of variable treatment delivery across Europe, these findings suggest that greater treatment benefits could be achieved by optimising treatment structures as well as available interventions. xt

Published: Volume 14 • Issue 4 • December 2012 (pages: 51 - 64)

Title: Assessing the current state of public-health-related outcomes in opioid dependence across Europe: data from the EQUATOR analysis

Authors: Stöver H.

Summary: Many opioid users across Europe remain outside treatment, and not all of those in treatment derive optimal benefit. The European Quality Audit of Opioid Treatment (EQUATOR) analysis shows that opioid-dependent people report high levels of polydrug use, high rates of unemployment and past imprisonment, and significant physical and mental health comorbidities regardless of whether they are currently in or out of treatment. Improved strategies are required to deliver the benefits of treatment while managing the risks of non-compliance (e.g., misuse/diversion/drug use). Treatment systems should be judged by their ability to effectively reduce harm and promote individual recovery and social reintegration.

Published: Volume 14 • Issue 4 • December 2012 (pages: 65 - 80)

Title: Barriers to treatment access and informed patient choice in the treatment of opioid dependence in Europe

Authors: Benyamina A., Stöver H.

Summary: According to the European Quality Audit of Opioid Treatment (EQUATOR) analysis, there is large variation across Europe in the conditions attached to treatment of opioid dependence. Treatment conditions, such as supervised dosing and the need to attend regular appointments, may constitute important barriers to treatment that may impact on successful outcomes for opioid-dependent individuals. Greater flexibility in the provision of treatment and improved education for patients, users and physicians with regards to therapy options may help to improve recruitment and retention of opioid users in treatment, and consequently improve patient outcomes.

Published: Volume 14 • Issue 4 • December 2012 (pages: 81 - 94)

Title: Aggressive behaviour and Heroin Addiction

Authors: Bacciardi S., Maremmani A. G. I., Rovai L., Rugani F., Lamanna F., Dell'osso L., Pacini M., Maremmani I.

Summary: In this review we discuss the correlations between aggressiveness, defined according to a behaviourist model, and heroin dependence according to DSM-IV-R criteria. Criminality appears to be only an indirect, partial index of aggressive behaviour in heroin addicts. The aggressive behaviour of heroin addicts is probably different from that of other kinds of mentally ill patients, non-opiate substance abusers and the general population, and seems to be specifically related to the degree of chronic intoxication. Gender differences, aggressive habits before heroin use, and modulation during intoxication and/or withdrawal states have been documented. The association between cerebral opioidergic abnormalities and psychiatric disorders characterized by affective instability, feelings of anger and hostility, perception abnormalities and sexual dysfunction, could explain highly aggressive behaviours of heroin addicts which are not directly related to drug supply. Knowledge about the anti-aggressive property of non-opioid drugs is limited. On the other hand, opioid agonists are promising agents for the treatment of aggressive behaviours in non-addicted patients, too.

Published: Volume 14 • Issue 4 • December 2012 (pages: 95 - 104)

Title: Post traumatic stress spectrum and maladaptive behaviour (drug abuse included) after catastrophic events: L'Aquila 2009 earthquake as case study

Authors: Dell'osso L., Carmassi C., Conversano C., Massimetti G., Corsi M., Stratta P., Akiskal K. K., Rossi A., Akiskal S. H.

Summary: PTSD is one of the most frequently occurring sequelae in earthquake survivors and increasing literature has been focused on its potential risk factors. More recently increasing evidence has highlighted the onset of maladaptive behaviours in the same populations. The aim of the present study was to explore: 1) the role of degree of exposure (“direct” vs “indirect”), gender and age (> o ≤40) as potential risk factors for PTSD in a sample of L'Aquila 2009 earthquake survivors; 2) the role of these same variables and of PTSD as potential risk factors for maladaptive behaviours in the same sample. A group of 444 subjects was evaluated by the Trauma and Loss-Self Report (TALS-SR) 10 months after exposure. Results showed significantly higher PTSD prevalence rates in: exposed with respect to not exposed subjects; women with respect to men (in the whole sample and in all subgroups, with the only exception of the older subjects not exposed); not exposed younger women with respect to the older ones. PTSD and “direct” exposure represented a major risk factor for the presence of at least one maladaptive behaviour, with female gender playing a role only among no-PTSD subjects. For the TALS-SR item n.99 (“Use alcohol or drugs or over-the-counter medications to calm yourself …?” ) only PTSD and “direct” exposure emerged as risk factors. Our results confirm the pervasive effects of earthquakes for mental health in the general population, and highlight the role of gender and proximity as primary correlates of PTSD, and of PTSD and degree of exposure for maladaptive behaviours, particularly alcohol and substance use.

Published: Volume 15 • Issue 1 • March 2013 (pages: 5 - 14)

Title: Aggressive behaviour in heroin addicts at treatment entry

Authors: Bacciardi S., Maremmani A.G.I., Rovai L., Rugani F., Pacini M., Lamanna F., Dell'Osso L., Maremmani I.

Summary: Background: Few studies have focused on the difference between heroin-dependent patients and the general population. Methods: We evaluated the aggressive behaviour of 252 heroin-dependent patients (163 males and 89 females) at treatment entry, comparing them with the Italian general population (standardization sample). We also studied correlations between aggressive behaviour and the addiction history of our patients. We used the Buss-Durke Inventory (BDI) to assess aggressive behaviour and the Drug Addiction History Questionnaire for addiction history. Results: Overall, heroin-dependent patients scored higher than the general population. Specifically, the highest values were reached for the suspicion, resentment and assault dimensions; the lowest for irritability and verbal hostility. Feelings of guilt were higher than in general populations. Only 18.7% showed a low aggression profile; 3 out of every 4 patients were characterized by violent behaviour due to suspicion and resentment (type 2). With respect to the general population, a greater number of heroin-dependent patients showed an aggressive type 2 profile (OR=3.2). Addiction history and type and degree of aggressive behaviour showed a weak correlation (only found with altered mental status, legal problems, periods of voluntary or forced abstinence, social leisure activity). Conclusions: At treatment entry, heroin addicts showed more violent behaviour than the general population; this was related to altered mental status and weakly correlated with addiction history. Thus, studies correlating aggressive behaviour with other symptomatological states are needed

Published: Volume 15 • Issue 1 • March 2013 (pages: 15 - 20)

Title: Benzodiazepine misuse in heroin addicts: results of a post-mortem study.

Authors: Licata M., Palazzoli F., Verri P., Beduschi G., Pajusco B., Lugoboni F.

Summary: Benzodiazepines, which are typically used to treat insomnia and anxiety disorders, are widely prescribed in all medical fields. This widespread use has led to frequent, often inappropriate forms of consumption. Although benzodiazepines and illicit drugs are commonly associated, the rise in consumption outside the sphere of legitimate prescriptions, even in the general population, has been seriously underestimated. To better describe this phenomenon we assessed benzodiazepine prevalence and typology in 212 autopsy cases examined by the Forensic Medicine Department, University of Modena (Italy) in the three-year period from 2006 to 2008. The biological samples analysed for this study were central blood and urine. All the tests were performed using ultrasensitive liquid chromatography coupled with mass spectrometry in “tandem Mass Spectrometers”. After classifying the various causes of death, the study population was divided into the following groups: 70 deaths from natural causes (33%), 51 from accidental injuries (24%), 40 due to overdose (19%), 23 to homicide (11%), 23 to suicide (11%) and 5 from medical professional causes (5%). 30.8% of the females were BZD-positive, while that feature was identified in 25.9% of the males. The xenobiotics most frequently found were: Diazepam (29.6%), Delorazepam (22.5%), Flurazepam (14.1%), Lorazepam (12.7%), Alprazolam (11.3%) and Lormetazepam (11.3%). It is worth noting the total lack of Flunitrazepam, which is particularly prominent in the Drug Users group, because, worldwide, Flunitrazepam has been the most abused benzodiazepine among polydrug users. This finding tends to suggest that Flunitrazepam has been disappearing from the illegal market in Italy; it also seems to show that recent restrictions on its prescription in this country have already decreased its legal use or actually reduced it to zero.

Published: Volume 15 • Issue 1 • March 2013 (pages: 21 - 28)

Title: “A School for Life”. Monitoring of a multidisciplinary prevention intervention experience in four Neapolitan Schools

Authors: Curcio F., Capraro C., D'Ascoli G., Focaccio F., Gaveglia M., Longobardo A., Losasso C., Masucci S., Parente M., Petti M., Plenzik M., Villano G., Veneruso C., Molinaro S., Siciliano V., De Rosa G.

Summary: Drug Addiction Unit No. 31 operating in the Centre of Naples for the city's Local Health Authority (“U.O. Ser.T. 31, ASL Napoli1 Centro”) has implemented the project called “A School for Life”. The project's aims were to: 1) Get adolescent schoolchildren involved in the problems arising from exposure to psychoactive drugs”; 2) Monitor epidemiological data; 3) Evaluate the efficiency of the instruments used. Teachers, students and opinion leaders were involved. Workshops were set up to make the intervention more incisive. The programme was evaluated by teachers. 1,234 adolescents and 93 teachers participated; students took part in a course for peer-operators. Teacher evaluation showed an increase in project quality over time; an increase in cigarette and alcohol use emerged from the questionnaires administered to the schoolchildren; the use of alcoholic beverages and habitual drunkenness were seen. We recommend a policy of prevention that should be focused on the use of alcoholic beverages and drugs in Middle Schools.

Published: Volume 15 • Issue 1 • March 2013 (pages: 29 - 38)

Title: Drug related mortality in Slovenia: differences between deceased treated and untreated illicit drug users

Authors: Lovrečič B., Šemerl J.Š., Lovrečič M., Selb J., Tavcar R., Pacini M., Rovai L., Maremmani A.G.I., Maremmani I.

Summary: In this study we assessed, in a three-year follow-up, Drug-Related Deaths (DRDs) in Slovenia and compared mortality and causes of death in deceased subjects who had been treated for addiction (DT) in specialized centres in Slovenia with those who had not been treated (DNT). A total of 223 DRD cases were found; in 60.1% of these, the cause was directly drug-related, and in 39.9% the cause was indirectly drug-related. 37.7% of DRDs were accidental, 27.4% were intentional and 35.0% were undetermined. The percentage of DT patients that were female was remarkably low. The treated patients who survived had a much lower mean age that patients in the DT and DNT cohorts; the DNT group was the one that had the highest mean age. Direct DRDs were more frequent in DNT than in DT patients. No differences were observed regarding the type of intentionality of death. Intentional poisoning by narcotics was less well represented in DT patients. On the whole, our data confirm the importance of agonist treatment in preventing narcotic-related deaths. In fact, the cause-of-death profile of deceased addicts in treatment is closer to that of the general population than that of deceased non-treated addicts.

Published: Volume 15 • Issue 1 • March 2013 (pages: 39 - 44)

Title: Changes in Sleep Quality and Alertness in Opiate-Dependent Subjects after 23 months stable Methadone and Buprenorphine Maintenance Treatment. A pilot exploratory report

Authors: Sarram S., Debrabant R., Fatseas M., Daulouède J.-P., Sagaspe P., Aillard J.T., Philip P., Auriacombe M.

Summary: We evaluated changes in subjective sleep quality in 40 opiate-dependent patients in stable methadone and buprenorphine maintenance treatment. Scores that measured sleep were compared with available normative data. An overall improvement in sleep problems has been reported since the onset of treatment 23 months (SD 19) ago. Two-thirds of the subjects reported an increase in their quality of sleep and daytime alertness as compared with the period before treatment. Compared with normative data, however, quality of sleep remained highly impaired in all participants with low sleep efficiency. Patients with comorbid depression and anxiety were the most impaired.

Published: Volume 15 • Issue 1 • March 2013 (pages: 45 - 52)

Title: The effects of a novel take-home treatment strategy in patients with opioid-dependence receiving long-term opioid replacement therapy with buprenorphine/naloxone in Italy: a cost analysis

Authors: Montesano F., Mellace V., on behalf of ATC-DPC project group

Summary: During opioid agonist maintenance treatment (OMT) in Italy, patients may experience problems accessing addiction assistance from the local drug addiction centers (SerTs [Servizi territoriali per le Tossicodipendenze]), resulting in reduced long-term adherence to treatment. To overcome this, the SerT in Soverato, Italy has developed a pilot project called Distribuzione per Conto (DPC), which distributes OMT through local pharmacies and involves general practitioners in the management of patients instead of the traditional treatment of these patients which was run solely through SerTs. Results of this study show that the DPC treatment strategy is a viable strategy as it increased patient satisfaction compared with the traditional strategy with no negative effects on the adherence to OMT and patient relapse rates. DPC also reduced the number of visits and counseling sessions at SerT, with a positive impact on time management and associated costs both for patients and clinical practitioners.

Published: Volume 15 • Issue 1 • March 2013 (pages: 53 - 56)

Title: The treatment goal in maintenance treatment of heroin addiction, ought to be more than retention

Authors: Öhlund L.S., Gunne L.

Summary: Not Available

Published: Volume 15 • Issue 1 • March 2013 (pages: 57 - 60)

Title: Is opioid agonist treatment the only way to treat the psychopathology of heroin addicts?

Authors: Maremmani A.G.I.

Summary: Not Available

Published: Volume 15 • Issue 1 • March 2013 (pages: 61 - 62)

Title: Comparing medications used in opioid addiction treatment in Greece

Authors: Newman R.

Summary: Not Available

Published: Volume 15 • Issue 1 • March 2013 (pages: 63 - 64)

Title: Can outcomes monitoring of opioid maintenance treatment be improved in Europe? A statement by some European experts with interests in opioid maintenance treatment and its safety

Authors: Alho H., Auriacombe M., Fischer G., Maremmani I., Scherbaum N., Torrens M.

Summary: Not Available

Published: Volume 15 • Issue 2 • June 2013 (pages: 5 - 6)

Title: The Psychopathology of Addiction

Authors: Maremmani I., and Pani P. P.

Summary: Not available

Published: Volume 15 • Issue 2 • June 2013 (pages: 7 - 18)

Title: It's time to admit the existence of a psychopathology of addiction

Authors: Pani P. P., Maremmani A. G. I., Trogu E., Ruiz P., Akiskal H. S., and Maremmani I.

Summary: The frequency of the association between substance use and psychiatric disorders is higher than what might be expected as a result of chance alone; the most frequently associated psychiatric symptoms, syndromes and disorders pertain to the domains of mood, anxiety and impulsivity. There are several reasons for taking these psychiatric manifestations into account when evaluating clinical presentations of substance-use disorders. DSM nosology does not seem to grasp the complexity of the interaction between the psychic structures involved, and neurobiological and physiopathological processes activated by encounters with substances of abuse. Based on neurobiological, epidemiological and clinical indications, an integrated, unified perspective explaining the pathophysiology and phenomenology of addiction has been proposed. The lack of substantial changes in the approach to the psychiatric comorbidity of addiction in the DSM V, despite the plausibility of the hypothesis that there may be a close link between addiction and other specific psychiatric conditions, can be explained by the persistent insufficiency of aetiological and pathophysiological evidence which supports that kind of association. The validation of an articulated clinical condition, encompassing part of the grey area of symptomatology that exists between addiction itself and other ‘independent' psychopathologies, certainly calls for special attention and specific research programmes.

Published: Volume 15 • Issue 2 • June 2013 (pages: 19 - 28)

Title: Drug addiction: affective temperaments as risk factor.

Authors: Rovai L., Maremmani A. G. I., Bacciardi S., Rugani F., Pacini M., Perugi G., Dell'osso L., Akiskal H., and Maremmani I.

Summary: The scientific community has recently examined whether correlations exist between affective temperaments and substance abuse disorders. We will try to summarize what is presently known about the nature of these relationships. After reviewing the theory of affective temperaments of Akiskal and Mallya, we will discuss affective temperaments in heroin addicts and alcoholics, with the aim of providing an “at-risk temperamental profile” for the development of substance abuse disorders. A working hypothesis is then formulated to help explain how temperamental profile may promote the initiation of substance use and contribute to the development of addiction.

Published: Volume 15 • Issue 2 • June 2013 (pages: 29 - 36)

Title: Drug (heroin) addiction, bipolar spectrum and impulse control disorders

Authors: Bacciardi S., Maremmani A. G. I., Rovai L., Rugani F., Pani P. P., Pacini M., Dell'osso L., Akiskal H. S., and Maremmani I.

Summary: In most cases, interactions between the brain and the external environment are controlled by a system in which external inputs tend to satisfy internal inputs, so leading to the extinction of the behaviours triggered by internal needs. In this way, a loss of interest extinguishes the search for pleasure. In some individuals, however, the tendency to seek pleasure, and their hypersensitivity to the increased stimulus, sets up a self-perpetuating circuit where the incoming stimulus fails to satisfy internal needs. In the case of addiction, the search for the addictive substance is constantly repeated, without any equilibrium being reached. The same can be said about individuals with bipolar disorder in whom excitement elicits behaviours that aim to maintain a state of euphoria. Individuals with substance abuse and bipolar disorder share many clinical features, such as the strength and urgency of craving. Behaviours associated with substance dependence are very similar to those of hypomanic bipolar patients, where self-preservation and self-aggrandizement are the common features. In addition to their similar clinical psychopathology, mania and addiction are linked by a common background: excitement and impulsivity. For these reasons, and considering the high frequency of comorbidity, we can assume that the two conditions probably share a common biological substrate with a common reinforcement; substance dependence could then be viewed as belonging to the bipolar spectrum, and impulsivity could be viewed as the ‘bridge' between these two entities. If so, this would have a major impact on the management and treatment of patients with substance dependence who have other comorbid disorders, raising the probability that opioid medications could have a therapeutic role that extends beyond substance dependence disorders.

Published: Volume 15 • Issue 2 • June 2013 (pages: 37 - 46)

Title: Psychopathological symptoms of heroin addicts at treatment entry

Authors: Maremmani I., Pani P. P., Maremmani A. G. I., Pacini M., Bizzarri I. V., Trogu E., Rovai L., Bacciardi S., Rugani F., Perugi G., Gerra G., and Dell'osso L.

Summary: Patients with substance use disorder (SUD) show a high rate of comorbidity with other mental disorders, particularly those involving mood, anxiety and impulse control. In addition, an equally strong correlation has been shown between psychotic disorders and substance use disorder (SUD). Application of the classic model of psychiatric comorbidity to the field of drug addiction is subject to limitations: the first is that the high frequency of co-occurrence of these two psychopathological events raises doubts as to their independence; the second is the insoluble problem of disentangling psychiatric symptoms from the heart of the psychopathology of drug addiction; lastly, the overlap between the biological substrates and the neurophysiology of addiction and psychiatric disorders cannot be disregarded. With this in mind, we have theorized that symptoms of mood swings, anxiety and impulse dyscontrol should be considered as constituting the psychopathology of addiction. We put forward the hypothesis that the dysregulation of the opioid system, that is determined by the chronic use of heroin, could give rise to a wide range of psychopathological symptoms that are prominent in distinguish heroin addicts, this being true regardless of the co-occurrence of another mental disorder, factors related to gender, education, history of abuse, the modality of abuse and treatment undertaken by patients in their history. We have considered 5 dimensions: 1. feelings of “worthlessness and being trapped”; 2. “somatic symptoms”; 3. “sensitivity-psychoticism”; 4. “panic anxiety”; 5. “violence-suicide”. Although these symptoms do not always reach the threshold that would qualify them as belonging to a psychiatric syndrome, their impact on a patient's life must be recognized; above all, these symptoms should be treated as belonging to the context of the treatment of drug dependence.

Published: Volume 15 • Issue 2 • June 2013 (pages: 47 - 56)

Title: The effects of agonist opioids on the psychopathology of opioid dependence

Authors: Maremmani A. G. I., Pani P. P., Rovai L., Bacciardi S., Rugani F., Dell'osso L., Pacini M., and Maremmani I.

Summary: Knowledge about the beneficial psychotropic effects of opiates dates back to the pre-pharmacological era, but the use of opiates has been restricted because of the controversial issue of their liability to abuse, and the potentially lethal effects of accidental or voluntary overdosing. We first review the literature on opiate use and its impact on depressive, anxious, manic and psychotic syndromes, mostly by referring to studies selected from the field of addiction treatment. We then go on to discuss the differences between methadone and buprenorphine in their impact on the psychopathological profiles of heroin addicts. The data gathered by us support the view that some opiates may be regarded as therapeutic not only in the treatment of addictive diseases, but also as candidates for the treatment of certain psychiatric disorders. Such properties are based on their specific activity on opiate receptors, but also on their kinetics, which explain the differences between a destabilizing drug of abuse and a therapeutic agent.

Published: Volume 15 • Issue 2 • June 2013 (pages: 57 - 62)

Title: Intentional self-poisoning versus other methods of suicide in illicit dug users, according to gender

Authors: Lovrečič M., Lovrečič B., Šemerl J. Š., Maremmani A. G. I., and Maremmani I.

Summary: Monitoring of the association between suicide and drug-related deaths (DRDs) in illicit drug users is not carried out consistently in many European countries. In our study, we evaluated DRD suicides unrelated to alcohol in Slovenia during the years 2002-2007, and compared suicide methods between males and females. Out of 356 cases of DRD, 106 (64 males and 42 females) were DRD suicides. Of these, 69 (65.1%) were due to intentional self-poisoning by drugs, 30 (28.3%) were due to other methods for committing suicide, and 7 (6.6%) utilized intentional poisoning together with another method. Females were older than males; self-poisoning with benzodiazepines was more frequent in females and, in our study, no females were self-harmed by hanging, by suffocation, or by firearms. In females, age was tested as a risk factor that has proved to be more important than suicide modality, but the use of benzodiazepines in female illicit drug users should be considered a critical issue with increasing age.

Published: Volume 15 • Issue 2 • June 2013 (pages: 63 - 78)

Title: The Italian Manifesto for the treatment of heroin addiction. The mixed care model. A proposed layout for a new healthcare system for citizens with heroin addiction

Authors: Maremmani I., Barra M., Burton-Phillips E., Cecchini I., Di Chiara G., Gerra G., Mantovani L., Pani P. P., Pitts G., Rossi A., Somaini L., and Starace F.

Summary: Not available

Published: Volume 15 • Issue N2S • September 2013 (pages: 5 - 12)

Title: Effetto di una nuova strategia di take-home in pazienti dipendenti da oppiacei in trattamento di mantenimento con buprenorfina/naloxone in Italia: un'analisi dei costi

Authors: Franco Montesano e Vincenzo Mellace per conto del gruppo “Progetto-ATC-DPC”

Summary: Durante il trattamento a lungo termine con agonisti oppiacei (OMT) in Italia, i pazienti possono avere problemi nel pre- sentarsi presso il proprio SerT di competenza territoriale per ricevere assistenza. Questo può tradursi in una riduzione dell'aderenza al trattamento, nel lungo termine. Per superare questi ostacoli, il SerT di Soverato, in provincia di Catanzaro, ha sviluppato un progetto pilota denominato "Distribuzione per Conto" (DPC), per distribuire la terapia OMT attraverso le farmacie locali, con il coinvolgimento dei medici di medicina generale nella terapia dei pazienti che normalmente viene svolta solamente all'interno dei servizi per le tossicodipendenze. I risultati di questo studio dimostrano che la strategia di trattamento DPC, confrontata con quella tradizionale, è una strategia praticabile, che aumenta il grado di soddisfazione del paziente, senza effetti negativi sull'aderenza al trattamento OMT e sul tasso di ricaduta. La strategia DPC riduce inoltre il numero delle visite mediche e delle sessioni di counseling presso il SerT, con un impatto positivo sui tempi di terapia e sui relativi costi sia per il paziente che per i medici del servizio.

Published: Volume 15 • Issue N1S • September 2013 (pages: 5 - 18)

Title: Manifesto Italiano per la Cura delle Tossicodipendenze: Il Modello di Cura Misto. Un manifesto per una nuova organizzazione dell'assistenza sanitaria a soggetti tossicodipendenti da oppiacei

Authors: Maremmani I., Barra M., Burton-Phillips E., Cecchini I., Di Chiara G., Gerra G., Mantovani L., Pani P.P., Pitts G., Rossi A., Somaini L., Starace F.

Summary: Not available

Published: Volume 15 • Issue 3 • September 2013 (pages: 5 - 8)

Title: Malleus maleficarum...

Authors: Pacini M., and Maremmani I.

Summary: Not Available

Published: Volume 15 • Issue 3 • September 2013 (pages: 9 - 18)

Title: Malleus maleficarum... the superstition of psychosocially centred intervention in addictive diseases. Heroin Addiction as case study

Authors: Pacini M., and Maremmani I.

Summary: The meaning of psychosocial features in drug addiction is often misunderstood. They are often regarded as the core of the disease, or as independent indicators of global severity, instead of being interpreted as possible expressions and consequences of addictive psychopathology. Furthermore, evidence about the psychosocial impairment of drug addicts is treated as if it were directly dependent on the theory and practice of psychosocially based treatment of such patients. Thus, we have become familiar with the paradox according to which psychosocial requirements or engagement are employed as therapeutic instruments in treating a condition characterized by the disruption and neutralization of psychosocial resources. We have tried to analyse the role of psychosocial factors in the diagnosis and treatment of drug addiction, with the aim of distinguishing between the possible frontiers of psychosocially assisted treatment and the counterproductive psychosocial engagement of untreated drug addicts. We have also tried to classify those factors and psychosocial treatments by applying the criterion of consistency with the main aims and known dynamics of drug addiction treatment.

Published: Volume 15 • Issue 3 • September 2013 (pages: 19 - 28)

Title: Transfer to buprenorphine from daily doses of methadone greater than 30mg – initial review of transfers

Authors: Conroy S., and Hill D.

Summary: Transferring from daily doses of over 30mg methadone to buprenorphine can be challenging due to receptor affinity for buprenorphine, but for many patients reduction to 30mg may be impossible. Other studies have demonstrated the process is possible but have only been conducted as inpatients. This study demonstrates that the transfer from a daily dose of methadone greater than 30mg can effectively be conducted without prior dose reductions in outpatients. It provides data and analysis of the 39 transfers completed to date, examining some biophysical measurements as well as reflecting on the patients' reasons for transfer and other social factors.

Published: Volume 15 • Issue 3 • September 2013 (pages: 29 - 34)

Title: Safety assessment of low doses of methadone in combination with benzodiazepines in real occasions during methadone maintenance treatment – a pilot study

Authors: Mijatović V., Dickov A., Petković S., Popov T., and Samojlik I.

Summary: Background. Methadone is a synthetic opioid used for methadone maintenance treatment (MMT) in patients with heroin addiction. However, at therapeutic levels methadone may be related to QT prolongation on the electrocardiogram (ECG), which might induce torsades de pointes. Aim. Our study assessed the safety of low methadone doses in combination with benzodiazepines in opiate addicts in MMT after ascertaining differences in corrected QT (QTc) intervals and side-effects. Materials and Methods The study included 20 opiate addicts who were referred to the MMT at the Department of Psychiatry, Clinical Centre of Vojvodina, in 2012. Before the beginning of the investigation, all patients underwent an ECG, and data were collected on their sociodemographic status, duration of heroin abuse period, other drugs used in combination with heroin and the presence of ECG disorders. One month after the beginning of MMT, the patients were interviewed about their general condition during the MMT and about the side-effects they had experienced, after which an ECG was performed. Data about the methadone dose applied and the use of other drugs were collected from the medical history of each patient. Results. A significant increase in the length of QTc intervals after one month of MMT compared with those at the baseline was observed. A dose-dependent correlation between the daily dose of diazepam, used in combination with methadone, and QTc was noted. None of the participants experienced any cardiac side-effects. Conclusions. On the basis of our results, it appears to be advisable to perform a pre-treatment ECG and then regular ECG check-ups after one month of MMT, especially in the case of a concomitant use of benzodiazepines.

Published: Volume 15 • Issue 3 • September 2013 (pages: 35 - 46)

Title: Psychosis, trauma, and opioid hypoactivity in the thalamus: a hypothesis

Authors: Vukadinovic Z.

Summary: There is a considerable overlap between opioid dependence, psychosis and trauma. This review article presents a neurobiological model that links these related clinical issues and centers on the role of the thalamus. Namely, one of the major roles of the thalamus is that of a hub for cortico-cortical interactions. Such interactions enable the recognition of self-initiated actions. Impairments in trans-thalamic cortico-cortical interactions may underpin psychosis by a mechanism whereby self-initiated actions are not recognized as such and are experienced as if they originate from outside of oneself. Impairments in trans-thalamic cortico-cortical communication could occur secondary to deficits in thalamic neuromodulatory mechanisms, including the endogenous opioid system. Indeed, there is evidence that in some individuals with an underlying genetic vulnerability to psychosis, exposure to stress may lead to endogenous opioidergic hypofunction in the thalamus, which could in turn be related to the emergence of psychosis and opioid dependence in such individuals. This scenario could account for reported antipsychotic efficacy of opioid agonist in some individuals with co-occurring psychosis and opioid dependence.

Published: Volume 15 • Issue 3 • September 2013 (pages: 47 - 54)

Title: Successful long-term (3-year) treatment of gambling with naltrexone. A case report

Authors: Piz L., Maremmani A. G. I., Rovai L., Bacciardi S., Rugani F., and Maremmani I.

Summary: Pathological gambling (PG) is classified as an impulse control disorder in the Diagnosis and Statistical Manual of Mental Disorder (DSM-IV-TR). There is still no properly validated pharmacotherapeutic treatment of PG. The involvement of the mu-opioid system in reward processes leads to the hypothesis that opioid antagonists have an impact on addictive behaviours. In reality, opioid antagonists have been used not only in substance abuse illnesses (narcotics, alcohol), but also in a variety of psychiatric conditions, including anorexia nervosa, bulimia, schizophrenia, self-injurious behaviour autism, obsessive-compulsive disorder, Tourette's disease and trichotillomania. We present a case report in which an Italian patient affected by pathological gambling was successfully given long-term treatment with naltrexone. Controlled studies on opiate antagonists from the literature have already shown positive results. This case report confirms these data, but the present innovative finding is, for the first time, focused on the long-term outcome of treatment without side-effects. The patient has, in fact, taken her medication for 3 years, and so far she has never relapsed into gambling.

Published: Volume 15 • Issue 3 • September 2013 (pages: 55 - 60)

Title: Recommendations for measuring treatment outcomes in opioid dependence management: consensus from the GLADD meeting

Authors: Subata E., Gilman M., Alho H., and Maremmani I.

Summary: This position paper reflects discussions and audience consensus feedback from an interactive symposium held at the Global Addiction (GLADD) & Europad conference on the 8th May in Pisa, Italy. The aim of the workshop was to highlight on-going work in the management of opioid dependence (OD).

Published: Volume 15 • Issue 3 • September 2013 (pages: 61 - 64)

Title: Vivitrol - A new modality for the treatment of opioid addiction

Authors: Parrino M.

Summary: Not available

Published: Volume 15 • Issue 4 • December 2013 (pages: 5 - 14)

Title: Opioid Maintenance in Primary Care: a case register based comparison

Authors: Broers B., Cassis I., Cerutti B.

Summary: The aim of our study was to compare basic facts, trends, and outcomes of mainly primary care based opioid maintenance treatment (n=3'824, 3.5 years follow-up) in two areas in Switzerland with different health care organizations, using administrative databases. We observed an aging population, no significant canton effect on retention in treatment. Prescribers practicing in or close to specialized centers were more compliant with methadone guidelines. Female patients were better retained in primary care settings. This study adds evidence for the effectiveness of opioid maintenance treatment in primary care, especially for female patients, but continuous education should be encouraged to increase congruence with guidelines.

Published: Volume 15 • Issue 4 • December 2013 (pages: 15 - 20)

Title: Mean platelet volume is elevated in patients with heroin addiction

Authors: Akpinar A., Varol E., Yalniz H., Guven M., Gecici O.

Summary: Increased cardiovascular risk have been reported in heroin abuse. It has been suggested that multiple mechanisms may be involved in the relationship between heroin abuse and cardiovascular risk; these include hypoxia, vasculitis and vasospasm. In some studies increased platelet aggregation and morphological changes have also been reported in heroin addicts. Mean platelet volume (MPV) is an indicator of platelet reactivity and it plays an important role in the pathophysiology of cardiovascular diseases. The aim of this study was to investigate MPV values in heroin addicts. We measured serum MPV values in heroin addicts and control subjects. MPV was significantly higher among heroin addicts than in the control group (8.6±1.1 vs. 7.8±0.7 fL respectively; p<0.001). In correlation analysis, there was correlation between duration of heroin use and MPV (r:-0,09 p:0.32). We have found that MPV was elevated in heroin addicts.

Published: Volume 15 • Issue 4 • December 2013 (pages: 21 - 24)

Title: Long-term replacement of methadone by equipotent buprenorphine for male heroin addicts with methadone-induced hyperprolactinemia and sexual dysfunction. A case report.

Authors: Pacini M., Maremmani A.G.I., Rovai L., Bacciardi S., Rugani F., Maremmani I.

Summary: Background: sexual dysfunction is one of the aspects that limit the feasibility of methadone maintenance at adequate dosages that aims to suppress cravings for street opiates. One reason for this is that sexual disorders are likely to be related to opiate-induced elevated serum prolactin levels. Aim: to provide evidence that buprenorphine, at μ-equivalent dosages, can facilitate control over craving and psychopathological discomfort, without any major increase in serum prolactin. Materials and Methods: case report presentation. Results: buprenorphine, a partial μ-receptor agonist, is resorted to as a replacement for methadone, for a subject suffering from hyperprolactinaemia during the maintenance phase. Conclusions: buprenorphine may be a preferable option for low-craving heroin addicts who suffer from methadone-induced hyperprolactinaemia.

Published: Volume 15 • Issue 4 • December 2013 (pages: 25 - 32)

Title: Do bipolar patients use street opioids to stabilize mood?

Authors: Maremmani A.G.I., Bacciardi S., Rovai L., Rugani F., Akiskal H.S., Maremmani I.

Summary: Introduction: The link between heroin addiction and bipolar disorder is generally accepted, both at the level of full-blown pathology and at the affective, temperamental level. Nevertheless, the nature of this relationship is still far from being elucidated. Aim: to verify whether the use of heroin in bipolar patients could lead to a faster progression of the illness or whether bipolar 1 drug addicts who use heroin are actually looking for the mood-stabilizing properties of the opiates. Method: we compared the clinical characteristics and the natural history of heroin addiction between bipolar 1 and non-dually diagnosed heroin-dependent patients at their first agonist opioid treatment; in fact, our starting point was that bipolar 1 heroin-dependent patients would show a more severe psychopathological condition and a shorter, less severe drug addiction history at treatment entry. This hypothesis would, if borne out, support a ‘self-medication' approach to heroin use in bipolar 1 heroin-dependent patients. Result: bipolar 1 heroin addicts showed faster progression of their illness, and a worse clinical presentation, both on the psychopathological and on the addictive plane. Conclusions: Even if the unprovable initial beneficial effect exerted by the substance on the emotional instability of bipolar patients were present to some degree, it would soon be followed by a mood-destabilizing action, which would then accelerate the course of the illness.

Published: Volume 15 • Issue 4 • December 2013 (pages: 33 - 38)

Title: Self-presentation and health issues of anonymous heroin addicts asking for a free internet medical consultation

Authors: Pacini M., Maremmani A.G.I., Rovai L., Rugani F., Bacciardi S., Maremmani I.

Summary: Background: Despite a considerable level of standardization, the practice of opiate addiction treatment remains heterogeneous and is not compliant with evidence-based guidelines. On the other hand, patients often complain about unmet needs with respect to the personalization of treatment and clarity of information about treatment strategies. Also, special conditions may raise specific difficulties, such as those arising in the case of dual diagnosis patients or poly-abusers. Aims: To clarify the characteristics of the unmet needs of heroin addicts (whether treatment-related or support-related). Methods: We examined the features of anonymous web consultation requests through a medical site, including all the details posted in questioners' replies to the expert's response. We grouped cases into three possible categories of requests for information: a) autonomous psychopathological symptoms b) addiction treatment issues c)abuse of non-opiate substances. Results: Most of the requests made are due to a lack of insight, which is a core cognitive symptom of addiction itself, independent psychopathology coming second. The underlying therapeutic substrate is consistent with this situation, since agonist dosages of methadone are, on average, far from being effective, in line with national data. Before any personalization or psychosocial strategy is considered, the discomfort of addicts before treatment entrance and throughout the course of treatment is likely to be no more than a symptom of active addiction, because of patients' persistent cravings and lack of insight, which do not allow them to reason from a heroin-free perspective. Conclusions: As long as therapeutic instruments are not employed according to their standards of effectiveness, such medical needs are bound to remain unmet.

Published: Volume 15 • Issue 4 • December 2013 (pages: 39 - 44)

Title: The intentionality of fatal poisonings among illicit drug users, and predictors for intentional intoxication in Slovenia during the years 2002-2007.

Authors: Lovrecic M., Lovrecic B., Selb Semerl J., Maremmani A.G.I., Maremmani I.

Summary: Background and aims: As a premature, unnatural and preventable form of death, fatal poisoning is a serious public health problem. Illicit drug users show a high risk factor for fatal poisoning. In this study regarding a cohort of Slovenian illicit drug users during the years 2002-2007, we differentiated between intentional and unintentional fatal poisoning, using demographic and toxicological data. Methods: We evaluated the fatal poisoning occurring in those years in Slovenia. Results: 125 (47.4%) subjects committed fatal poisonings with undetermined intent, 71 (26.5%) with accidental intent and 70 (26.1%) with full intent. Age at suicide was lowest for accidental intoxications and highest for intentional intoxication. Half of the victims for intentional intoxication were females. Widows/widowers were better represented in the intentional poisoning group. Alcohol intoxication was found less frequently in that same group; opioids were found less frequently in the intentional group; cocaine was found more frequently in accidental intoxications and only minimally in intentional intoxication. Regarding predictors of intentional intoxication, gender (males), age (older) and alcohol were the most discriminant characteristics. Conclusions: Gender (male), age (older) and non-use of alcohol during intoxication were the best predictors of the intention to commit suicide by poisoning (in Slovenian users of illicit drugs).

Published: Volume 15 • Issue 4 • December 2013 (pages: 45 - 48)

Title: A controversial side of addiction: new insight in eating behavior

Authors: Piccinni A., Costanzo D., Vanelli F., Franceschini C., Cremone I., Conversano C., Veltri A., Dell'Osso L.

Summary: Some recent investigations about the obesity pathogenesis have suggested the design of a food addiction model for the overeating, whereby the habitual exposure to palatable and hyper-caloric foods would foster progressive alterations in appetitive and rewarding brain pathways.Dopamine and opioids have been indicated as crucial mediators of both food and drug abuse development, and the peculiar signs of dependence (tolerance, withdrawal, craving, etc.) have been described in several animal models of food addiction. The over-eating may soon be recognized as a psychopathological condition overlapping with substance abuse, obsessive-compulsive and impulse-control disorders. The food over-intake, however, appears to be a spectrum of different phenomena, including not only severe forms of food addiction, but also sub-clinical forms of addiction-like conditions as hedonic eating, emotional eating or specific food craving. Despite their contribution to overweight development, these conditions are not yet officially accepted in current diagnostic systems.Could the spectrum approach to eating addiction problem represent a valid neurobiological and psychopathological model for describing the links between over-eating, eating disorders and substance addiction disorders?

Published: Volume 16 • Issue 1 • March 2014 (pages: 5 - 8)

Title: Addiction as an extended form of brain disease: heroin-free clinical pictures in the history of addiction. Towards the concept of masked heroin addiction

Authors: Maremmani I., and Pacini M.

Summary: Not Available

Published: Volume 16 • Issue 1 • March 2014 (pages: 9 - 16)

Title: Effect of Methadone Maintenance Therapy (MMT) on serum leptin and lipid profile and anthropometric parameters in opioid addicts

Authors: Montazerifar F., Karajibani M., Lashkaripour K., and Yosefi M.

Summary: Background and Aims: In many drug abusers Methadone Maintenance Therapy (MMT) is accompanied by weight gain, changes in quality of diet, and improvement in hormonal disorders. The aim of this study was to evaluate serum leptin levels and their relationship with lipid profile and anthropometric parameters in addicts on MMT. Methods: Twenty-five drug addicts (mean age 37.4 ± 8.7 years) who had been referred to the Addiction Treatment Clinic and twenty-two healthy controls (mean age 35 ± 9.5 years) were included in the study. Anthropometric parameters (weight, height, waist circumference (WC) and waist-to-hip ratio (WHR), serum leptin and biochemical tests (serum albumin, total protein, glucose, cholesterol, triglycerides, LDL, HDL) were measured in the opioid-addicted group (before and after MMT) and in healthy controls one time only. Results: Serum leptin level was significantly lower than that of controls, at baseline (P<0.001). After 6 months of methadone maintenance treatment, the mean level of leptin had increased dramatically, along with body mass index, WC, WHR, and serum triglyceride levels (P < 0.01). No changes were found in blood pressure or other biochemical parameters. Conclusions: Further studies are needed to evaluate serum leptin as a marker of atherogenic substances. In addition, the assessment of serum leptin concentration may contribute to identifying metabolic clinical problems.

Published: Volume 16 • Issue 1 • March 2014 (pages: 17 - 24)

Title: Heroin maintenance treatment and immunity: a 12 months follow-up study

Authors: Broers B., Roux-Lombard P., Becciolini-Lebas E., Curchod-Fernandez C., and Mino A.

Summary: Background: Comprehensive diacetylmorphine (heroin) prescription programmes for severely dependent opioid users having failed repeatedly in conventional treatment have been available in Switzerland since 1994. Several studies have shown the feasibility, safety and efficacy of such programmes for this specific group. In vitro studies have shown a negative influence on immunity of acute administration of heroin. Methods: We assessed, in a prospective observational study, the change in immunological parameters of 8 HIV-uninfected patients entering a heroin prescription programme in Geneva and followed up at 1, 6 and 12 months. Results: Immunity status at start of treatment and follow-up were within the normal range for most of the patients and there was a tendency towards improvement in immune status after 12 months. Clinical follow-up showed that patients globally improved; there were no hospitalization and few medical consultations for infectious problems in the first 12 months of treatment. Conclusions: There is no reason to suspect a negative impact of pure diacetylmorphine maintenance treatment on immunity status of chronic substance abusers.

Published: Volume 16 • Issue 1 • March 2014 (pages: 25 - 34)

Title: Illicit use and diversion of buprenorphine/naloxone among patients in buprenorphine/naloxone maintenance treatment in Istanbul/Turkey

Authors: Evren C., Bozkurt M., Cetin T., and Evren B.

Summary: Background and aims. Besides noting the measures taken in Turkey against the buprenorphine/naloxone (BNX) combination to suppress the misuse of therapeutic opiates, a detailed study on the illicit use of BNX has become a compelling priority. The aim of this study is, in fact, to evaluate the extent of the illicit use and diversion of buprenorphine/naloxone (BNX) by patients in BNX maintenance treatment (BMT). Methods. 281 heroin-dependent patients were included in the study. These patients had consecutively attended the Alcohol and Drug Research Treatment and Training Center (AMATEM) polyclinic as BMT outpatients, and had reached the end of the stabilization phase at least 2 weeks after induction. Results. Of these 281 heroin-dependent subjects in BMT, 110 (39.1%) were considered as belonging to the group that had used illicit (i.e. unprescribed) BNX. This group presented higher current doses, a higher use of BNX before treatment, a shorter period of BNX treatment and a lower frequency of remission of drug use. There was no difference between the two groups in estimates of dose adequacy, receiving education for BNX use, having a legal problem and/or probation, using different routes for BNX other than the sublingual route of administration, or giving away BNX doses. Those in the group that did use illicit BNX showed higher percentages both for the more frequent use of BNX or higher doses of it, and its less frequent use or for lower doses, besides the more frequent use of other substances during BMT, compared with the group unaffected by illicit BNX. Conclusions. Most of the patients that used illicit BNX had done this before their monitored use of BNX and had used it to relieve withdrawal symptoms, which suggests that the main difficulty for those seeking illicit BNX in Istanbul is how to access treatment.

Published: Volume 16 • Issue 1 • March 2014 (pages: 35 - 40)

Title: Requests for quetiapine from jailed substance abusers: are they a form of abuse or self-medication in response to long-term opioid dysphoria?

Authors: Pacini M., Santucci B., and Maremmani I.

Summary: Background and aims: Quetiapine is an available resource in the treatment of psychotic symptoms and agitation in schizophrenia and bipolar disorder. It has also proved effective in relieving withdrawal from opiates and other substances, with a favourable impact on anxiety, pain perception, insomnia, reduced appetite and negative craving. Cases of abuse have been documented in jails. So far no study has related illegal quetiapine use to one specific category of substance abuse. Methods: the anamnestic and clinical data of 17 substance abusers, who had been asking for quetiapine, were gathered during a period of imprisonment. Results: Subjects were adult males, mostly of Arabian origin, who asked to be given quetiapine after imprisonment, showing stabilization at therapeutic dosages, especially in the lower dosage range. Their shared clinical features were dysphoria and aggressiveness, while they showed heterogeneous profiles for substance abuse patterns and pictures, psychiatric history and on-going treatments. Conclusions: All the cases described in this paper, indicate a phenomenon of quetiapine use, with no clear core features of abuse or addiction, but a usage pattern that is, certainly, specifically oriented towards quetiapine.

Published: Volume 16 • Issue 1 • March 2014 (pages: 41 - 44)

Title: Prevalence of HCV infection and adherence to DOT therapy in Italian and non-Italian iv drug users in Rome, Italy

Authors: Nosotti L., Fagetti R., Rocchi L., Khoperia M., Mirisola M.C., Testa R., and Leonardi C.

Summary: Background: The prevalence of HCV-related liver disease among Italian drug addicts is high. Although screening for HCV infection should be offered to all injection drug users (IDUs), only a few of them have been tested for the virus in recent years, and even fewer have been treated. Aims: To assess the prevalence of HCV infection in an IDU sample in Rome and to compare adherence to treatment in Italian vs non-Italian patients. Methods: 261 IDUs underwent screening for HCV, HBV and HIV infection. Patients eligible for treatment were treated with Directly Observed Therapy (DOT). Results: The prevalence of HCV infection among IDUs screened in our Unit was 47.1% (123/261). 96 patients were males, 37 females; average age was 46.2±11.2 years. The most frequent genotype was 1 (45.4%) followed by genotype 3 (36.1%), genotype 4 (11.6%) and genotype 2 (6.9%). Among HCV-positive drug addicts, the prevalence of HBsAg and HIV positivity was 7.2% and 1.5%, respectively. Only 23.1% of subjects had been vaccinated, whereas 48.2% were negative for any HBV marker. The HCV-RNA qualitative test was performed on 53.5% (66/123) of patients; of these, 84.3% (56/66) were HCV-RNA positive. A higher percentage of foreign patients started treatment than Italian ones (69.5% versus 48.3%), but a higher percentage of dropouts was reported among immigrants than among Italian drug users (56.2% versus 23.3%) (p<0.05). Conclusions: The present study confirms the importance of DOT therapy (showing a considerably lower percentage of dropouts) and of the multidisciplinary approach, together with the inclusion of cultural mediators in the management of foreign IDUs in overcoming linguistic and cultural barriers, and in raising awareness of the disease.

Published: Volume 16 • Issue 1 • March 2014 (pages: 45 - 48)

Title: How to treat the treatment system

Authors: Reisinger M.

Summary: The ancient Greek maxim "Know thyself" also applies to health care systems, which cannot adequately cure the patients if they cannot cure themselves. They should be able to identify and repair their own shortcomings. Treatment should be available for all patients who need it and there should be no waiting-lists. To reach this availability primary care physicians should provide these treatments. Regulations should be eased, because excessive regulations and controls are counter- productive. They are a barrier to treatment and they increase the risk of death for patients.

Published: Volume 16 • Issue 1 • March 2014 (pages: 49 - 54)

Title: Does a buprenorphine augmentation control manic symptoms in bipolar disorder with a past history of heroin addiction? A case report.

Authors: Bizzarri J., V., Conca A., and Maremmani I.

Summary: Background and aim. Bipolar disorder (BD) is often associated with substance use disorders with resulting negative outcomes, including increased severity of symptoms, more hospitalizations and poor treatment response. The aim of this case study presentation is to support the hypothesis that augmentation treatment with an opiate agonist may be indicated in psychotic patients with a history of heroin addiction during an acute psychotic episode. Case Presentation. A 40-year-old female with BD and a previous history of opiate addiction was treated with a combination of an antipsychotic, mood stabilizers and benzodiazepine for an acute dysphoric manic episode. She did not show any significant clinical improvement until the introduction of an opiate agonist medication. Although the patient did not present with a relapse into heroin use, it was considered that the severity of her symptoms and the low level of her response to therapy could be related to a hypophoric/dysphoric syndrome induced by previous long-term opiate abuse. We decided to start with a very low dose, considering that our patient had no opiate tolerance. Buprenorphine treatment was initiated at a dose of 1 mg on day 14 and was increased to a maintenance dose of 2 mg on day 15. There was a consequent rapid reduction in levels of agitation and dysphoria. Conclusions: The good clinical outcome in this case suggests that augmentation with an opiate agonist may be indicated in patients with BD and a history of opiate addiction, even in those who have not had a recent opiate relapse.

Published: Volume 16 • Issue 1 • March 2014 (pages: 55 - 62)

Title: Case note review – Transfer of patient to buprenorphine from daily doses of methadone greater than 30mg.

Authors: Hill D., and Conroy S.

Summary: This paper examines 5 cases studies of patients transferring from greater than 30mg daily of methadone to buprenorphine using the agreed protocol in NHS Lanarkshire. The history and circumstances of the patients all vary as does their previous daily dose of methadone; this are captured in the demographics of the group selected. The article reflects on the personal experiences the patients had during the process and also records and examines some of the biophysical measurements taken. The article demonstrates that the patient experiences are unique and benefit the patients whilst the overall transfer is safe and effective.

Published: Volume 16 • Issue 1 • March 2014 (pages: 63 - 64)

Title: Can the buprenorphine-naloxone association outperform buprenorphine alone?

Authors: de Bernardis E., and Busà L.

Summary: Not available

Published: Volume 16 • Issue 1 • March 2014 (pages: 65 - 68)

Title: The probable impact of the global financial and economic crisis on medical addiction treatment

Authors: Lovrecic M., and Lovrecic B.

Summary: Not available

Published: Volume 16 • Issue 2 • June 2014 (pages: 5 - 10)

Title: Breastfeeding may protect against heroin addiction

Authors: Akpinar A., Yalniz H., Gecici O., and Guven M.

Summary: Background: Heroin addiction is a biopsychosocial disorder and the role of some early environmental factors has also been suggested. The aim of the study was to assess whether breastfeeding may or may not affect the development of heroin addiction in adult life. Methods: We compared the incidence of breastfeeding in the first four months of life and the duration of breastfeeding in patients suffering from heroin addiction with the results for the control group. We also compared the timing of the introduction of complementary foods between the two groups. The addicted group consisted of 88 patients (27 females/61 males; mean age 22 ± 4 years) suffering from heroin addiction, while the control group included a group of 57 healthy individuals (22 females/35 males; mean age 23 ± 5 years). The breastfeeding history was obtained retrospectively by means of face-to-face interviews with the mothers of patients and controls. Results: The incidence of breastfeeding between 0 and 4 months was 73% (n=64) in patients with heroin addiction and 88% (n=50) in the control group. Weaning within the first 4 months of life (OR; 0.33; CI, 0.13-0.85; p=0.02) was associated with a high risk of heroin addiction in later life. Duration of breastfeeding, and the timing of the introduction of complementary foods were found to be similar in the two groups (p >0.05). Conclusions: This study suggests that early weaning (i.e. weaning during the first 4 months) may be associated with an increased risk in adult life to be faced by the offspring of parents showing heroin addiction. Duration of breastfeeding and the timing of the introduction of complementary foods (solid foods and cow's milk) might not have any effect on the development of heroin addiction.

Published: Volume 16 • Issue 2 • June 2014 (pages: 11 - 16)

Title: Defining a new approach to measuring outcomes in opioid dependence management:

Authors: Alho H., Littlewood R., and Maremmani I.

Summary: There is no adequate tool to measure outcomes across different systems for opioid dependence management. Measuring the outcomes of interventions in opioid dependence management is important because it can lead to a better understanding of the important decisions over patient care in this area. The suggested outcomes system is based on the concept of 4 different areas of measurement. These are mortality in treatment, individual patient response, impact on society and harm related outcomes. An online consensus survey was operated to test expert opinion. 65 experts were polled on their opinion of the specifics within these areas of measurement. A consensus was reached that the components in the suggested system described are valid and should be developed further.

Published: Volume 16 • Issue 2 • June 2014 (pages: 17 - 22)

Title: A survey of patients on methadone programmes in Wheatfield Prison, Dublin, Ireland.

Authors: Galander T., Rosalim J., Betts-Symonds G., and Scully M.

Summary: We surveyed all prisoner patients in Wheatfield Prison (Dublin, Ireland) on methadone programmes on 3 October 2011.Socio-demographic and medical data were recorded. Basic descriptive statistics were used. 119 out of 664 prisoners were on methadone treatment. Almost two thirds of patients were on 60 mg or less doses of methadone. Half of the patients on methadone were prescribed other psychotropic medications. Over one third of patients had an unknown HIV, HBV and HCV status. Drug treatment and in particular OST are an integral part of healthcare provision in prison settings. More extensive screening of Blood-Borne Virus infections in this population is required. Prisoner patients on methadone treatment appear to have a high level of psychiatric comorbidity.

Published: Volume 16 • Issue 2 • June 2014 (pages: 23 - 30)

Title: Benzodiazepine use in a Methadone Maintained Opiate Dependent Cohort in Ireland

Authors: Gilroy D., O'Brien S., Barry J., Ivers J.-H., Whiston L., Keenan E., and Darker C.

Summary: Background: Benzodiazepines (BZDs) are one of the most widely abused substances by opiate-dependent patients. Aim: This research aims to identify patterns of BZD use in methadone maintained opiate dependent patients attending an addiction treatment clinic in Dublin, Ireland. Materials and Method: Patients (n=78) testing positive for BZDs by urinalysis completed a face-to-face survey. Results: Daily BZD use was reported by 70.1% (n= 54) with 67.9% (n= 53) consuming up to 5 tablets a day. A BZD prescription was provided for 50% (n=39) and 61.5% (n=48) used illicit BZDs. The primary BZD of use was Diazepam reported by 93.6% (n= 73) of patients. Analysis showed source of BZDs is related to frequency of consumption [x2 (2)= 10.98, p < 0.01] and use of others drugs [x2 (2)= 6.972, p< 0.04]. Conclusion: BZD use is common place among methadone maintained patients. Source of BZDs is associated with frequency of consumption and use of other drugs.

Published: Volume 16 • Issue 2 • June 2014 (pages: 31 - 36)

Title: Buprenorphine/ Buprenorphine-naloxone treatment in opioid dependence and risk of peripheral oedema: Mini-review

Authors: Soyka M.

Summary: Safety issues are of great concern in opioid maintenance therapy. Recently the European medicines agency raised the issue of peripheral oedema in buprenorphine treated patients. A medline search for reports on peripheral oedema in buprenorphine was performed and relevant websites were screened. To date few cases have been reported but the side effect is listed as common. Histamine release is associated with opioid use but not shown for buprenorphine in the skin. Possible implications are discussed.

Published: Volume 16 • Issue 2 • June 2014 (pages: 37 - 42)

Title: Alcohol use disorder and past heroin addiction. A successfully treated ‘masked heroinism' patient

Authors: Maremmani A.G.I., Quaranta G., Bacciardi S., Rovai L., Rugani F., Pacini M., Nisita C., and Maremmani I.

Summary: Background. A history of exposure to opiates and subsequent opiate use disorder is a frequent background in subjects who apply for alcohol abuse treatment. Shifting from heroin to alcohol use can lead to misunderstandings, as it may easily be mistaken for the remission of opiate addiction. Aim. We propose that alcohol abuse in former heroin addicts should be considered a masked form of heroinism, or a sign of enduring opiate dysfunction that needs treatment with an opioid medication. Methods. Case report presentation. Case report. We present a case in which a 5-year heroin-free, methadone treatment discharged patient was totally involved in alcohol misuse, not responding to standard treatments for alcoholism or to psychopharmacotherapy. A successful outcome (drinking cessation) was reached after the reintroduction of agonist opioid medication (buprenorphine). Conclusions. In responding to the challenge of identifying different alcoholic subgroups that can benefit from specific treatment, we want to shed light on the idea that alcoholics with a history of heroin use should be considered a specific group, and a treatment target should be set on the rebalancing of the opioidergic system after passing through agonist opioid treatment.

Published: Volume 16 • Issue 2 • June 2014 (pages: 43 - 46)

Title: American Association for the Treatment of Opioid Dependence (AATOD) Guidelines for Guest Medication

Authors: Parrino M.

Summary: Not available

Published: Volume 16 • Issue 2 • June 2014 (pages: 47 - 52)

Title: Case report: Pregnancy and birth under Heroin-assisted Treatment (HAT)

Authors: Groh A., Urlichs F., Hillemacher T., Bleich S., and Heberlein A.

Summary: The treatment of opiate-dependent women during pregnancy is a common problem. Maintenance treatment with methadone is the best-established treatment, although a few case reports demonstrate the possible advantages of buprenorphine and slow release morphine in limiting the intensity of the postnatal, neonatal withdrawal syndrome. Here we report on the course of pregnancy and the postnatal withdrawal symptom of the son of a 25-year-old, first childbearing woman in her 38th week of pregnancy under diamorphine-assisted treatment (HAT=heroin-assisted treatment). Until the beginning of her pregnancy Mrs. X was maintained on diamorphine for about a year; apart from diamorphine, the only medicinal treatment was low dosages of quetiapine ad libitum, which were prescribed to treat nightmares and sleep-onset disorder. The pregnancy under diamorphine maintenance caused no major problems, and childbirth by Caesarean section took place in the 38+2 week of her pregnancy, although Mrs. X's son's neonatal withdrawal syndrome turned out to be more severe, and to show an earlier onset compared with methadone or buprenorphine treatments.

Published: Volume 16 • Issue 2 • June 2014 (pages: 53 - 56)

Title: Drug dreams as a signal of drug craving persistence in time

Authors: Colace C.

Summary: Drug dreams, that is, dreams in which patients addicted to drugs typically use or make an attempt to use the drugs they are addicted to, are a well-documented clinical phenomenon in various forms of addiction. One clinical function of these dreams is their ability to signal the latent recrudescence of drug craving even long after the patients have resolved their addictive behaviours. The following case is an example of how drug dreams reveal the extraordinary persistence in time of drug craving and the patient's risk of potential relapse, even after as many as 10 years of living in a drug-free state.

Published: Volume 16 • Issue 3 • September 2014 (pages: 5 - 6)

Title: Preventing opioid overdoses: is the first still the best? should we go back to the origins?

Authors: Maremmani I., and Maremmani A.G.I.

Summary: Not available

Published: Volume 16 • Issue 3 • September 2014 (pages: 7 - 14)

Title: Substance abuse in Romania. A clinical medical-legal perspective

Authors: Dermengiu D., Sorin H., Radu D., Aciu F., Astarastoae V., Ioan B., Constantinescu G., Enache A., Ciocan V., Talos I., Gorun G., and Curca G.C.

Summary: Objective. In Romania medical-legal studies on the pattern of drug consumption have not yet been conducted nationwide; the purpose of this study was, therefore, to determine whether such a pattern could be identified. Material and methods. A total number of 577 analyses were performed during a three-year period on people suspected of non-lethal substance abuse, in more than two-thirds of the counties in Romania. Preliminary tests were conducted using immunoassay tests (blood or urine) and confirmatory tests were carried out using either GC-MS or HPLC. Results. 240 cases (41.6%) were negative while 327 cases (58.4%) tested positive for illegal drugs, central nervous system medication or both. Men represented 89.5% of all cases, while women accounted for only 10.5%. The pattern of substance abuse varied significantly, depending on the geographical area. In most cases, the identified drugs of abuse were cannabinoids and opiates, with a significantly different distribution of cases, depending on the geographical area. The highest number of positive cases was identified in the month of October, whereas the smallest numbers were identified in July and December. The annual trend of consumption revealed a significant decrease in the analysed substances in 2011. Conclusions. Our study has determined the presence of a specific pattern of consumption in different geographical areas – a result that suggests the need for more targeted prevention programmes, addressing local particularities in consumption behaviours. A significant decrease in the identification of drugs of abuse in the third year of our study, combined with data attesting the significant increase in the consumption of legal highs suggests that the forensic toxicology laboratories need to be equipped with apparatus able to detect these newer substances of abuse more efficiently.

Published: Volume 16 • Issue 3 • September 2014 (pages: 15 - 34)

Title: The role of opioid system in Eating Disorders. Perspectives for new treatment strategies.

Authors: Rovai L., Maremmani A.G.I., Bacciardi S., Rugani F., Massimetti E., Gazzarrini D., Pacini M., Dell'Osso L., and Maremmani I.

Summary: Introduction: Growing evidence drawn both from observational and biological sources supports the hypothesis that eating disorders share the feature of inducing an alteration in the reward system, with a central role being played by opioid neuropeptides. Aims: To estimate i) epidemiological and clinical correlations between opioid use disorder and eating disorders; ii) the nature of the correlation between opioid medications, feeding behaviours and eating disorder symptoms; iii) the feasibility of using opioid medications in the management of eating disorders, especially anorexia nervosa, bulimia nervosa and binge eating disorder; iiii) the risk-benefit ratio of opioid medications compared with that of medications traditionally used to treat eating disorders. Methods: Overview after a thorough search on the “Scopus data base”. Results: We found few available data on the correlations between opiate addiction and eating disorders, whether on the epidemiological or the clinical plane. Opioid full and partial agonists seem to present a promising profile of effects that could be useful in treating anorexia nervosa. Opioid antagonists have been shown to be effective on both bulimia nervosa and binge eating disorders. Nalmefene should be preferred to naltrexone in bulimic patients of normal weight who are able to benefit from a double stabilization. Conclusions: Despite the scarcity of clinical and epidemiological data on the correlations between eating disorders and opiate addiction, evidence from both human and animal studies prompts the suggestion that opioid medications can play a far from negligible role in the treatment of eating disorders.

Published: Volume 16 • Issue 3 • September 2014 (pages: 35 - 40)

Title: Comparing emotional clarity, emotion experience, and emotion regulation in persons with heroin addiction with and without physical withdrawal

Authors: Xin Z., Lu X., Li F., Renlai Z., Ge J., Ling Y., and Yueyue C.

Summary: Background: Emotional problems play a key role in inducing relapse among those who suffer from substance addiction. Methods: In the present study, we determine differences in emotional clarity and experience, and the regulation of emotion in the two groups selected by us: 28 men with heroin addiction who were not experiencing physical withdrawal symptoms (M = 39.64, SD = 4.12, range: 32–50 years) and 28 men with heroin addiction who were experiencing such symptoms (M = 40.96, SD = 4.47, range: 32-50 years). To measure these variables, we used the Positive and Negative Affect Schedule, the identification subscale of the Toronto Alexithymia Scale, and the Emotion Regulation Questionnaire. Results: Compared with the abstinent group, the non-abstinent group experienced increased negative emotion and made less use of cognitive reappraisal strategies. In addition, the groups did not significantly differ in emotional clarity, positive emotional experience, or frequency in their use of suppression strategies. Conclusions: Our study suggests that, among heroin addicts, abstinence contributes to the release of negative emotions and the use of effective emotion regulation strategies, but that, at the same time, it failed to enhance positive emotional experiences.

Published: Volume 16 • Issue 3 • September 2014 (pages: 41 - 48)

Title: Why do heroin users refuse to participate in a heroin-assisted treatment trial?

Authors: Demaret I., Litran G., Magoga C., Deblire C., Dupont A., De Roubaix J., Lemaître A., and Ansseau M.

Summary: Background: Heroin-assisted treatment (HAT) can improve the condition of heroin addicts resistant to other treatments. However, in a new HAT trial in Belgium fewer subjects than expected were included. Aim: Our research team explored the reasons given by heroin users explaining why they did not want to participate. Materials and methods: In 2011, during the trial recruitment, we interviewed heroin users (n=52) who were never met by the research team during the recruitment process of the trial. Results: Of those 52 heroin users, 25 were afraid of the limited length of the HAT and 11 feared becoming more dependent with HAT. Conclusion: A trial for a limited length of time can demotivate heroin users who could otherwise have benefited from this new program.

Published: Volume 16 • Issue 3 • September 2014 (pages: 49 - 54)

Title: Sexual dysfunction in male patients receiving methadone and buprenorphine maintenance treatment in Iran

Authors: Tafreshian S., Javadi M., Fakhraei F., and Seddigheh Fatemi S.

Summary: Background: methadone and buprenorphine are the major modalities of substitution treatment for opioid dependence in Iran. There are still only limited data on alterations in sexual function during methadone or buprenorphine maintenance therapy (MMT, BMT) and the impact of sexual dysfunctions on patients' life and treatment. Aims: to evaluate whether the incidence of sexual dysfunctions differs in samples of men in maintenance treatment with methadone or those with buprenorphine; evaluate correlations between sexual dysfunction and substitution treatment of opioid dependence. Methods: 158 opioid-dependent men were recruited from two methadone maintenance clinics in Mashad, Iran, between December 2011 and April 2013. Data were collected by organizing interviews and questionnaires. Sexual function has been investigated with IIEF, an extensively validated questionnaire covering five domains of male sexual function. Results: methadone has stronger effects on sexual dysfunction than buprenorphine. In both groups, erectile dysfunction seems to be the main form of sexual dysfunction. Methadone dose and the duration of therapy showed a correlation with sexual dysfunction: (p=0.011) and (p=0.012), respectively. On the other hand, no valuable statistical correlations were found between duration of opioid use and sexual complaints in our patients. Conclusions: the frequency of sexual dysfunction in people treated with methadone is higher than in the BMT group. Sexual dysfunctions lowered the quality of patients' sexual life and damaged their most intimate relationships. This problem may increase the risk of treatment failure and illicit drug abuse. Thus, physicians should screen sexual dysfunctions in men receiving opioid treatment and carefully assess the issue of the medication of choice. Erectile and orgasmic dysfunctions may respond to methadone dose reduction. Further studies are needed to evaluate the benefits of methadone dose reduction in patients receiving treatment.

Published: Volume 16 • Issue 3 • September 2014 (pages: 55 - 64)

Title: Outcomes of clonazepam maintained benzodiazepine-heroin addicted patients during methadone maintenance: A descriptive case series

Authors: Maremmani A.G.I., Bacciardi S., Rugani F., Rovai L., Massimetti E., Gazzarrini D., Dell'Osso L., Pani P.P., Pacini M., and Maremmani I.

Summary: Background. The use of benzodiazepine (BDZ) by patients on methadone maintenance treatment (MMT) has the effect of complicating the clinical picture. The relative safety of BDZ use by methadone- or buprenorphine-treated patients has still not been systematically examined. It is not yet clear whether a maintenance strategy with clonazepam is a useful BZD treatment modality for BZD-dependent MMT patients with a long-term history of abuse and previous attempts at detoxification. Methods. In this study our aim has been to collect and present detailed information regarding the outcomes of a small group of our patients who were treated with clonazepam maintenance during methadone maintenance. Results. In our sample of BZD-dependent MMT patients, who were treated with a methadone-clonazepam combination, the retention rate, at 8 years, was 57.1%. Baseline-endpoint improvements were significant for clinical global impression and the level of social adjustment. Conclusions. Patients with a severe comorbid dependence, when treated with over-standard dosages of methadone and co-treated with CMT, may have outcomes that are satisfactory as long as they are maintained on their medication in the long term.

Published: Volume 16 • Issue 3 • September 2014 (pages: 65 - 74)

Title: Gender differences in severity of addiction in opiate-dependent outpatients.

Authors: Mezzatesta-Gava M., Roncero C., Rodriguez-Cintas L., Fuste G., Barral-Picado C., Martinez-Luna N., Casas M., and Miquel L.

Summary: Background. Opioid dependence is a prevalent health problem. The literature now available on how to achieve a better knowledge of how this problem affects women, and on the importance of gender differences, is still limited. Aim. The aim of this study was to characterize gender differences in socio-demographic features, clinical manifestations, comorbid disorders and severity of opiate addiction, so as to define the role of gender differences in the severity of the addiction. Methods. A cross-sectional, observational, descriptive study evaluated a total of 124 opiate-dependent patients seeking treatment from an urban outpatient programme. Both Axis I and Axis II diagnoses were assessed by applying the Structured Clinical Interview for DSM Disorders I and II (SCID-I and SCID-II). The severity of addiction was evaluated through the application of the European Addiction Severity Index (EuropASI) instrument. Results. Women experienced a stronger impact from opioid addiction on their employment status, considering that the risk of presenting a severe ASI composite score was 4.4 times higher than the risk for men (IC95% 1.3-15.1). Females had a higher likelihood of being diagnosed with an affective disorder. Men showed a greater duration of regular heroin use, and were more likely to meet the current criteria for alcohol dependence; these data correlated with a higher severity of the related ASI composite score (OR=3.8 (IC95% 1.1-13.5). Conclusions. Significant differences in the severity of addiction, substance use profile, psychiatric comorbidity and areas of impaired functioning were found to be due to gender differences.

Published: Volume 16 • Issue 3 • September 2014 (pages: 75 - 86)

Title: Limbic system irritability and drug dreams in heroin-addicted patients

Authors: Colace C., Belsanti S., and Antermite A.

Summary: Background. Drug dreams, that is, the dreams of drug-addicted patients with contents related to their craving for the drugs they are addicted to, have been investigated in their clinical and prognostic significance, as well as in their implications from the standpoint of general dream research and theory. Recent progress in neurobiology of drug addiction and drug craving, affective neuroscience, and neuropsychology of dreaming, provide a background for investigating the possible neurobiological correlates of these dreams, that may help to understand the intimate link between them and drug craving. Aim. This paper investigates on drug dreams and limbic system activity in drug addicted patients as measured by means of the Limbic System Check List-33 (LSCL). Methods. 53 heroin -addicted subjects were interviewed about their drug dreams (Drug Dreams Questionnaire). Results. The results show that drug-addicted patients reported a LSCL mean score indicating limbic system irritability. Furthermore, patients who have drug dreams reported a higher statistically significant LSCL mean score compared to non-dreamer patients. Results are also consistent with previous studies regarding the phenomenological picture of drug dreams and their clinical applications. Discussion and conclusion. We assume that in the patients who reported drug dreams, the higher LSCL scores may be due to the presence of a stronger drug craving, of which the higher mesolimbic-mesocortical dopamine tone is the neurobiological correlate. The association between the greater limbic DA tone and the occurrence of drug dreams appears consistent with the results of clinico-anatomical studies of dreaming on the crucial role of the mesolimbic-mesocortical dopamine system in the instigation of dream.

Published: Volume 16 • Issue 3 • September 2014 (pages: 87 - 98)

Title: Induction and Switch to Buprenorphine-Naloxone in opioid dependence treatment: Predictive Value of the First Four Weeks

Authors: Apelt S.M., Scherbaum N., and Soyka M.

Summary: Background/Aims: Clinical studies report the highest risk of drop out in the first weeks of opioid dependence treatment. This secondary analysis of data from a non-interventional study with buprenorphine-naloxone (BNX) aims to evaluate the predictive value of the first four weeks for treatment outcome in routine care. Methods: Data from a multicentre 12-month study in N=337 opioid dependent patients from N=69 sites in Germany was used. Results: Patients with negative urine screenings for opiates, cocaine or benzodiazepines at screening, maximum daily dose of 8mg BNX during first four weeks, significantly lower Global Severity Index (GSI) of the SCL-90-R at day 0 and week 4 had a significantly higher chance to be retained in treatment. Patients switched from d/l-methadone, levo-methadone, buprenorphine or active heroin use differ in almost all evaluated parameters. Conclusion: The first four weeks of treatment with BNX have a high predictive value for treatment outcome especially urine screening, dosing of BNX and psychiatric distress. But the treating physician needs to determine if the patient is pre-treated with d/l-methadone, levo-methadone or buprenorphine or if the patient is induced to BNX directly from heroin, because most of the predictive values seem to be unique for a sub group of patients only.

Published: Volume 16 • Issue 3 • September 2014 (pages: 99 - 100)

Title: Using oral or i/m morphine for rapid tolerance assessment in patients starting methadone maintenance: a proposal for discussion based on over 25 years of experience

Authors: Brewer C.

Summary: Not Available

Published: Volume 16 • Issue 3 • September 2014 (pages: 101 - 104)

Title: 30 Years of Naloxone. The Experience of Villa Maraini Foundation

Authors: Barra M., and Lelli V.

Summary: Not Available

Published: Volume 16 • Issue 4 • December 2014 (pages: 5 - 14)

Title: Evaluation of the Quality of Life in 171 patients under Methadone Maintenance Treatment and in 46 benzodiazepine mono-dependent patients.

Authors: Lugoboni F., Carli S., Bissoli G., Musi G., Florio E., Civitelli G., Brizio M., Smacchia C., Biasin C., Cifelli G., Manzato G., Rosa S., and Manzato E.

Summary: Opiate Substitution Treatment – in particular, with methadone – has been the subject of multiple evaluations of key aspects related to heroin addiction, such as the incidence of overdose, seroconversions for HIV, and the risk of incarceration. It is worth noting that the perceived quality of life (QoL) has been studied far less often in heroin-addicted patients than in those with a variety of other common conditions. Paradoxically, the QoL of chronic users of benzodiazepines (BZD) has been evaluated even less often, although BZDs are among the most widely prescribed drugs in developed countries. The present paper evaluates the QoL by using the GHQ-12 questionnaire and comparing 2 groups: 171 heroin dependents in methadone maintenance treatment and 46 high-dose benzodiazepine monodependents without any history of alcoholism, illicit drug use or psychiatric illness. The data from benzodiazepine high-dose users (B-HDUs) were collected randomly over the period 2010-2012 among the people who had applied to the Addiction Unit, Department of Internal Medicine, Verona University Hospital, Verona, Italy, for admission to detoxification therapy. The average daily BZD intake was 13 times the maximum dose recommended by the package insert. For the 171 heroin addicts, the criteria for inclusion were being over 18 years old and being in MMT, thus excluding other types of treatment or addiction. The following parameters were considered: gender, age, marital status, presence of children, work, whether BZD was being used or not. The average GHQ12 score among the subjects in methadone treatment turned out to be 2.74, while that of B-HDU subjects came out at 8.33. Comparing these results with a cut-off ≥ 4, referring to the general population in Italy, we find that the B-HDUs were "GHQ-12 cases", clearly exceeding the threshold value, whereas patients in opiate substitution treatment were "not GHQ-12 cases". In other words, the GHQ values of heroin addicts were mostly comparable with those of the general population in Italy, whilst those of B-HDUs were absolutely not. The B-HDUs showed that they had a health perception much worse than that of the general population. In sharp contrast, the subjects in MMT had shown that they perceived themselves at a much higher level of psychosocial health than the B-HDUs, and they were completely in line with the general population in Italy in that respect. So far, this has been the first study that has evaluated the QoL in monodependent benzodiazepine abusers.

Published: Volume 16 • Issue 4 • December 2014 (pages: 15 - 24)

Title: Is it possible to treat heroin addicts with severe comorbid benzodiazepines addiction combining enhanced methadone maintenance and clonazepam maintenance treatments?

Authors: Maremmani A.G.I., Bacciardi S., Rugani F., Rovai L., Massimetti E., Gazzarrini D., Dell'Osso L., Pani P.P., Pacini M., and Maremmani I.

Summary: Objective. The aim of this naturalistic (observational) controlled cohort study was to compare the long-term outcomes of treatment-resistant heroin addicts with (HA+BDZ) and without (HA-BDZ) comorbid benzodiazepine (BDZ) severe addiction. Method. 63 HA-BDZ and 14 HA+BDZ patients were monitored prospectively along an enhanced methadone maintenance treatment programme (MMTP). HA+BDZ patients were treated, also, with clonazepam maintenance treatment (CMT). Results. Survival-in-treatment rates were no different in HA+BDZ and HA-BDZ patients. HA+BDZ patients showed better outcome results than HA-BDZ patients. HA+BDZ patients needed a higher methadone dosage in the stabilization phase. Conclusions. This study supports the possibility to use methadone maintenance and clonazepam maintenance combination in heroin-addicted patients with comorbid severe BDZ dependence.

Published: Volume 16 • Issue 4 • December 2014 (pages: 25 - 32)

Title: Health-related quality of life of patients on opiate replacement therapy

Authors: McLaughlin J., Surah S., Synnott C., Adams R., Walsh C., O'Dea S., Noone S., Keenan E., Keating S., Barry M., Bergin C., Mulcahy F., and Lyons F.

Summary: Background. Substance misuse poses a huge health burden worldwide. Individuals who misuse drugs have higher rates of morbidity and mortality. It has been widely documented that health-related quality of life (HRQOL) is lower in people who misuse drugs, particularly intravenous drug users (IDU), than in the general population. Aim. To evaluate HRQOL and contributing factors in individuals receiving opiate replacement therapy. Methods. This was a cross-sectional study of patients attending for methadone therapy in an inner city drug treatment centre. EQ-5D, SF-36, SF-6D, Hospital Anxiety Depression Scale (HADs) were assessed, along with substance abuse via the Treatment Outcomes Profile (TOPs). Mean values, ranges and standard deviations were calculated and utility scores were derived. Statistical relationships between HRQOL and other variables were explored using univariate and multivariate analysis. Results: 115 patients were included, 72% were male and the mean age was 35 years. 63% were HCV-PCR positive and 49% admitted to using drugs in the past month. 57% of patients had high levels of anxiety with the mean score being 11.14 (anxious). 35% were depressed with the mean score being 8.40 (borderline depressed). The mean EQ-5D utility score was 0.56 with 7% having a utility score that was worse than death. The mean SF-36 utility score was 0.55. The mean SF-36 physical component score was 44.25 and the mean mental component score was 33.18. Anxiety and depression were significantly correlated with EQ-5D and SF-6D utility values on both univariate and multivariate analysis. Conclusion: HRQOL was reduced in this opiate replacement therapy cohort with only anxiety and depression having a significant impact.

Published: Volume 16 • Issue 4 • December 2014 (pages: 33 - 40)

Title: Meeting Report: Guidelines in the treatment of opiate addiction, a review and recommendations

Authors: Alho H., Fischer G., Torrens M., Maremmani I., Ali R., and Clark N.

Summary: A meeting report from the worshop at ISAM 2013, "Guidelines in the treatment of opiate addiction, a review and recommendations". Guidelines assist practitioners in the management of opioid dependence, however, important day-to-day issues in the field must be addressed, such as “Which medication to use, how to start, how to dose, when to stop, how to manage complications and comorbidities?” The workshop aimed to define the approach to managing the gap between guidelines for opioid dependence management and the real life clinical situations. 6 expert speakers in the field of opioid dependence management presented detailed guidelines examination, the evidence for the guidelines, and expert clinical experience highlighting the practical needs for prescribers in opioid dependence management for individualised patient care and comorbidities. Results: Sufficient evidence supports the treatment of opioid dependence, but evidence gaps remain which are likely to be important in guiding specific decisions about individual patient care. Clinical experience is vital to bridge the gaps between Guidelines advice, effective individual patient tailored care in the treatment of opioid dependence. Conclusions: It is important to tailor care to individual patient needs under the consideration of evidence based facts. Initial recommendations for treatment directed by a system based on tolerance to opioids, level of existing psychopathology, and abuse of other substances could bridge the gap between Guidelines and the real life clinical setting.

Published: Volume 16 • Issue 4 • December 2014 (pages: 41 - 48)

Title: Dietary intakes of opiate abusers before and during Methadone Maintenance Treatment

Authors: Montazerifar F., Karajibani M., Lashkaripour K., Dorzadeh H., yosefi M., and Dashipour A.-R.

Summary: Introduction: The poor diet resulting of drug abuse has been reported in opiate –using populations. Substitution treatment with methadone has been used as one of the possible ways to prevent and control of opioid-dependent patients.The aim of study was to evaluate of energy, micro and macronutrient intakes of drug abusers before and after methadone maintenance treatment (MMT). Methods: 55 opioid - dependent abusers (mean aged 31.6 ± 10 years) and 39 healthy controls (mean age 32 ± 9.5 years) were enrolled in the study. Food patterns and dietary intake data were assessed by two questionnaires including 24–hour dietary recall and food frequency questionnaire (FFQ) in the three steps; before MMT, after 2 and 6 months of treatment in addicts, and in healthy controls one time only. Results: The findings showed that the diet of patients contained inadequate amounts of nutrients compared to Dietary Reference Intake (DRI) and control group (P<0.0001).The opiate abusers consumed the minimum daily servings of fruits, vegetables, dairy products and meats group recommended by the food pyramid, at baseline and compared with controls. An increased intake of nutrients and all food groups' servings was demonstrated after treatment, and was similar to control group.Conclusion: This study is a qualitative and quantitative assessment in term of the dietary intakes and habits of opiate dependents which supports the concept that dietary intakes got better by methadone maintenance treatment. Further studies are required to clarify whether opioid -dependent patients can go on diet in longtime treatment or not.

Published: Volume 16 • Issue 4 • December 2014 (pages: 49 - 54)

Title: Motor impulsivity discriminated relapsed male heroin dependents from those who were still in buprenorphine maintenance treatment at the 12-month follow-up

Authors: Evren C., Yilmaz A., Bozkurt M., Can Y., Umut G., and Evren B.

Summary: Aims. Aim of this study was to evaluate whether impulsivity was able to discriminate relapsed male heroin dependents from those who were still in buprenorphine maintenance treatment at 12-month follow-up, while checking the effects of depression, and state and trait anxieties. Methods. Of 78 consecutively admitted male heroin dependents, 52 were examined during a face-to-face interview 12 months after discharge from hospital. Patients were investigated by applying the Barratt Impulsiveness Scale, version 11 (BIS-11), Beck Depression Inventory (BDI) and State and Trait Anxiety Inventory (STAI) at the end of 12 months. Results. Of 52 heroin-dependent inpatients, 23 (44.2%) were considered as having relapsed into heroin use during the previous twelve months, whereas 29 (55.8%) were still in the maintenance treatment. Demographic variables did not differ between the two groups. Mean scores on the impulsivity subscales (motor, attentional and non-planning) and total BIS-11 were higher in the relapsed group than in the maintenance group at follow-up. So too, depression and anxiety scores were higher in the relapsed group. Impulsivity, particularly motor impulsiveness, discriminated the relapsed group from the maintenance group, together with state anxiety. Conclusions. Although motor impulsiveness was able to discriminate the relapsed group from the maintenance group, together with state anxiety, this cross-sectional study did not evaluate the causal relationship. Despite the limitations, our results suggest that motor impulsiveness and state anxiety may be the areas to focus on in the treatment of relapsed heroin dependents.

Published: Volume 16 • Issue 4 • December 2014 (pages: 57 - 62)

Title: Evaluation and cost analysis in two groups of patients who had been randomized for toxicological monitoring

Authors: Stella L., Guida F., Nava E., Romano A., Pisanti F., Aprea E., Scala G., Crinisio A., Alfieri A., Coppola O., Leone A., and de Novellis V.

Summary: Aim: identify factors which may be responsible for variations in methadone-related deaths in Scotland. Method: computer modelling based on data from drug-related deaths in Scotland in 2012 was used to predict the most effective combination of clinical parameters (methadone dose; supervision rates and provision of buprenorphine) that may predict how to reduce methadone-related deaths. Results: doubling the proportion of patients receiving buprenorphine (from 12% to 24%) would reduce the overall death rate by 18% (from 7.58 to 6.20 deaths per thousand problem drug users ~ 82 deaths). This would cost an additional £2.52 million (£31 000 per life saved). Increasing the supervision rate for methadone from 57% to 67% would reduce the overall death rate by 0.68% (3 deaths ~ £423 000 per life saved) while increasing the average daily dose of methadone from 90 mg to 100 mg would reduce the overall death rate by 2.5% (11 deaths ~ £48 000 per life saved). Conclusion: greater use of buprenorphine products could significantly reduce methadone-related deaths.

Published: Volume 16 • Issue 4 • December 2014 (pages: 63 - 70)

Title: Deleterious effects of benzodiazepine abuse among Methadone Maintenance Treatment patients

Authors: Peles E., Schreiber S., and Adelson M.

Summary: Background: Benzodiazepines (BDZs) abuse was found to cause diverse harmful effects among MMT patients. Aims: The current report summarizes BDZ aspects with respect to sleep, depression, anxiety, retention and survival, hepatitis C, and trends of abuse during 20 years of the Adelson methadone maintenance treatment (MMT) clinic experience. Methods: We summarized several finding of our MMT patients and relevant aspects from other studies. Results: BDZ abuse was found to be associated with poor outcome that expanded to all aspects. Conclusions: Based on our 20 years cohort follow up, we found that BDZs abuse, at least in part, can be significantly reduced by behavioral methods, such as adherence to policy and procedures regulations, and staff attitude.

Published: Volume 16 • Issue 4 • December 2014 (pages: 71 - 78)

Title: Increasing importance of measuring outcomes in opioid dependence care: what matters now and in the future?

Authors: Maremmani I., Hill D., Gilman M., and Littlewood R.

Summary: Drug use represents a major public health issue in Scotland: there are more than 50000 people with opioid dependence. Specific actions have been introduced to improve services and promote recovery; these include simple treatment guidelines, protocols to allow for high dose methadone to buprenorphine transfers and non-medical prescribing. Currently used outcome measures provide a limited picture of results; these measures should be developed to improve metrics of success. Investments in opioid dependence treatment have been increasing in the last 30 years. Public health spending in England has reached a record high of almost £1 billion in 2013. The change of decision-makers in commissioning of care is increasing interest in new treatment models and outcomes to measure in opioid dependence care. Lower cost treatment pathways, including those based on mutual aid (e.g. Narcotics Anonymous (NA) and SMART Recovery) rather than medication, can be counter posed and described as important alternatives to medical therapy. The most likely outcome for treatment model success is a combination of all the tools currently employed, but it will be essential to have the outcome measures in place to guide the decisions and ensure access to the right mix of appropriate services and interventions. Review of evidence shows that there is no holistic tool for measuring outcomes in opioid dependence care. Existing tools provide measures of progress at patient level – comparison of outcomes above the patient level is needed. A consensus process was operated to test suggested metrics in a balanced score card approach to measuring such outcomes. Interesting differences in results across Europe were discovered using this tool for measuring outcomes in opioid dependence care. It remains important to progress with the measurement of outcomes in opioid dependence care and to ensure that all stakeholders from different backgrounds are able to engage in this work.

Published: Volume 17 • Issue 1 • March 2015 (pages: 5 - 16)

Title: Observational study in an outpatient clinic specializing in treating opioid- dependent pregnant women: neonatal abstinence syndrome in infants exposed to methadone-, buprenorphine- and slow-release oral morphine

Authors: Metz V.E., Comer S.D., Pribasnig A., Wuerzl J., and Fischer G.

Summary: Background: The factors determining severity and course of Neonatal Abstinence Syndrome (NAS) in infants born to opioid-dependent pregnant women are still poorly understood. Aim: To compare and evaluate Neonatal Abstinence Syndrome (NAS) in 390 infants born to opioid-dependent women undergoing comprehensive treatment during pregnancy, including methadone (n=184), buprenorphine (n=77) and slow-release oral morphine (SROM, n=129) maintenance therapy. Materials and Methods: An observational design was applied for this complete case analysis, taking into account maternal opioid dose at time of delivery, third trimester concomitant consumption of opioids, benzodiazepines and nicotine, as well as breastfeeding status. Results: The infants exposed to buprenorphine before birth had significantly lower average (p<0.001) and peak NAS scores (p<0.001), needed less morphine for their NAS treatment (p<0.001), had shorter mean durations of treatment (p<0.001) and hospital stay (p<0.001) compared with the infants exposed to methadone or SROM. No associations were found between NAS parameters and maternal opioid dose in the buprenorphine group, where concomitant consumption of benzodiazepines and opioids did not influence NAS significantly. Breastfeeding status did not influence NAS in buprenorphine-exposed neonates, in contrast to children in the methadone- or SROM-group. Conclusions: Breastfeeding proved to be especially beneficial to methadone- and SROM-exposed infants whose NAS showed significant, but weak, associations with daily maternal opioid dose. Buprenorphine seems recommendable for women who respond well to it; further research is needed for SROM administration during pregnancy. Cautious interpretation of the results is warranted, because of the individually tailored treatment and subsequent non-random medication group assignment.

Published: Volume 17 • Issue 1 • March 2015 (pages: 17 - 22)

Title: Methadone deaths in Scotland

Authors: Nikolaou V., and Luty J.

Summary: Aim: identify factors which may be responsible for variations in methadone-related deaths in Scotland. Method: computer modelling based on data from drug-related deaths in Scotland in 2012 was used to predict the most effective combination of clinical parameters (methadone dose; supervision rates and provision of buprenorphine) that may predict how to reduce methadone-related deaths. Results: doubling the proportion of patients receiving buprenorphine (from 12% to 24%) would reduce the overall death rate by 18% (from 7.58 to 6.20 deaths per thousand problem drug users ~ 82 deaths). This would cost an additional £2.52 million (£31 000 per life saved). Increasing the supervision rate for methadone from 57% to 67% would reduce the overall death rate by 0.68% (3 deaths ~ £423 000 per life saved) while increasing the average daily dose of methadone from 90 mg to 100 mg would reduce the overall death rate by 2.5% (11 deaths ~ £48 000 per life saved). Conclusion: greater use of buprenorphine products could significantly reduce methadone-related deaths.

Published: Volume 17 • Issue 1 • March 2015 (pages: 23 - 32)

Title: Psychological needs of men under MMT- A mixed method study

Authors: Jalali A., Hassanpuor-Dehkordi A., Mahvar T., Moradi M., and Dinmohammadi M.

Summary: Background Psychosocial needs of participants in methadone maintenance treatment method are considered as an important issue in the healing process. Aim Therefore, this study was designed and performed with the aim to determine psychosocial needs of men undergoing Methadone therapy. Materials & Methods It was a simultaneous mixed method study. In the qualitative part of the study, using snowball sampling method, 19 male clients interested to participate in the study with at least one month methadone therapy were selected and in-depth, semi-structured individual and face to face interviews were conducted. In the quantitative part, a descriptive study was conducted and 136 male clients from 12 substance abuse treatment clinics in the city of Kermanshah were selected by convenience sampling method and analyzed using Basic needs satisfaction scale. The content analysis method was used to analyze qualitative data, while quantitative data was analyzed by SPSS v.18 software. Results The qualitative results were obtained in 15 subtheme and 5 main themes. The main categories included the need for support, the need for tranquility, fear of ostracism, deficiency in self-esteem and vague self-image. The quantitative results indicated a low sense of self-determination, competence, and dependence in clients that such results were consistent with the qualitative results. Conclusions The results showed that drug-using participants need family and community supports during treatment in order to cover their psychosocial needs.

Published: Volume 17 • Issue 1 • March 2015 (pages: 33 - 42)

Title: Prescription opioids (substitution medications and pain medications) in patients looking for Opioid Agonist Treatment in Northern and Southern Italy, using a 18-month survey methodology

Authors: Maremmani I., Guareschi M., Deruvo G., Somaini L., Maremmani A.G.I., Green J., McBride K., and Dart R.C.

Summary: Background: In many countries, the broad availability of prescription pain medications (PPMs) and prescription substitution medications (PSMs), coupled with public misconceptions about their safety and addictive potential, have contributed to the recent surge in the non-medical use of prescription opioids (POs), and corresponding increases in treatment admissions for problems related to opioid misuse. This Italian study has aimed to assess the prevalence of the primary substance of abuse, the differences between heroin use and the use of POs in the previous month and the prevalence of combined use (heroin, PSMs and PPMs), while stressing the geographical differences between Northern and Southern Italy. Methods: This has been a cross-sectional, observational study. The data were collected prospectively, over an 18-month period in 2012 e 2013. The Survey Questionnaire on Opioids was administered during an 18-month survey to all patients entering Opioid Agonist Treatment (OAT) in two National Health Drug Addiction Units – the first in Northern and the second in Southern Italy. Results: 317 subjects requested OAT at Drug Addiction Units in the cities of Cossato and Bitonto, in Southern and in Northern Italy, respectively. Heroin was named most frequently as the primary substance of abuse, followed by PSMs (buprenorphine and methadone). Heroin was the substance most used in the previous 30 days, followed by PSMs. About half of the patients were only using heroin, approximately a quarter PSMs only, 15% heroin and PSMs together, and 10% PPMs only. Northern Italian patients were characterized by the combined use of heroin and PSMs (OR=0.025), but also by using PPMs – in order of importance, codeine (OR=0.008), oxycodone (OR=0.011), and tramadol (OR=0.013) – as their primary substance of abuse. Conclusions: In Italy, in patients requesting OAT, the most frequent primary substance of abuse and the most frequently used substance in the previous 30 days is still heroin. As in many other countries, however, the use of POs is increasing, especially if we consider the combined use of heroin and PSMs. In Italy, the dreaded transition from PPMs to heroin still seems almost non-existent, and is just beginning to appear, but only in Northern Italy.

Published: Volume 17 • Issue 1 • March 2015 (pages: 43 - 50)

Title: Economic Evaluation of Suboxone® for substitution treatment of opioid drug dependence in Portugal

Authors: Gouveia M., Sousa R., Costa J., and Borges M.

Summary: Background: According to a recent Portuguese study the prevalence of lifetime consumption of heroin in the global population (between15 and 74 years) is 0,5%. Methadone is the standard pharmacological treatment and buprenorphine is available since 1999 as an alternative treatment. Nevertheless, no economic evaluation comparing the cost-effectiveness of these therapies is available at this point. Aim: This study estimates the cost-effectiveness and cost-utility of a fixed dose combination of buprenorphine-naloxone (B/N) versus methadone as substitution treatments for opioid drug dependence from the Portuguese social perspective. Material and Methods: The comparator was methadone, corresponding to the most common pharmacological strategy and current clinical practice in Portugal. Health gains were measured using the number of heroin-free days per year (indicator of effectiveness) and quality-adjusted life years (QALY) associated with each treatment. Estimated costs included acquisition, preparation and transport of medication; costs of dispensing and supervision of administration; costs with periodic monitoring of patients and non-medical direct costs of crime. Results: B/N combination is associated with an incremental cost-utility ratio of €5,914 per QALY gained. B/N combination is dominant when the analysis includes costs of crime associated with drug addiction. Conclusions: The results suggest that B/N combination is cost-effective and has the potential to generate health gains in the target population at low cost.

Published: Volume 17 • Issue 1 • March 2015 (pages: 51 - 64)

Title: Experts beliefs on suicide among illicit drug users

Authors: Lovrecic M., Lovrecic B., and Dernovsek M.Z.

Summary: Background and aims: Both data and studies have documented high rates of suicide in Slovenia. More specifically, suicide accounts for a considerable share of premature deaths in illicit drug users, where heroin addicts predominate. The analysis of national data on suicide among illicit drug users in Slovenia revealed several differences in suicide behaviours between the general population and the illicit drug user population. The aim of this study has been to find out the opinions of a group of psychiatrists about the calculated results and the indicators used in analysis. Methods: The national data on suicide among illicit drug users were analysed and presented to a focus group. Focus group methodology was used. Results: The psychiatrists in the group showed little awareness of Slovenian data on suicide and of the differences between data that refer to the general population and those referring to the illicit drug use population. Conclusions: Those psychiatrists expressed interest in being updated on the periodic analysis of these data and indicators, so that they would be able to use them in everyday clinical practice. Specific suicide prevention programmes tailored to the needs of illicit drug users, especially heroin addicts, should be developed after reviewing the results of both quantitative and qualitative research.

Published: Volume 17 • Issue 1 • March 2015 (pages: 65 - 72)

Title: Prospective pathways between heroin use and nonmedical use of prescription opioids: Trajectories among young Swiss men

Authors: Baggio S., Iglesias K., Fournier N., Studer J., N'Goran A., Deline S., Mohler-Kuo M., and Gmel G.

Summary: Background. So far few studies have focused on the last steps of drug-use trajectories. Heroin has been described as a final stage, but the non-medical use of prescription opioids (NMUPOs) is often associated with heroin use. There is, however, no consensus yet about which one precedes the other. Aims. The objective of this study was to test which of these two substances was likely to be induced by the other using a prospective design. Material and methods. We used data from the Swiss Longitudinal Cohort Study on Substance Use Risk Factors (C-SURF) to assess exposure to heroin and NMUPO at two times points (N = 5,041). Cross-lagged panel models provided evidence regarding prospective pathways between heroin and NMUPOs. Power analyses provided evidence about significance and clinical relevance. Results. Results showed that heroin use predicted later NMUPO use (β = 1.217, p < 0.001) and that the reverse pathway was non-significant (β = 0.240, p = .233). Heroin use seems to be an important determinant, causing a 150% risk increase for NMUPO use at follow-up, whereas NMUPO use at baseline increases the risk of heroin use at follow-up by a mere non-significant 20%. Conclusions. Thus, heroin users were more likely to move to NMUPOs than non-heroin users, whereas NMUPO users were not likely to move to heroin use. The pathway of substance use seemed to include first heroin use, then NMUPO use.

Published: Volume 17 • Issue 1 • March 2015 (pages: 73 - 78)

Title: Consequences of cardiac toxicity in patients on low methadone doses during methadone maintenance treatment

Authors: Mijatovic V., Samojlik I., Petkovic S., Uvelin A., Dickov A., Popov T., and Pejakovic J.

Summary: Background. Methadone has been extensively studied and prescribed worldwide in the methadone maintenance treatment (MMT) of opiate addicts. However, methadone-induced prolongation of the corrected QT (QTc) interval has been reported, and it could be associated with torsades de pointes (TdP). In cases of more persistent TdP, ventricular fibrillation leading to cardiac arrest and sudden death could develop. Aim. We report the consequences of cardiac toxicity in two patients who were receiving low doses of methadone (≤ 60 mg), along with diazepam as the main adjunctive therapy. Surprisingly, one patient developed malignant arrhythmia and the other one died at the very start of MMT. Case Presentations. A 28-year-old male died at the very start of MMT while receiving low doses of methadone (30 mg/day), diazepam (30 mg) and clozapine (25 mg). The forensic pathologist who reported his death classified it as being methadone-related, with signs of acute lung oedema of cardiac origin and myocardial changes. A 37-year-old male on a low methadone dose (60 mg/day) and diazepam (30 mg) developed significant QTc prolongation and malignant arrhythmia during triple antibiotic therapy (gentamicin, ceftriaxone, metronidazole) of phlegmon of the lower limb. After treatment at the Intensive Care Unit and the discontinuation of methadone and diazepam, a regular cardiac function was restored. Conclusions. It is highly advisable for health care professionals to be cautious in prescribing benzodiazepines and other drugs, even when patients are on low MMT doses. Significant QTc prolongation, followed by the development of potentially fatal arrhythmia in opiate addicts on low-dose MMT is more likely to occur when several concomitant factors are acting simultaneously.

Published: Volume 17 • Issue 1 • March 2015 (pages: 79 - 90)

Title: Outcomes of buprenorphine-naloxone maintenance therapy: One-year follow up study from Turkey

Authors: Mutlu E., and Bilici R.

Summary: This study examined the outcome and predictors of the effectiveness of outpatient buprenorphine/naloxone treatment, a combination used in the treatment of opioid dependence (OD) that has recently become available in Turkey. 76 patients on opioid maintenance treatment were recruited from an OD treatment programme at the substance dependence treatment clinic (AMATEM) in Istanbul. At the end of the first year, 56.6% of patients were still in treatment and were not using heroin or other opioids. Individuals participating in the psychotherapy programme were found to benefit significantly more from treatment than individuals who were not. Having higher income and having no relatives with substance abuse problems were factors associated with more positive outcomes. Participants who had legal problems related to substance use and who had polysubstance use also had better treatment outcomes than patients who did not. These results support the effectiveness of buprenorphine/naloxone maintenance therapy in a Turkish population. The authors believe that the effectiveness of pharmacological treatment would increase further through the addition of a comprehensive approach including psychosocial support. This study is one of the first studies that has investigated the effectiveness of opioid dependence treatment in Turkey, as the medication has only become available very recently, and the data obtained by us reflect the earliest results.

Published: Volume 17 • Issue 1 • March 2015 (pages: 91 - 98)

Title: Subjective quality of life in drug addicted patients: A cross-treatment comparison

Authors: Ambroziak A.

Summary: Background: Previous research focused on indicating success rate of treatment in terms of withdrawal from addictive behavior. Patients' subjective experience was omitted. This study examines the relationship between treatment types and subjectively perceived quality of life (QoL). Methods: A total of 115 drug addicted persons voluntarily participated in the study. Experimental groups were recruited from clinics providing: individual out-patient treatment – IOT (n = 28); group out-patient treatment – GOT (n = 24); group in-patient treatment – GIT (n = 31). Control group – C (n = 32) was recruited from shelters for active drug users not receiving treatment. QoL was assessed with: Beck (1988) Hopelessness Scale; Cantril's (1965) Ladder; and Czapinski's (2005) tools measuring QoL. Sense of coherence was assessed with Antonovsky's Sense of Coherence Questionnaire SOC-29. Between-group differences in QoL and coherence were analyzed using ANCOVA with Scheffe post hoc comparisons. Results: Self-rating of QoL in treatment groups was significantly higher (p < 0.05) than in controls. Between-treatment comparisons showed that GOT had significantly higher will to live (p = 0.015) and satisfaction with life (p = 0.002) than IOT participants. GOT also showed significantly higher sense of controllability (p = 0.022) than GIT. Conclusions: Participants of all analyzed types of drug addiction treatment had higher subjective QoL than active drug users. However, group out-patient treatment participants showed the greatest will and satisfaction of life, as well as sense of controllability.

Published: Volume 17 • Issue 2-3 • June 2015 (pages: 5 - 8)

Title: Controversy or misunderstanding?

Authors: Maremmani I.

Summary: No summary

Published: Volume 17 • Issue 2-3 • June 2015 (pages: 9 - 16)

Title: The Level of Readiness for HCV treatment among infected drug users at the centre for prevention and treatment of drug addicts in Celje, Slovenia

Authors: Gabrovec B.

Summary: Introduction: Drug users, especially intravenous drug users, are those who experience the highest risk of HCV and HIV infection. A high prevalence of hepatitis C (HCV) has been observed among drug users; however, the number of users who decide to enter treatment remains low. Aims: The goal of the present study has been to establish the prevalence of HCV among drug users receiving OST (Opioid Substitution Therapy), while collecting drug users' thoughts on the matter, as well as their awareness and knowledge of HCV. Results: The results show a high prevalence of HCV (45%) and a lack of knowledge about HCV infection and treatment among drug users receiving OST, which is a result of the unavailability of relevant information. Conclusion: A systematic approach to raising awareness and enhancing the provision of information about HCV infection and treatment to patients receiving OST is now required.

Published: Volume 17 • Issue 2-3 • June 2015 (pages: 17 - 24)

Title: Psychopathological symptoms in detoxified and non-detoxified heroin-dependent patients entering residential treatment

Authors: Pani P.P., Maremmani A.G.I., Trogu E., Vigna-Taglianti F., Mathis F., Diecidue R., Kirchmayer U., Amato L., Davoli M., Ghibaudi J., Composeragna A., Saponaro A., Faggiano F., and Maremmani I.

Summary: Background: In a previous study, by evaluating patients entering an Outpatient Agonist Treatment, or a residential Therapeutic Community, through the use of SCL-90, a 5-factor solution was identified: a depressive 'worthlessness and being trapped' dimension, a 'somatization' dimension, a 'sensitivity-psychoticism' dimension, a 'panic anxiety' dimension, and a 'violence-suicide' dimension. Aim of the present study is to compare these dimensions between heroin-addicted patients that have already been detoxified (DTX) and those not yet detoxified (NDTX) from heroin at the time of entering a Therapeutic Community Treatment. Methods: The demographic and clinical variables of NDTX patients and DTX patients were first compared; all patients were then assigned to the appropriate SCL-90-based dimension among the five just identified ones. Differences in psychopathological dimensions were analysed at univariate and multivariate level. Results: Out of 1,015 subjects included in the study, 374 (36.8%) were DTX patients, while 641 (63.2%) were NDTX patients. Distribution of demographic and heroin addiction history variables between NDTX and DTX heroin-addicted patients at residential treatment entry were very similar. In the univariate analysis, the SCL-90 total score and all the SCL-90 factors showed higher statistical significance in NDTX than in DTX patients. In the discriminant analysis, severity of ‘somatic symptoms' was the factor differentiating NDTX from DTX-patients, with 64.4% of the originally grouped cases shown to be correctly classified. Differences in qualities of psychopathological symptoms between NDTX and DTX patients were found regarding ‘somatic symptoms' ‘sensitivity psychoticism' and ‘panic anxiety', the last two features being better represented in DTX patients. Conclusions: All the five aggregations of symptoms resulting from the application of Principal Component Analysis to the SCL-90 of opioid addicts were present in subjects actively involved with opioids as well as already detoxified ones. Although the severity of psychiatric damage was lower in the DTX than in the NDTX patients, the only dimension that successfully discriminated between the two groups of patients was that of ‘somatic symptoms'.

Published: Volume 17 • Issue 2-3 • June 2015 (pages: 25 - 34)

Title: The extent of misuse and diversion of medication for opioid substitution treatment: a review and expert opinions

Authors: Alho H., D'Agnone O., Krajci P., McKeganey N., Maremmani I., Reimer J., Roncero C., Somaini L., Wright N., and Littlewood R.

Summary: Introduction: Opioid dependence is a major global problem associated with negative health, social and economic outcomes. Opioid Substitution Treatment (OST) is the prescription of opioid-containing medicines as a substitution for illicit opioid drugs. OST, as an intervention for opioid dependence, reduces illicit drug use and is proven to improve outcomes by preventing harm and mortality. Provision of access to OST is associated with the misuse and diversion of opioid-containing medications. This misuse and diversion is a serious public health problem; it results in worsening outcomes with an increased risk to the individual's health, a lack of progression in recovery and an increase in criminal activity. Aim: The aim of this paper is to describe the extent of misuse and diversion of OST medication. Methods: An assessment of the scale of the problem was made based on a defined process including analysis of evidence from a systematic review of published literature and experts' practice. Results: Results describe rates of misuse of OST medication ranging from 18 to 81%; diversion occurs in 23 to 39% of cases. Misuse and diversion of OST is common and is associated with negative outcomes for individuals and society. Conclusion: Greater understanding of the extent and impact of misuse and diversion will assist in the development of strategies to reduce this problem and its significant consequences. As part of ensuring appropriate care for those with opioid dependence, addressing misuse and diversion must be considered an important priority.

Published: Volume 17 • Issue 2-3 • June 2015 (pages: 35 - 44)

Title: Neonatal abstinence syndrome after intrauterine opioid exposure: Standards, cost-effectiveness of treatment and maternal rights

Authors: Brandt L., Fischberger S., Unger A., Jagsch R., Moser L., and Fischer G.

Summary: Background: Multiple studies have confirmed the superiority of opioid maintenance therapy (OMT) during pregnancy, with buprenorphine giving better results than methadone in limiting neonatal abstinence syndrome (NAS) severity and treatment length. While the presence of the mother, in addition to pharmacological treatment, has a proven alleviating effect on neonates' withdrawal symptoms, joint admission perinatally is hardly possible in most countries. Methods: A prospective, standardized, observational study design was used to assess the effects of OMT on maternal and neonatal outcomes, together with NAS duration and severity, including supervised urinalysis. Sixty-eight mothers [of whom 39 were maintained on methadone (mean daily dose at delivery: 58.62 mg); 29 on buprenorphine (9.60 mg)] in multidisciplinary treatment, and their neonates were analysed. NAS was assessed by applying a modified Finnegan scale, and was treated with morphine solution. Results: For both groups mean gestational age at delivery was 39 weeks, with a mean birth weight of 2,967 g. Exposure to buprenorphine, when compared with exposure to methadone, yielded a significantly lower neonatal morphine dose (mean total dose 8.65 mg vs. 22.80 mg, p=0.008) and NAS treatment length (12.38 vs. 18.86 days, p=0.040), with no correlation between mean OMT dose and NAS severity. However, no significant difference in neonatal hospital stay occurred (19.23 vs. 23.43 days; p=0.241); intrauterine buprenorphine-exposed neonates were hospitalized for an average of seven additional days after the completion of NAS treatment. Conclusions: By now high quality standards of care for OMT during pregnancy have been successfully established; even so, considerable improvements in postnatal care are still required, partly to reduce the heavy economic burden due to prolonged hospitalization.

Published: Volume 17 • Issue 2-3 • June 2015 (pages: 45 - 50)

Title: Psychometric evaluation of the Slovenian translation of the Circumstances, Motivation and Readiness Scales

Authors: Delić M., Kajdiž K., Melnick G., and Pregelj P.

Summary: Background: According to the available data, treatment motivation and readiness are closely linked to retention. There are instruments for measuring the stages of motivation and readiness, and predicting treatment retention and outcome. Aim: This study describes psychometric properties, while focusing on the reliability of the Slovenian version of the Circumstances, Motivation and Readiness (CMR) scales. Methods: We included 109 male and female patients with opioid addiction at the Centre for Treatment of Drug Addiction, Ljubljana. The CMR was translated into Slovenian by using the 'forward-backward' procedure by our team and its author. Data analysis addressed psychometric properties of the CMR. Internal consistency was examined by applying exploratory and confirmatory factor analysis, while reliability was examined with Cronbach's coefficient alpha. Results: Cronbach alpha coefficients of reliability were calculated for each of the three CMR subscales and for the total score. The total alpha was 0.842. Alpha for Motivation was 0.860, for Circumstances 0.372 and for Readiness 0.818. Exploratory factor analysis extracted a 3-factor solution with 56% explained total variance. The factors do not provide an exact match with the dimensions C, M and R. Conclusion: On the basis of these results we can conclude that the Slovenian translation of the CMR is a valid instrument for evaluating patients' motivation and readiness for treatment.

Published: Volume 17 • Issue 2-3 • June 2015 (pages: 51 - 58)

Title: Psychosocially assisted pharmacological treatment of opioid dependence – treatment practice and political regime in Germany

Authors: Deimel D., and Stover H.

Summary: Background: Since its introduction in Germany, agonist opioid treatment (AOT) has been deemed an established type of therapy for the treatment of opioid dependence. In this connection, psychosocial services are both a recognized and an obligatory component of AOT. This type of care, which is mainly provided by clinical social workers, is being provided in very heterogeneous settings and in accordance with diverse standards. In addition, it is still not based on strong scientific evidence. Methods: Our analysis included the exploration of the political regime, as well as the different practices of psychosocial care for substituted opioid-dependent patients in Germany. On the basis of this exploration, we have put forward suggestions to help further develop this treatment approach. Results: We note sharp differences between the guidelines for AOT laid down by the WHO and treatment practices in Germany. This was particularly evident with regard to the provisional regional structure, funding of psychosocial services, and the situation of imprisoned opioid-dependent individuals, as well as the conceptual focus set by providers of psychosocial services. Conclusion: Compared with other European countries, the drug policy regimen established in Germany constitutes a novelty with regard to the AOT of opioid-dependent persons. What is now urgently required is to further develop existing conceptions and practices. In addition, readjustments should be implemented by taking into consideration differences in the needs of patients and in regional care practices. Also, a stronger orientation towards scientific evidence is crucial. Further, it is critical to place the current drug policy regimen on a new footing.

Published: Volume 17 • Issue 2-3 • June 2015 (pages: 59 - 62)

Title: Is Agonist Opioid Treatment (AOT) best done by GPs or in a specialized setting?

Authors: Haraldsen M.

Summary: Not available

Published: Volume 17 • Issue 4 • August 2015 (pages: 5 - 8)

Title: Towards the future of the treatment of heroin addiction. New challenges/issues to be addressed

Authors: Maremmani I., and Maremmani A.G.I.

Summary: Not available

Published: Volume 17 • Issue 4 • August 2015 (pages: 9 - 68)

Title: Antagonist Opioid Medications in Mental Illness: State of Art and Future Perspectives

Authors: Maremmani I., Rovai L., Maremmani A.G.I., Bacciardi S., Rugani F., Massimetti E., Gazzarrini D., Pallucchini A., and Janiri L.

Summary: Introduction: The involvement of the opioidergic system in the pathogenesis of various addictive and non-addictive disorders has led to a renewed interest in expanding the clinical uses of opioid antagonists. Aim: To critically discuss the question whether opioid antagonists can be used in the management of psychiatric diseases, in association with, or as offering an alternative to, standard pharmacotherapy. Methods: To review past and current literature on the action displayed by opioid antagonists on a wide range of psychiatric diseases, while taking into account standard pharmacotherapy for the same psychiatric diseases. To compare the risk-benefit ratio of opioid antagonists with that of medications traditionally used in the same diseases. Results: Opioid antagonists should be considered a possible treatment choice in all those pathological behaviours that share an instinctive or impulsive nature. Such behaviours are both innate (sexual, aggressive, feeding) and acquired (drug-seeking, gambling), depending on the nature of the rewarding stimulus that reinforced them. On the other hand, opioid antagonists should be excluded from the treatment of all the external or internal conditions experienced by patients as punishing and ego-dystonic (as leading to anxiety, depression, obsessive thoughts). Conclusions: Opioid antagonists have proved to be suitable tools for the treatment of a wide range of addictive and non-addictive psychiatric diseases. In the specific case of the addictive diseases, they can be used to treat patients suffering from alcohol, cocaine, and cannabis use disorders, but also from pathological gambling, and to reverse potentially fatal opiate-related overdoses. In all forms of non-addictive diseases they can be used in the management of a first pure manic episode, negative symptoms of schizophrenia, self-injuring, some kinds of aggressiveness, autism, bulimia nervosa and binge eating disorder, when appropriate in association with standard pharmacotherapies.

Published: Volume 17 • Issue 4 • August 2015 (pages: 69 - 76)

Title: The prevalence of methamphetamine, MDMA and new drugs among opiate addicts on Agonist Opioid Treatment

Authors: Gabrovec B.

Summary: Introduction: Opiate addicts receiving Agonist Opioid Treatment (AOT) usually decide to join the treatment programme as a positive response to their opioid addiction. Aims: The purpose of this study has been to evaluate the prevalence of other types of illicit drug use among opiate addicts who had previously been included in an Agonist Opioid Treatment (AOT) programme. Methods: This investigation has focused mainly on the following illicit drugs: methamphetamine, MDMA (ecstasy) and designer drugs, while excluding heroin, cocaine and THC. It explores the use of a group of substances that are poorly known, in a cohort of heroin addicts in agonist opioid maintenance. In addition, we have tested a number of hypotheses by comparing outpatients belonging to various age-groups visiting different AOT programme centres. Results: According to our results, the use of these types of illicit drugs is not common among opiate addicts receiving Agonist Opioid Treatment (AOT) in Slovenia (such illicit drugs are only consumed by users to a minimum extent). Further, opiate addicts rarely decide to use these types of drugs to get intoxicated, and any such decision would only be likely if they were unable to obtain drugs such as heroin and cocaine. Conclusion: At present, drugs such as methamphetamine (crystal meth), MDMA/ecstasy and new drugs, such as synthetic or designer drugs: synthetic cannabinoids, mephedrone, 3MMC – meth ice, methylone), are not widely used by opiate addicts on AOT in Slovenia, despite their increasing availability on the black market.

Published: Volume 17 • Issue 4 • August 2015 (pages: 77 - 84)

Title: Suicide by narcotic poisoning in Slovenia, according to gender, during the period 2004-2007

Authors: Lovrecic M., Lovrecic B., Selb Semerl J., and Maremmani I.

Summary: Background. Suicide is a serious public health problem in Slovenia. Illicit drug users are in greater danger than the general population. There are several differences in ways of committing suicide that set the illicit drug population apart from the general population. This study has aimed to compare the external causes of death by suicide (specifying the methods used), and to compare narcotic with non-narcotic overdoses among illicit drug users according to gender in the 2004-2007 period in Slovenia. Methods. Information on the subjects was made available by linking the records kept in three national data sources. Results. More than half of these suicide victims had died because of an overdose; more precisely, overdose by prescription drugs was predominant. In more than half of the cases of suicide committed by males, death was due to an indirect, external cause, whereas in more than half of the cases of suicide committed by females, death was due to an overdose. No other gender differences were found. Females tend to be unregistered by agonist opioid treatment centres. Conclusions. The most common method of suicide was overdose for both genders, with females at greater risk than males. Caution in prescription practice is needed, especially when treating female patients.

Published: Volume 17 • Issue 5 • October 2015 (pages: 5 - 12)

Title: Gender Differences in Opioid Maintenance Treatment

Authors: Schoofs N., Wiers C., Bald L.K., Bermpohl F., and Gutwinski S.

Summary: Background: Despite the fact that about a third of the patients receiving opioid maintenance treatment (OMT) are women, little is known about gender differences regarding OMT in chronically affected opioid-dependent patients. Aim: The aim of the survey has been to explore gender aspects of OMT in a naturalistic, representative sample of chronic opioid dependence patients receiving OMT. Our investigation has focused on the profile of OMT, clinical characteristics of the dependence, the socioeconomic and health status of patients. Methods: We performed a regionwide survey of subjects with opioid dependence in Berlin, Germany. In the survey, 986 subjects (260 of them female) took part, comprising 19.6% of all registered patients in OMT in Berlin. 52.2% of the participants were below and 47.8% above 40 years old. Results: Women were significantly more often treated with levomethadone (p=0.028) and had been longer in OMT (p<0.001) than men. The duration of the opioid dependence did not differ between genders, and no significant difference in prescribed OMT dosages was found. The number of detoxification treatments did not differ between men and women. Concerning concomitant use, we found that current concomitant use of illegal substances was more frequent in men (p< 0.05), specifically for cannabis (p<0.001) and alcohol (p<.05). Focusing on the issue of health status, we found no gender differences in the prevalence of infectious diseases. Men showed significantly higher rates of lifetime prevalence of imprisonment than women (p<0.001). Conclusion: We conclude that there are substantial gender differences in OMT, above all, in the choice of type of medication and the duration of OMT.

Published: Volume 17 • Issue 5 • October 2015 (pages: 13 - 18)

Title: Optimising Service Provision for Prescribed Opioid Analgesic Dependence

Authors: Marr E., and Hill D.

Summary: We share our experience of treating a patient with inadvertent co-codamol and tramadol dependency after treatment for dental pain and question the current Substance Misuse Service model that does not distinguish iatrogenic opioid dependency from illicit opioid use disorder. We suggest the appropriateness of a comprehensive primary-care-led treatment service tailored for opioid analgesic dependent (OAD) patients rather than a classic addiction service.

Published: Volume 17 • Issue 5 • October 2015 (pages: 19 - 26)

Title: Overdose Risk Perceptions and Experience of Overdose among Heroin Users in Cork, Ireland. Preliminary Results from a Pilot Overdose Prevention Study

Authors: Horan A.J., Deasy C., Henry K., O Brien D., and Van Hout M.C.

Summary: Background. Opioid overdose is the primary cause of death among injecting drug users (IDU). Overdose is generally not sudden, occurs over one to three hours, and often in the presence of bystanders. This presents a unique window of opportunity to intervene. Aim. Successful overdose prevention training includes appropriate clinical and non-clinical responses. The study aimed to investigate Irish IDU experience of overdose, and need for education and resuscitation skills programming. We report on pilot findings. Methods. Phase One assessed service user experience of overdose, substances used, setting for overdose, and awareness of appropriate non-clinical responses (n=52). Phase two implemented an educational intervention at two Cork addiction service sites. This involved assessing service user awareness of appropriate non-clinical methods to manage overdose and their interest in receiving resuscitation training (n=26). Phase three piloted a resuscitation skills training intervention for staff, family and IDU consisting of instruction on how to recognise and prevent overdose, appropriate response techniques; rescue breathing, and calling emergency services (n=26). Results. The findings illustrated the majority had experienced overdose, described the main substances involved, the settings, the responses employed, and the perceptions of risk. The need for education equipping IDU with overdose prevention and management skills was identified. Awareness of appropriate responses (correct emergency numbers, recovery and resuscitation skills) improved following the educational and skills training interventions. Conclusions. Continued efforts in Ireland to integrate culturally specific overdose prevention into agonist opioid treatment services, prison discharge, homeless primary health and needle and syringe exchange are warranted.

Published: Volume 17 • Issue 5 • October 2015 (pages: 27 - 42)

Title: Opioid Agonist Maintenance Treatment: A Short Guide for Beginners

Authors: Trogu E.

Summary: Opioid dependence is a health issue of worldwide concern. There are estimated to be 15 million users, 11 million of which heroin users. Only a limited percentage of patients with drug dependence is prescribed maintenance therapy. A proportion of patients shows a limited response to treatments, in addition to intolerance or unacceptable side effects. The complexity of the disorder has led researchers to investigate other drugs capable of carrying out a substitutive function. This article focuses on the pharmacological characteristics of the clinical significance of methadone, of the isomer R-methadone, of buprenorphine (with and without naloxone), of slow-release oral morphine.

Published: Volume 17 • Issue 5 • October 2015 (pages: 43 - 50)

Title: Misuse and Diversion of Opioid Agonist Opioid Treatment Medicines: Assessment of the Scale of the Problem and Review of the Changing Environment for Care in the Nordic Countries

Authors: Alho H., Jansen J., Krajci P., Littlewood R., Rúnarsdóttir V., and Nyberg F.

Summary: Background: Opioid addiction is effectively treated via a multidisciplinary approach including agonist opioid treatment (AOT) and psychosocial intervention. Misuse and diversion of AOT medicines such as methadone and mono-buprenorphine comprise a significant problem occurring in the Nordic countries with some of the highest frequencies in Europe. Misuse and diversion are associated with poor treatment compliance and increases in risk of blood-borne infections, crime, and mortality. Regulations and guidelines for provision of AOT medication vary among the Nordic countries. Aim: The extent and impact of misuse and diversion in the Nordic countries has not been documented in the literature. This review of local sources summarizes the extent and impact of misuse and diversion of AOT medication to provide a basis for improving outcomes in opioid addiction care. Methods: PubMed was searched using the terms “methadone” or “buprenorphine” and “misuse” or “diversion”. Titles and abstracts of search results were inspected for location and relevance. Government sources and mainstream media were also searched for relevant reports. Results: Misuse and diversion of AOT medicines is a significant issue in the Nordic countries; these opioids are available outside of treatment and are misused, including by young addicts. To address this problem, changes in medicines used in treatment in Finland and Iceland have already been implemented and considerations are under way in Norway and Sweden. Conclusions: All persons involved in AOT should take action to better understand AOT medication misuse and diversion as this can lead to a step change improvement in outcomes.

Published: Volume 17 • Issue 5 • October 2015 (pages: 51 - 60)

Title: An Inventory for Assessing the Behavioural Covariates of Craving in Heroin Substance Use Disorder. Development, Theoretical De-Scription, Reliability, Exploratory Factor Analysis and Preliminary Construct Validity

Authors: Maremmani A.G.I., Rovai L., Bacciardi S., Massimetti E., Gazzarrini D., Rugani F., Pallucchini A., Piz L., and Maremmani I.

Summary: Introduction: No room is currently being allocated in the literature to correlations between patients' craving for heroin and their actual addictive behaviours, due to the fact that research is focused instead on risk behaviours leading to infectious diseases and the risks being incurred through overdoses. Methods: An expert panel open to rehabilitated patients built an inventory to assess craving behaviours in heroin use disorder patients. We administered it to a sample of 114 ‘typical respondents', with the aim of testing the value of the various items in the inventory in demonstrating their discriminative effect, their reliability, and the existence of behavioural clusters. We tested the sensitivity of our inventory (its preliminary construct validity) by comparing groups each of which could be expected to be prone to a different type of craving. Results: The inventory demonstrated good internal consistency (reliability) across the sample. This high level of internal consistency suggests that the items measure the craving construct. Preliminary split-test data showed acceptable agreement for the subset of items examined. Preliminary construct validity was established through significant association in the expected direction observed for the utilized variables in identifying the modalities of heroin use. Preliminary factor analysis suggests that this inventory is unidimensional. Conclusions: The inventory appears to qualify as a tool that may be able to evaluate craving in patients with heroin use disorder through their addictive behaviours.

Published: Volume 17 • Issue 6 • December 2015 (pages: 5 - 8)

Title: The Finger and the Moon. Alarming reactions to the opioid overdose alarm

Authors: Pacini M., and Maremmani I.

Summary: Not available

Published: Volume 17 • Issue 6 • December 2015 (pages: 9 - 16)

Title: Towards a specific psychopathology of heroin addiction. Comparison between Heroin Use Disorder and Major Depression patients.

Authors: Maremmani A.G.I., Cerniglia L., Cimino S., Bacciardi S., Rovai L., Rugani F., Massimetti E., Gazzarrini D., Pallucchini A., Pani P.P., Akiskal H.H., and Maremmani I.

Summary: Introduction: It is our conviction that mood, anxiety and impulse-control dysregulation, lie at the psychopathological core of the Addictions. In this vision, we are confident that Heroin Use Disorder (HUD) has a specific psychopathology when compared with other mental disorders. Methods: We compared 972 HUD patients with 504 Major Depression (MD) patients on the basis of five SCL-90 dimensions that had previously been identified in HUD patients, with the purpose of estimating the magnitude of the differences, in terms of psychopathological symptoms. Results: Prominent psychopathological domains are more frequent in HUD patients, in particular, “worthlessness and being trapped”, “somatic-symptoms” and “sensitivity psychoticism”. The “violence-suicide” dimension is more frequent in MD patients, while the “panic anxiety” dimension fails to differentiate between the two groups. The prominent psychopathological groups are the most important factor in significantly differentiating between the two groups, when drawing comparisons on the basis of age, male gender and the severity of psychopathological symptoms. Conclusions: Our results suggest that the five found psychopathological dimensions seem to confirm the trait, instead of the state, nature of our proposed psychopathology of heroin addiction. In any case, the psychopathological symptoms of HUD and MD patients seem to differ quantitatively and qualitatively.

Published: Volume 17 • Issue 6 • December 2015 (pages: 17 - 22)

Title: Case series of heroin induced non-cardiac pulmonary edema

Authors: Arslan E.D., Büyükcam F., Avcı S., Genç S., Demir Ö.F., Usul E., Birgi E., Aydın M., and Özkan S.

Summary: Background. Heroin usage is a significant health care problem in many countries. It can cause altered mental status, and even induce respiratory depression. Respiratory manifestations are generally caused by exacerbation, pulmonary oedema and respiratory distress. In this study we report eleven cases of patients that were admitted to an emergency department with dyspnoea in a ten-month period. Methods. The age, gender, past medical history, laboratory results and radiological images were collected retrospectively. Results. The median age of the patients was 27 (range: 21-70). Naloxone was administered to three of the patients because of respiratory depression. Mean WBC count was 20136±8773. 10 out of 11 patients had abnormal chest x-ray findings: 8 of them had peribronchial thickening, 6 had consolidation. Chest computed tomography (CT) was obtained from 10 of the patients; in 7 of them peribronchial thickening and ground glass densities were detected. None of the patients were intubated. All of the patients but one left the emergency department in the first 24 hours. One of the patients was hospitalized; in the first 48 hours significant improvement was seen and on the 7th day after admission his chest CT was completely normal. Conclusions. Heroin addiction not only causes respiratory depression but also marked pulmonary oedema at an early phase. Patients with pulmonary oedema due to heroin use may respond well to supportive therapy, including oxygenation via a face mask or mechanical ventilation; in heroin users it should, however, be considered as an alarming predictor of upcoming fatalities.

Published: Volume 17 • Issue 6 • December 2015 (pages: 23 - 30)

Title: Is there any relationship between drug users' bereavement and substance consumption?

Authors: Masferrer L., Garre-Olmo J., and Caparros B.

Summary: Background: People with substance use disorders frequently present life stories marked by suffering and loss. Few studies have assessed the role of bereavement of a significant person in the drug dependent population. Aim: This study explored the loss of a significant person among 196 bereaved drug dependent patients before and after the age when they consider that their drug consumption increased. Methods: Socio-demographic characteristics, bereavement and drug related variables were examined. Perceived relationship between the significant loss and drug consumption was also assessed. Complicated grief symptomatology was measured by the Spanish version of the Inventory of Complicated Grief (ICG). Results: 83.2% of all participants stated that, after suffering the loss, they increased drug consumption. 12.3% of the patients who first increased drug consumption and after suffered the loss of a significant person reported a relapse after the loss. However, 54% of the participants who first experienced the loss and after increased their drug consumption did not perceive any relationship between the loss and their own drug consumption. The most frequent losses were the parents (father and mother), sibling being the third most significant loss. 34.2% of patients reported symptoms of complicated grief. Conclusions: Results show a relationship between the loss and the important increase of substance consumption. This study suggests the importance of including the process of grief psychotherapy within the treatment of drug dishabituation for those cases which presented symptoms of complicated grief.

Published: Volume 17 • Issue 6 • December 2015 (pages: 31 - 40)

Title: Effects of treatment diversification on neonatal abstinence syndrome:1999-2002 vs. 2009-2012

Authors: Unger A., Brandt L., Fischberger S., Moser L., Fischer G., and Jagsch R.

Summary: Background: In the past ten years opioid maintenance treatment options for pregnancy have diversified, yet the incidence of neonatal abstinence syndrome (NAS) has increased. Aim: To compare NAS treatment outcomes in light of maternal treatment diversification of two cohorts treated in the same specialized facility monitored between 1999-2002 and 2009-2012. Methods: Maternal and neonatal outcomes of 42 mother-neonate dyads monitored 1999-2002 [n = 36 (86%) maintained on methadone (MET), mean daily dose at delivery 68.46 mg; n = 6 (14%) on buprenorphine (BUP), 8.80 mg/day] were compared with 68 opioid dependent mother-neonate dyads monitored between 2009-2012 [n = 39 (57.4%) maintained on MET, mean daily dose at delivery 58.62 mg; n = 29 (42.6%) on BUP, 9.60 mg/day] in terms of maternal demographic and treatment variables, birth outcome parameters and NAS outcomes. Results: The main finding was a reduction of pre-term birth rates (19% in the 1999-2002 cohort compared with 7% in the 2009-2012 cohort, p = 0.065) and the length of neonatal hospital stay (1999-2002: 27 days vs. 2009-2012: 18 days, p = 0.030). The average duration of gestation increased from 37.9 weeks (1999-2002) to 39.0 weeks (2009-2012) (p = 0.085). In addition, for methadone-maintained women, a significant reduction of concomitant substance use was shown over the investigated time frame. Conclusions: These results support the diversification of treatment options for pregnant opioid-dependent women in order to improve treatment efficacy for mother and child, with the potential to reduce the high costs of care in this population.

Published: Volume 17 • Issue 6 • December 2015 (pages: 41 - 48)

Title: Correlation between methadone dosage, cortisol plasma level and depression in methadone maintained patients

Authors: Ignjatova L., Spasovska Trajanovska A., and Bonevski D.

Summary: Background. Opioids can affect neuroendocrine functions, with the consequence that various endocrine abnormalities, including the increased level of cortisol that can result from depression, may be acceptable in patients who use opioids. Aim of this study is to examine the correlation between methadone dosage, cortisol plasma level and depression in methadone-maintained patients. Methods. This is an analytical, cross-sectional study that included 45 patients, who were divided into two groups. The first group consisted of 10 patients (4 females and 6 males), whose doses ranged between 10 and 55 mg. The second group consisted of 35 patients (5 females and 30 males), whose doses ranged between 65 and 120 mg. To discover demographic characteristics we used medical records, to determine cortisol plasma level we relied on the Chemiluminescence Immunoassay (CLIA) method, and to determine depression we made use of the Beck depression inventory (BDI). The results were statistically analysed using a combination of descriptive methods – the t-test for independent samples, the χ² test, the Mann-Whitney U test and the Pearson coefficient of linear correlation. Results. The results obtained show statistically significant differences between the two groups in terms of their BDI scores, with higher scores indicating patients who were taking higher doses. There is a statistically significant correlation between cortisol plasma level and depression, but not between methadone maintenance dose and cortisol plasma level, even if a high proportion of patients in the group taking higher doses showed a higher cortisol plasma level. Conclusions. In methadone-maintained patients the methadone dose is not statistically correlated with cortisol plasma level, but some other factors in the group taking higher methadone doses tend to determine higher BDI scores.

Published: Volume 17 • Issue 6 • December 2015 (pages: 49 - 58)

Title: Life events (loss and traumatic) and emotional responses to them in acute catastrophe survivors and long-lasting heroin use disorder patients never exposed to catastrophic events

Authors: Dell'Osso L., Massimetti E., Rugani F., Carmassi C., Fareed A., Stratta P., Rossi A., Massimetti G., and Maremmani I.

Summary: Background. Symptoms of PTSD denote alterations in several neurobiological systems, including the opioid system. In a previous work on methadone treated heroin use disorder (HUD) patients we demonstrated strong correlations between the severity and progression of HUD and the consequent higher severity of PTSD spectrum symptoms, suggesting a unitary perspective. Methods. A comparative cross-sectional study was carried out evaluating the post-traumatic spectrum reactivity to loss and traumatic events in acute catastrophic event survivors experiencing (N=77) and not experiencing PTSD (N=77) with a group of long-lasting HUD subjects, never exposed to catastrophic events (N=77). Results. To obtain an index of the magnitude of emotional response to losses and traumatic events we conducted a preliminary ROC analysis on TALS-SR total scores observed in our L'Aquila 2009 earthquake data-base after having classified subjects as PTSD and No-PTSD (according to SCID-questionnaire). The analysis determined the cut-off value assuring the best balance between sensitivity and specificity. The rate of over threshold subjects in HUD group resulted almost the same of the one observed in PTSD earthquake survivors group [51 (66.2%) vs 56 (72.7%), Chi-square=0.49, p=.484] while it resulted significantly higher than the one observed in No-PTSD earthquake survivors group [51 (66.2%) vs 11 (14.3%), Chi-square=41.07, p<.001]. Furthermore the discriminant analysis utilizing TALS-SR domains score as predictive variables, was not able to discriminate between HUD group and PTSD earthquake group while seems well differentiate No-PTSD earthquake group from the two others. Conclusions. This study, providing evidence of similarities in type of reaction to loss and traumatic events between HUD patients and Earthquake survivors with PTSD further supports the possible implication of the opioid system in the aetio(patho)logy of PTSD.

Published: Volume 18 • Issue 1 • February 2016 (pages: 5 - 5)

Title: Is Detoxification Still Being Proposed as the Only Form of Treatment for Opioid Dependence? Opioid Analgesic Dependence as a Case Study

Authors: Maremmani I.

Summary: Not Available

Published: Volume 18 • Issue 1 • February 2016 (pages: 9 - 18)

Title: Addictive Behaviours in Heroin Use Disorder Patients. Correlation with Heroin-Craving Patients' Self-Evaluation

Authors: Maremmani A.G.I., Rovai L., Bacciardi S., Bertoni S., Massimetti E., Gazzarrini D., Rugani F., Pallucchini A., and Maremmani I.

Summary: Introduction: Repeated exposure to heroin leads to addictive behaviours that focus on obtaining that drug by any means and taking the drug under adverse psychosocial and medical conditions. Currently, in the DSM-5, craving is recognized as an important diagnostic criterion for the diagnosis of Substance Use Disorder. Nevertheless, there is still no consensus on the behavioural covariates of craving, or evidence of which behaviours are considered by patients to be related to their craving, and which are not so considered. The aim of this study is to look at correlations between addictive behaviours and the self-evaluation by patients of their heroin craving. Methods: 114 heroin use disorder patients were evaluated, at treatment entry, on the presence and severity of 13 kinds of addictive behaviour. Correlations between these addictive behaviours and the presence and severity of heroin craving in the self-evaluation of patients were calculated at multivariate levels. Results: The most prominent craving scenario is the following: patients think about injecting heroin most of the day (OR=10.32); they get their fix with something else that they think will ‘work', if they have all that is needed for a fix except heroin itself (OR=6.13); they don't even think about saving any heroin if they have some, even if they don't know whether any will be available a day later (OR=5.13). Craving is recognized as very strong if they think about injecting heroin most of the day, if they get their fix with something else that they think will ‘work', if they have all that is needed for a fix except heroin itself, if they go there in any case, if their imaginary friend will give them heroin for free in a place that is very difficult to get access to. Conversely, among behaviours that are independent of the self-evaluation of craving, those distinguished by the greatest medical impact are needle exchanges and use/relapses that are cue-induced. Conclusions: Patients fail to recognize some addictive behaviours as signs of heroin craving. Of these behaviours, those displaying the greatest medical impact are needle exchanges and use/relapses that are cue-induced.

Published: Volume 18 • Issue 1 • February 2016 (pages: 19 - 30)

Title: Patients' Quality of Life (Qol) and Medication Misuse and Diversion During Suboxone Maintenance in Italy. A National Opinion Leaders' Interview-Based Survey

Authors: Leonardi C., Mariani F., Salvadori S., and the Italian Multi-QoL-MiD Group

Summary: Background: Buprenorphine-naloxone combination therapy justified the present investigation because of the insights it offered on patients' behaviour and Quality of Life (QoL). Methods: By means of interviews with 62 Italian Opinion Leaders (IOL), retrospective data about patients during their first six months of treatment with BNX were recorded. The evaluation covered social and professional data on subjects; social and interpersonal aspects in relation to each subject's environment: family, workmates, friends; the profile of the urine tests performed during the assessment period; impact on quality of life, together with the mental health profile that emerged during take-home treatment; drug craving levels as measured during treatment; other non-pharmacological treatments carried out during the reporting period; the global clinical assessment of the treatments performed during the period of observation; the impact, in terms of management, on the Drug Addiction Centres and on professional activities at the Centers during take-home therapy; the Quality of Life of the patients. Results: Take-Home Therapy patients (N=761) were significantly more frequently married and employed than Supervised Daily Therapy patients (N=54). THT patients showed lower craving for heroin than SDT patients. THT patients used less frequently cocaine and/or reported lower craving for it. The IOL's global clinical judgment was better regarding THT patients, and THT patients' QoL was considered higher. Conclusions: This study may provide general indications about how to achieve better clinical management of heroin addiction by using buprenorphine-naloxone combination during a Take-Home Therapy.

Published: Volume 18 • Issue 1 • February 2016 (pages: 31 - 36)

Title: Attachment Style, Self Esteem and Anxiety as Factors for Opiate Addiction

Authors: Bonevski D., Ignjatova L., and Naumovska A.

Summary: Background: Insecure attachment is usually connected with lower self-esteem or with higher manifest anxiety, and can be a risk factor in those facing a variety of emotional problems, including problems associated with substance abuse. Aim of the present study is to examine the most frequent attachment style, and the level of manifest anxiety and self-esteem in patients undergoing treatment for opiate addiction compared with individuals who have no form of addiction. Methods: The sample included 47 (61%) male and 30 (39%) female, opiate addicts; they were at least 18 years old, with a mean age of 22.82 years (min. 18; max. 27; SD = 2.25 yr) and 77 mentally healthy controls, who were examined with the Coopersmith Self-Esteem Inventory (CSEI), Attachment Style Questionnaire (ASQ) and Taylor Manifest Anxiety Scale (TMAS). Comparison between the two groups focused on the percentages recorded for the various attachment styles found in each group, and the Chi-Square test was used to assess the significance of the divergences between those attachment styles in the two groups. The mean values recorded for self-esteem and manifest anxiety in the two groups were compared too, by applying the t-test. Results: The results indicate a more secure attachment style in the healthy individuals and a more fearful form of attachment in opiate-addicted individuals. The result of the present study indicated that opiate addicts are less confident and more anxious. Conclusion: Fearful attachment, low self-esteem and high manifest anxiety proved to be more frequent in opiate addicts.

Published: Volume 18 • Issue 1 • February 2016 (pages: 37 - 44)

Title: Analysis of Patient Data on Admission to Treatment in Nhs Lanarkshire Addiction Services

Authors: Hill D.

Summary: Introduction: Over time the substances misused in a population changes as does other simple demographics, such as age, number of treatment episodes and treatments. Methods: This article reflects on data obtained from patients engaging or re-engaging with NHS Lanarkshire addiction services to look at these demographics and also ensure that the treatment services offered are still appropriate to the population. Results: The data demonstrates that the population is growing older before they access treatment. The substances being misused are also changing with time. The most common profile for a new patient accessing treatment in NHS Lanarkshire during the data collection period can also be determined. Conclusions: The data shows that NHS Lanarkshire Addictions Services are addressing the issue and offering a choice of opioid agonist treatment to individual patients.

Published: Volume 18 • Issue 1 • February 2016 (pages: 45 - 50)

Title: How to Improve a Poorly Running Opiate Substitution Therapy. Part 1: how Effective Are We?

Authors: Ulmer A.

Summary: Objective: In this paper the author introduces an evaluation of how good we actually are at treating patients. It could always be shown that patients receiving treatment with long-acting agonist opioid medications (LAAOMs) have a much better outcome than patients left untreated. But, compared with people who have no addiction disease, especially those with some other chronic illness, many patients receiving LAAOM treatment suffer, in fact, from a substantial difference in their quality of life. This comparison is the essential benchmark. Aim is a life that is as unimpaired by any illness as possi-ble. Methods: The status of addiction patients has been documented regularly, through the use of a 15-step impression scale in our practice for >20 years. In this study we followed up by evaluating the average of all recorded ratings of 109 patients of whom we had especially detailed case histories and a development diagram based on these documentations. In addition, our evaluation was divided up into the first and second half of treatment, as well as including a review of the last three years to examine whether the treatment period had exerted an influence. Results: The average of all evaluations was 6.61 ± 2.0 on the 15-step scale, which was on the borderline between “better, but not good” and “not completely good”. The average difference between the average values recorded for the first and second halves was no more than 0.95 ± 1.7. There was no correlation with the length of therapy. No distinctive improvement emerged until the last three years, where the mean value was at 8.61 ± 2.1, 2.45 better than that recorded in the first half of treatment, and only 21.6% of the cases reviewed satisfied the criteria for the evaluation “not good”. Conclusion: The evaluation shows alarmingly bad treatment results, even in a practice that included individual patient guidance. A distinct improvement only emerged in the final years of treatment, after the optimization of several treatment measures. There is a considerable need for improvement in many forms of treatment with LAAOMs.

Published: Volume 18 • Issue 2 • April 2016 (pages: 5 - 12)

Title: Relationships between addictive behaviours and dual disorders, as found in heroin use disorder patients at treatment entry

Authors: Maremmani A.G., Rovai L., Bacciardi S., Massimetti E., Gazzarrini D., Pallucchini A., Pani P.P., and Maremmani I.

Summary: Introduction: In dual diagnosis (DD) patients, a clear trend emerges towards greater chronicity and severity, and more serious somatic, social and psychological problems, than in cases of uncomplicated addiction. In Heroin Use Disorder (HUD) patients, we found some clinical aspects that were related (violence and self-injurious behaviours), and others unrelated (temperamental aspects, psychopathological subtypes) to DD. More recently, we proposed an inventory for assessing the behavioural covariates of craving in HUD showing good psychometric properties. This topic required further examination among DD-HUD patients. Methods: At univariate level, we compared 70 DD-HUD and 44 HUD patients with reference to their demographic, clinical and anamnestic data, and whether they showed addictive behaviours. At multivariate level, we used a logistic regression analysis to select the prominent behavioural characteristics of DD-HUD patients by checking the analysis for the variables that were found to be significantly different at univariate level. Results: At treatment entry, DD-HUD patients reported a higher number of addictive behaviours (p=0.024) and more frequently recognized the presence of subjective craving (p=0.013). More specifically, they tended to use other substances on top of heroin (p=0.012); they prized heroin much more than anything else they had ever enjoyed before (p=0.030); they appeared to have trouble using anti-withdrawal pills (p=0.005); they accepted heroin even if they were trying to rehab (p=0.003); and they were willing to put up with a lot of stress to get heroin (p=0.004). They accepted heroin even during rehab (OR=6.34), accepted a lot of stress in their search for heroin (OR=2.85), and refused to use other substances to compensate for the unsuitable dose of heroin, when they were feeling down (OR=0.17); in all these aspects, polyabuse (OR=2.95) proved to discriminate DD-HUD from HUD patients. Conclusions: Specific addictive behaviours of DD-HUD patients appear to be correlated with finding and taking opioids to alleviate psychopathology. By contrast, behaviours linked to obsessive and relief craving (closely correlated with the progress of addiction) did not turn out to be present in significantly different form in DD-HUD vs. HUD patients.

Published: Volume 18 • Issue 2 • April 2016 (pages: 13 - 20)

Title: Parental bonding in substance and alcohol abusers

Authors: Segura-Garcia C., Rania M., Aloi M., Palmieri A., Pellegrino A., Manfrida A., Montesano F., Grande B., De Fazio S., and De Fazio P.

Summary: Background: Deficient parental bonding (PB) during childhood and adolescence and, more specifically, a pattern of “affectionless control” has been associated with the development of substance abuse. Aim: Our aim is to investigate PB style among drug and alcohol abusers so as to be able to assess whether it may influence the age of onset and the type of abuse. Methods: The Parental Bonding Instrument (PBI) was administered to patients with a diagnosis of alcohol (N=26) and drug abuse (N=62). PB styles, paternal/maternal care and overprotection, type of substance, age at onset and sociodemographic features were analysed and compared between the two groups of abusers. Spearman's correlations between PB dimensions and styles, type of abuse and age at onset were run. Results: “Affectionless control” is the most frequent PB style among drug and alcohol abusers. There is a negative correlation between paternal care and the use of cocaine, heroin and LSD, and a positive correlation with ecstasy and alcohol abuse. Father overprotection correlates positively with all substances except for ecstasy, and negatively with alcohol abuse. Mother care correlates negatively with LSD, and positively with ecstasy abuse. Mother overprotection correlates positively with all substances, and negatively with alcohol abuse. With comparable overprotection, a high level of paternal care correlates with earlier onset of drug abuse (p=.017). Maternal overprotection is related to the early onset of alcohol abuse (p =.033). Conclusions: Drug and alcohol abusers describe their PB as “affectionless control”. Specific PB styles and levels of maternal/paternal care and overprotection are associated both with the onset and the use of specific substances.

Published: Volume 18 • Issue 2 • April 2016 (pages: 21 - 24)

Title: Illicit and over-the-counter codeine dependence after acute back pain—successful treatment and ongoing recovery after buprenorphine/naloxone taper

Authors: Kean J.

Summary: Increased prescribing of opioids for pain has been associated with an increase in dependency and associated morbidity and mortality. There are no evidence-based guidelines to direct the treatment of prescription or over-the-counter codeine dependency, including the use of maintenance and tapered dosing, or its use in conjunction with psychosocial interventions (PSI). Here we report the case of a family man who developed opioid analgesic dependence after being prescribed opioids for acute back pain. After his repeat prescription was stopped, he sourced both illicit and over-the-counter codeine. After 4 years of escalating use to a daily codeine dose of 1250 mg, he presented to a substance misuse service, The Bridge Project, Bradford. After successful induction and stabilisation on buprenorphine/naloxone (8 mg/2 mg) over the course of one week, our client successfully tapered over a 4-month period. He remained in work during treatment, and experienced side effects that were limited to headaches and some depressive thoughts. Opioid substitution treatment—buprenorphine/naloxone within a holistic Change Programme that included structured behavioural change psychosocial interventions—was successful, supporting slow taper across a 4-month period conducted within Unity Recovery Centre, part of the Bridge Project.

Published: Volume 18 • Issue 2 • April 2016 (pages: 25 - 30)

Title: High-Dose Methadone: management of an opioid-addicted patient

Authors: Dilaghi A., Occupati B., Lapucci A., Masini E., and Mannaioni G.

Summary: Introduction: Methadone (MT), a synthetic opioid used in racemic form to treat opiate dependence, is metabolized primarily by CYP3A4, CYP2B6 and CYP2D6 enzymes. Interindividual variability in drug response can occur as a consequence of variations in cytochrome P-450 (CYP) isoenzyme activity or in the single–nucleotide polymorphisms (snps) of drug transport proteins and/or receptors. Genetic variations in the OPRM1 gene locus of μ opioid receptors and/or in P-glycoprotein (ABCB1/MDR1 gene) are thought to play an essential role in interindividual responses to opiates. We investigated how best to make a genetic assessment of an opiate-addicted man who needed a high methadone dose to control withdrawal symptoms. Case presentation: We report the case of a patient in methadone maintenance treatment (MMT) who kept on demanding an increase in methadone dose; he ended up consuming 480 mg of MT daily, with the consequent development of cardiac toxicity. The patient was admitted to our Toxicology Unit to allow us to evaluate plasma MT concentration, to make a genetic evaluation of CYP2B6, CYP3A4, OPRM1 and ABCB1/MDR1, and to allow the patient to undergo a double shift from methadone to buprenorphine via oxycodone, a short-acting opioid. R/S MT plasma concentrations were above the range that corresponds to a normal MT metabolism. Genetic assessment of the opioid μ receptors revealed a variant G allele of the OPRM1 A118G SNP, thus confirming the patient's poor response to methadone treatment. Conclusions: Some opioid-addicted patients fail to respond adequately to MT treatment, despite their high dosage; in such cases the evaluation of plasma MT concentration, genetic assessment of opioid pharmacokinetic/pharmacodynamics and, possibly, an opiate drug switch may be helpful.

Published: Volume 18 • Issue 2 • April 2016 (pages: 31 - 40)

Title: Safe storage of Methadone in the home: results from an Irish audit of service users and pharmacists.

Authors: Horan J.A., Gooney M., and Van Hout M.C.

Summary: Background: Safe storage of oral methadone at home is an important issue given the risk of accidental paediatric consumption. Pharmacy protocols centre on provision of information to patients relating to general and paediatric dangers of methadone and safe storage of methadone in the home. Aim: The study aimed to audit the effectiveness of pharmacy provision of information on safety of methadone consumption and storage in the home. Methods: The study involved an audit of five criteria relating to patient awareness of general dangers of methadone use and paediatric risks, patient information recall on safe storage of methadone in the home; take home methadone dispensing in child resistant containers and safe and secured storage of methadone. Audit information was collected using a survey with consecutive adult patients attending a specialist methadone clinic over the course of four weeks (n=94), and telephone interviews with dispensing pharmacists recorded in the specialist clinic register (n=43). Results: None of the criteria reached a 100% standard. 51% reported never being provided with safety information. 97% of patients were aware of the dangers of methadone use, with females significantly more aware of dangers of methadone to users. 86% did not place their take-home methadone in a locked place. 90% reported they would seek medical help if a child had accidentally consumed methadone. 58% of pharmacists never questioned patients around storage, but 58% reported counselling patients on safe storage. Conclusions: Safe storage of methadone warrants regular and proactive pharmacy provision of information around harms associated with methadone.

Published: Volume 18 • Issue 2 • April 2016 (pages: 41 - 48)

Title: Test-Retest Reliability and Descriptive Analyses of the Modified Important People and Activities (MIPA) Interview

Authors: Zywiak W.H., Stout R.L., Braciszewski J.M., Wray T.B., and Longabaugh R.

Summary: Background: The Important People and Activities (IPA) instrument assesses network characteristics and social support for drinking and abstinence. The IPA has garnered widespread use in the alcohol treatment field. We modified the IPA to assess HIV status, drug of choice, and IV drug use among social network members. Further, we queried frequency of unprotected sex, between the participant and network members. Aim: Since this measure was modified, and the test-retest reliability of the IPA has only rarely been examined, we conducted a small substudy (n=26) to examine 1-week test-retest reliability of this measure. Methods: Participants were individuals in a day treatment program with an SUD and/or AUD diagnosis. Results: Drug of choice for the participants represented roughly equal thirds of heroin, cocaine, and alcohol. The sample was 62% female and 39% Latino/a. At pretest 198 persons were named on the MIPA (M=7.6 network members per subject). It was determined that 152 of the people were overlapping between the test and retest. Conclusions: Percent agreement, ICCs, and kappas for the items ranged from acceptable to excellent across the two time periods. Classification of network members as positive, negative, or neutral influences on sobriety also demonstrated good to excellent kappas.

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Published: Volume 18 • Issue 3 • June 2016 (pages: 5 - 8)

Title: Improving agonist opioid treatment to reduce the risk of reinfection in HCV treatment

Authors: Maremmani I.

Summary: Not available

Published: Volume 18 • Issue 3 • June 2016 (pages: 9 - 14)

Title: Effect of methadone maintenance treatment of opioid dependent fathers on mental health and perceived family functioning of their children

Authors: Hassanpour-Dehkordi A., Safavi P., Parvin N., and Mosayebi B.

Summary: Background: Substance abuse has negative effects on the mental and social adaptation of children living with the adults who are involved in this behaviour. This study was carried out with the aim of assessing the effects of methadone maintenance treatment (MMT) of opioid-dependent fathers on the mental health and perceived family functioning of their children. Methods: In this clinical trial, 40 children (with ages ranging from 11 to 18 years) whose fathers were in methadone maintenance treatment in two MMT clinics in Shahrekord, Iran, were assessed using the Strengths and Difficulties Questionnaire (self- and parent report), Family Assessment Device (FAD), and Parent-Child Relationship Survey (PCRS) conducted prior to, and then 3 and 6 months after the intervention. The collected data were analysed by applying repeated measure tests using SPSS16 software. Results: There were significant differences between the data collected initially at baseline, and then 3 and 6 months after the intervention measurements that were based on SDQ mean difficulty scores in the parent and child versions (p=0.001 and p<0.001, respectively), and on the pro-social behaviour subscale in the form prepared for parents (p=0.003), but not in that prepared for children (p=0.085). Mean total score and subscale scores of FAD did not change significantly (p=0.064), except for the emotional involvement subscale (p=0.032). PCRS mean scores did not change significantly, either (p=0.108). Conclusions: The emotional and behavioural difficulties of children of substance-abusing fathers improved during 6 months of methadone maintenance treatment, but neither perceived family functioning nor the parent-child relationships involved changed significantly. Family-based psychological interventions such as training in parenting skills, communication training, and problem solving may be necessary to improve the family and parenting functions of fathers on MMT.

Published: Volume 18 • Issue 3 • June 2016 (pages: 15 - 22)

Title: The filing of addicts at addiction units is correlated with a reduction in mortality due to illicit opioids, but also to prescribed opioids and other substances of abuse

Authors: Lovrecic M., Lovrecic B., Selb Semerl J., Maremmani I., and Maremmani A.G.

Summary: Background: Opioid agonist treatment reduces mortality in heroin addicts. This study investigates differences in causes of death between people whose data were filed at addiction units and those whose data had never been filed at addiction units. Methods: All drug users who applied for opioid agonist treatment in Slovenia in the period 2004-2006 were cross-linked through a general mortality register and a special mortality register. The vital status of cohort members was checked at the mortality register on the last day of follow-up (covering the period from 1st January 2004 to 31st December 2007). Results: Out of 331 deceased people, the data of 232 proved to have been filed whereas the data of the other 99 had not been filed at any addiction treatment unit. The mean age of all the deceased was 32.2 years; 85% were males. Of all deaths, 63% were due to an overdose. The difference between the two groups was statistically significant, Three-quarters of the cases of poisoning were found in the group without data filed, while, among the group whose data had been filed, cases of poisoning were present in less than half of the victims. 88.7% of all overdoses were due to opioids (whether illicit narcotics or prescription opioids), with a higher proportion of overdoses due to prescription opioids and other prescription drugs occurring in the group without filed data. Conclusion: Among those whose data had not been filed at the addiction units, a greater percentage of deaths proved to be due to an overdose, mostly of heroin or prescription opioids, including methadone, than was true of the population of addicts whose data were on file. Younger subjects, in the second group, were subject to greater risks.

Published: Volume 18 • Issue 3 • June 2016 (pages: 23 - 28)

Title: Will non-compliant “hard-to-treat” opioid dependent patients profit from low threshold methadone treatment? A prospective 15-month evaluation of patients on Low Dosage Methadone treatment at Oslo University Hospital.

Authors: Henriksen K., Waal H., and Krajci P.

Summary: Introduction: In 2014, Oslo University Hospital introduced a Safe Low Dose Methadone (SLDM) project in an effort to reach ‘hard-to-treat' opioid-dependent patients that were unable to comply with previous treatment plans. The basic assumption was that a dosage of 60 mg methadone adminstered daily should provide adequate physical abstinence relief with only a low risk of respiratory depression, even when combined with central depressants. Methods: This prospective study is a follow-up of 20 ‘hard-to-treat' patients in SLDM over a period of 15 months. All patients were benefiting from a ‘stable living situation' prior to titration. Treatment status was evaluated at 2, 7 and 15 months after the cut-off period for inclusion. Results: Eighty per cent of the patients were on methadone at the 15 months evaluation follow-up. There were no serious intoxications or overdoses reported among any of the 20 patients during the study period. Conclusions: ‘Hard-to-treat' patients may be treated successfully and responsibly with low dose methadone when this takes place within a tightly controlled framework.

Published: Volume 18 • Issue 3 • June 2016 (pages: 29 - 42)

Title: Study on users' perception of agonist opioid treatment in the Galician network of drug addiction

Authors: Carrera I., Sánchez L., Sabater E., Pereiro C., Flórez G., Conde M., Pino C., Serrano M., Casado M.Á., and TSO-GALICIA GROUP

Summary: Background: The opiate derivatives treatment programme (ODTP) is a high-user-volume therapeutic programme in the Galician Network of Addictive Disorders (Red Gallega de Trastornos Adictivos – RGTA). Aim: Our aim has been to assess the quality of life and the perceived satisfaction of ODTP users in the context of the Galician Network of Addictive Disorders (RGTA). Methods: This is an observational, prospective cohort study of patients enrolled in ODTP. Two groups were enrolled: the first consisted of patients initially treated in methadone maintenance programmes (MMPs) who then transferred to treatment with buprenorphine-naloxone (BUP-NLX), and the second of patients who stayed in their methadone maintenance programme. Two questionnaires, the Verona Service Satisfaction Scale for Methadone Treatment (VSSS-MT) and the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF), were distributed to participants at baseline and again at 3 months. Two discussion groups were formed. Results: A total of 135 patients (83 BUP-NLX, 52 MMP) were recruited. Satisfaction was associated with sex (p=0.023), length of drug use (p=0.019), cocaine use (p=0.021), mood disorders (p=0.049) and work activity (p=0.013). Quality of life was mainly associated with age (p=0.027), anxiety disorders (p=0.027), psychopharmacological treatments (p=0.004), medical and psychosocial follow-up (p=0.027), type of cohabitation (p=0.001), satisfaction with life (p<0.001) and treatment received (p=0.004). In the qualitative study, a greater number of advantages was mentioned by the discussion group treated with BUP-NLX than by the MMP group. Conclusions: ODTP users value their inclusion in these programmes, but patients treated with BUP-NLX evaluated their quality of life more favourably than patients in MMPs.

Published: Volume 18 • Issue 3 • June 2016 (pages: 43 - 52)

Title: Opioid misuse in the 30 days prior to entering Agonist Opioid Treatment in four European Countries. A pilot study

Authors: Maremmani I., Somaini L., Deruvo G., Maremmani A.G.I., Touzeau D., Walcher S., Fonseca F., Bacciardi S., Guareschi M., Green J.L., McBride K., and Dart R.C.

Summary: Introduction: The broad availability of opioid analgesics (OAs) probably complicates the misuse of Agonist Opioid Treatment (AOT) medications, or even pave the way to dependence on heroin. Methods: In this observational study, based on a thorough survey of new AOT enrollees, our main aim was to determine the extent to which the problem of prescription opioid (PO) misuse that is currently evident in the US is also a concern in the EU. We assessed the prevalence of primary substances of abuse (PSAs), and differences in patterns of PO misuse in the previous month, by reviewing the situations to be found in four European countries. Results: In the centers investigated by us, heroin was preferred as PSA in Spain, buprenorphine and opioid analgesics were the prevalent PSAs in France, while methadone and fentanyl prevailed in Germany. Heroin alone frequently proved to be the substance used in Italy and Spain. AOT medications only were used more frequently in Italy, less so in Spain. Opioid analgesics only were used more frequently in France. Combined use occurred more frequent in Italy, with special reference to heroin and AOT medications; in Germany especially with heroin and opioid analgesics; in France especially with opioid analgesics and AOT medications. The combined use of heroin, AOT medications and opioid analgesics was a frequent finding in Germany. Conclusions: In Europe, the combined use of opioid analgesics, AOT medications and heroin – already dreaded in the US, and rightly so – is just beginning to appear, notably in Germany and in France.

Published: Volume 18 • Issue 3 • June 2016 (pages: 53 - 56)

Title: Pentedrone induced acute psychosis at patient with opioid addiction: a case report

Authors: Segrec N., Kastelic A., and Pregelj P.

Summary: Background: New psychoactive substances (NPSs) have been emerging into prominence on the European drug scene and around the world in the last few years. The number of NPSs is constantly increasing, but there is a lack of research in this field, while their unwanted effects are still barely known (as is true also of their long-term consequences). Unfortunately, when unwanted effects do occur they can lead to serious consequences on physical and mental health, in line with the descriptions given in the literature. Case report: The case report refers to a 25-year-old man who had been treated with buprenorphine to cure opioid addiction, and then developed an acute psychotic reaction after pentedrone had been abused. He was frightened, and experienced altered mental states and socially disruptive responses: logorrhoea, disorganized behaviour, with delusions of persecutions and reference, haptic hallucinations, anxiety and impaired insight. In order to allow treatment of his acute psychotic disorder, the patient was admitted to a psychiatric hospital, and antipsychotic medication was administered in combination with benzodiazepines. Meanwhile, buprenorphine tapering was performed rapidly. Only a few days later the psychotic symptoms resolved. Treatment of the patient continued at the addiction department for a short period, but he was not motivated or prepared for that. His imminent discharge was followed by relapse into drug use. Conclusions: It seems that pentedrone use could be associated with the resolution of acute psychosis after a short period of antipsychotic treatment.

Published: Volume 18 • Issue N4s1 • August 2016 (pages: 5 - 10)

Title: Towards a Unified Perspective between Ptsd and Substance Use Disorders: Ptsd Spectrum as Part of a Specific Psychopathology of Substance Use Disorder

Authors: Maremmani A.G.I.

Summary: Not available

Published: Volume 18 • Issue N4s1 • August 2016 (pages: 11 - 18)

Title: Relationship Linking Adhd Symptoms with Severe Dissociative Experiences and Ptsd Symptoms in a Sample of Inpatients with Alcohol Use Disorder

Authors: Evren C., Umut G., Alniak I., Carkci O., Karabulut V., Cetin T., Evren B., and Agachanli R.

Summary: Introduction: The aim of the present study was to evaluate the relationship between ADHD symptoms and the severity of PTSD symptoms, while controlling the effects of dissociative experiences, anxiety and depression in a sample of inpatients with alcohol use disorder (AUD). Methods: Participants included 190 inpatients with AUD. Participants were evaluated by applying the State-Trait Anxiety Inventory (STAI), Beck Depression Inventory (BDI), the Adult ADHD Self-Report Scale (ASRS), Dissociative Experiences Scale (DES) and PTSD Checklist Civilian version (PCL-C). Results: ASRS total score and subscale scores (hyperactive/impulsive-HI, inattentive-IN) were moderately correlated with PCL-C score, while they were mildly and moderately correlated with anxiety, depression and DES scores. Severity of ADHD (both ASRS-18, particularly HI dimension, and ASRS-6 score) predicted the severity of PTSD symptoms even after controlling patients' dissociative experiences, depressive symptoms and trait anxiety. Conclusion: These findings suggest that the severity of ADHD symptoms, particularly the HI dimension, may be related to the severity of PTSD symptoms, together with dissociative experiences and trait anxiety among inpatients with AUD.

Published: Volume 18 • Issue N4s1 • August 2016 (pages: 19 - 26)

Title: Psychometric Properties of the Turkish Version of the National Stressful Events Survey for Ptsd-Short Scale in a Sample of Inpatients with Alcohol Use Disorder

Authors: Evren C., Dalbudak E., Umut G., Bozkurt M., Evren B., Agachanli R., and Teksin-Unal G.

Summary: Background: The National Stressful Events Survey for Posttraumatic Stress Disorder (PTSD)-Short Scale (NSESSS-PTSD) allows the dimensional self-rating assessment of PTSD according to DSM-5, and the Turkish version of the scale had previously been validated in a sample of undergraduate students. Aim: The aim of the present study was to evaluate the psychometric properties of the Turkish version of the NSESSS-PTSD in a sample of inpatients with alcohol use disorder (AUD). Methods: The group of participants consisted of 190 inpatients with AUD, 174 (91.6%) of whom reported trauma. Participants were evaluated by applying the NSESSS-PTSD, the PTSD Checklist Civilian (PCL-C) version, the Dissociative Experiences Scale (DES), the State-Trait Anxiety Inventory (STAI) and Beck Depression Inventory (BDI). Results: The NSESSS-PTSD was found to be a psychometrically sound PTSD screening measure with high convergent validity when compared with PCL-C (r=0.77), and to have a Cronbach's α of 0.88. Test-retest correlation for NSESSS-PTSD (n=119) was moderate (r=0.60). NSESSS-PTSD was also moderately correlated with DES (r=0.50), STAI-I (r=0.58), STAI-II (r=0.63) and BDI (r=0.59). In addition, a single component accounted for 50.66% of total variance for NSESSS-PTSD. NSESSS-PTSD had sensitivity and specificity scores of 0.79 and 0.84, respectively, when using the optimal cut-off score of 16. Additionally, the NSESSS-PTSD showed good discriminant validity as it significantly differentiated alcohol-dependent inpatients with a high risk of PTSD from those with a low risk. Conclusions: These findings support the Turkish versions of NSESSS-PTSD as being valid and reliable PTSD screening instruments that measure a unidimensional construct among inpatients with AUD.

Published: Volume 18 • Issue N4s1 • August 2016 (pages: 27 - 36)

Title: Association between Adverse Childhood Experiences and Health Risk Behaviors Such as Smoking, Use of Alcohol and Substance Abuse in Adolescence

Authors: Raleva M., and Ignjatova L.

Summary: Background. Adverse childhood experiences (ACEs) constitute a great proportion of the risk factors that predict poor health in later life. Aim. This study examined the association between ACEs and use of alcohol and illicit drugs, and recourse to smoking, as well as the role of gender in the association between ACEs and those health-harming behaviours. Methods. The study was retrospective and included 1,277 young adults that completed the survey on ACEs. Results. ACEs raised the likelihood of illicit drug use 2.2- to 4-fold, early initiation of smoking 2- to 3-fold, and smoking and alcohol use 1.5- to 2-fold. Compared with students without any ACEs, students with >3 ACEs showed a 2.2-fold probability of reporting illicit drug use, a 2-fold probability of starting to smoke early, and students with >4 ACEs were 60% more likely to be smokers. Almost the same percentage of female and male students smoked and used alcohol, male students smoked twice as much as female students and a significantly higher number of male students (11.3%) had drunk 6 drinks or more on a single occasion 3 or more times during the last month compared with 3.3% of female students. Significantly more male (7.6%) than female (3.6%) students had used illicit drugs in their lifetime and 3.5% of male versus 1.6% of female students had used illicit drugs more than 3 times in their life. Conclusions. ACEs increase the risks of smoking and substance use in students. Significantly more male students than female ones had used illicit drugs, and had smoked and drunk significantly greater quantities of cigarettes and alcohol.

Published: Volume 18 • Issue N4s1 • August 2016 (pages: 37 - 44)

Title: Clinical Syndromes, Complicated Grief and Substance Use Disorder

Authors: Masferrer L., Garre-Olmo J., and Caparros B.

Summary: Background: People with substance use disorders present high psychopathological comorbidity. Research has demonstrated that bereaved individuals with Complicated Grief (CG) symptomatology present unusually severe and prolonged symptoms, and that affects important domains. Aim: This study aimed to assess the association between clinical syndromes and CG symptoms among patients with Substance User Disorder (SUD). Methods: A convenience sample of 196 bereaved drug-dependent patients was studied. Sociodemographic characteristics, bereavement and drug-related variables as well as psychopathology were examined. CG symptomatology was measured by the Spanish version of the Inventory of Complicated Grief (ICG). Anxiety, Major Depressive Disorder and Posttraumatic Stress Disorder (PSTD) were assessed by utilizing the clinical syndrome section of the Spanish version of MCMI-III. A logistic regression analysis was adjusted to identify which variables were associated with CG symptoms. Results: 78.1% were men, and mean age in the sample was 45.59 years (SD=10.14). 34.2% of participants reported symptomatology of CG. Individuals with CG symptoms showed 31.2% higher frequency of Anxiety, 12.5% higher Major Depression and 7.4% higher PTSD. The symptomatology of CG was associated with the presence of Major Depressive Disorder (OR= 1.029) as well as PTSD (OR=1.041). Conclusions: Depression and PTSD were associated with symptomatology of CG. This study suggests the importance of carrying out a rigorous and accurate differential diagnosis of CG symptomatology as well as clinical syndromes among addicted people.

Published: Volume 18 • Issue N4 • August 2016 (pages: 5 - 12)

Title: Illicit Drugs and Others Substances Used by Young Athletes between Ages of 10 and 25

Authors: Gabrovec B.

Summary: Background and aim: The purpose of this study was to establish the details about how illicit and other substances are abused among young recreational athletes according to the type of sport, training frequency, and other parameters. This study examined young, active athletes from Slovenia between the ages of 10 and 25 that were actively engaged in any kind of sport at least twice per week. Methods: The survey involved a total of 1,780 participants; of these, 1,095 (61.51%). responded by providing appropriately filled out questionnaire forms. These respondents included 575 (52.5%) men and 520 (47.5%) women. Results: 31.5% of our respondents had tried smoking or actually smoked cigarettes at least once in their life, whereas as few as 4.6% reported smoking on a daily basis. Most of the respondents reported having tried alcohol (67.5%); of these, 21.5% had tried alcohol in the previous month. 19.9% of the respondents had tried smoking cannabis, but 9.1% specified that this was a one-time event. 13.6% had tried stimulants, but 5.9% added that this was a one-time event. At much lower frequencies, the respondents had tried heroin (3.1%), cocaine (4.5%), and amphetamines, LSD, new synthetic drugs (3.6%). According to the evidence provided by this study, active young athletes consume some substances less often than the general population and, in any case, they first try the substances mentioned above at a higher average age. Research shows that athletes who train more often (4 times per week or more) are less prone to trying or consuming a variety of substances. Conclusion: Our study shows that young athletes who are actively engaged in sports activities use a variety of types of substance, but do so less frequently than the general population. In cases where athletes have already been exposed to various substances, their average age at their first encounter with drugs is higher than that recorded for the general population.

Published: Volume 18 • Issue N4 • August 2016 (pages: 13 - 22)

Title: Audit of Admission Urines in Two Scottish Prisons in Prisoners Self-Reporting Opiate Misuse

Authors: Campbell G.

Summary: Background: Illicit drug use is common in those who come into the criminal justice system. Opioid replacement therapy (ORT) improves outcome but these drugs can be diverted and misused. Aim: The primary aim was to assess the urines of new admissions to the prison service with regard to opiate misuse, the numbers on opioid replacement therapy (ORT) and estimate the extent of diversion of ORT in new prisoners who self-reported opiate misuse. Methods: We performed urinalysis for the presence of methadone, buprenorphine, opiates, cocaine, benzodiazepines and amphetamines on admission to HMP Barlinnie and HMP Low Moss, two large male prisons in Scotland. From Jan–April 2015, a supervised urine sample (50 ml) was collected from consecutive new prisoners who were receiving ORT or who gave a current history of opiate misuse. Results: 209 prisoners fulfilled the inclusion criteria. In total, 51.7% (108/209) reported receiving ORT at prison admission. 47.4% (99/209) tested positive for methadone. Of these, 88.9% (n=88/99) were in receipt of a methadone prescription (one of whom tested negative for methadone) and 12.1% (n=12/99) were without a prescription. 29% of prisoners (62/209) tested positive for buprenorphine, the majority of which (67.7%, 42/62) was not prescribed. Six patients prescribed methadone were positive for diverted buprenorphine. Thus, diverted ORT was detected in 25.8% of cases (54/209) and was significantly more likely to be buprenorphine than methadone (p<0.0001). Polydrug use was common; 69.4% (145/209) of prisoners were using at least two illicit substances, but there was significantly less use of three or more illicit drugs in those receiving ORT (16.7% vs. 41.6%, respectively, p<0.0001). Conclusions: An encouraging number of prisoners with a history of opiate misuse were receiving prescribed ORT. There were high levels of polysubstance misuse. We found evidence of diverted ORT in more than 25% of prisoners. Of those without a prescription for ORT taking buprenorphine, more than a quarter were opiate negative, perhaps indicating self-treatment.

Published: Volume 18 • Issue N4 • August 2016 (pages: 23 - 32)

Title: Possible Trajectories of Addictions: The Role of Bipolar Spectrum

Authors: Maremmani A.G.I., Pacini M., Pani P.P., Ceccanti M., Bacciardi S., Akiskal H.S., and Maremmani I.

Summary: Background: Real-world practice forces us to deal with polydrug use disorders and addiction trajectories that show considerable heterogeneity. Several studies indicate a specific relationship between bipolar disorder and cocaine use disorder (CUD), whether in heroin use disorder (HUD) or in alcohol use disorder patients (AUD). Aims: This topic required further investigation among former heroin, now alcohol use disorder (FHUD-AUD) patients. Methods: The selection of 60 FHUD-AUD out of 448 consecutive AUD patients, made it possible to design a comparative cohort study to differentiate prevalence, and clinical characteristics (diagnosis, addiction and treatment history), between FHUD-AUD patients with and without CUD. Results: The prevalence of FHUD-AUD-CUD in sample over the study period of 3 years was 45/60 (75%). FHUD-AUD patients with CUD were more frequently diagnosed as bipolar spectrum patients and showed higher concomitant use of benzodiazepines and cannabis than peers. These cases were more frequent and they reached a higher maximum level of alcohol consumption than FHUD-AUD patients without CUD. The most important predictors of concomitant cocaine use disorder were the presence of comorbid cannabinoid use disorder and of bipolar spectrum. No differences were found in severity of heroin addiction history or treatment history when comprising the kind of Agonist Opioid Treatment (AOT). Conclusions: FHUD-AUD patients showing comorbid cannabinoid use disorder and presence of bipolar spectrum are those who have the highest risk of developing comorbid CUD too. Using previous inadequate AOT as a possible discriminating factor fails to differentiate between FHUD-AUD patients with and without CUD, so emphasizing the crucial role of a proper diagnosis of mood disorder (especially if belonging to the bipolar spectrum).

Published: Volume 18 • Issue N4 • August 2016 (pages: 33 - 42)

Title: Acute Risk Factors in Fatal Opioid Overdoses as a Result of Hypoxia and Cardiotoxicity. A Systematic Review and Critical Appraisal.

Authors: Baldacchino A., Tolomeo S., Khan F., Humphris G., and Carra G.

Summary: Background: The rates of fatal opioid overdoses (FOO) have increased rapidly over the last 10 years. The actual phenomenon occurs as a result of a toxic opioid effect on the cardiorespiratory system. Aims: The systematic review aimed to identify the acute risk factors in fatal opioid overdose (FOO) as a result of hypoxia and cardiotoxicity. Methods: A systematic review was undertaken. The selection of papers has utilised rigorous criteria of inclusion/exclusion, controlled for heterogeneity. Results: A total of thirteen articles met the inclusion criteria. Ten of the thirteen studies included were retrospective and the other three studies employed different designs namely longitudinal cohort, case control and case cohort. Factors that were modestly described with increased acute risk of FOO due to hypoxia and cardiotoxicity include multiple sedative use (opioids and alcohol), reduced tolerance and presence of an acute painful condition. Conclusion: This systematic review has highlighted the lack of information on acute risk factors of FOO due to hypoxia and cardiotoxicity. Future studies need to explore possible mechanisms underlying cardiotoxicity such as reported changes in arterial stiffness in opioid dependent populations and the unexplored potential effects on endothelial function.

Published: Volume 18 • Issue N4 • August 2016 (pages: 43 - 50)

Title: General Practitioner Perspectives on and Attitudes toward the Methadone Treatment Programme in Ireland.

Authors: Delargy I., O'Shea M., Van Hout M.C., and Collins C.

Summary: Background. Methadone maintenance treatment in Ireland is provided in addiction clinics, and in primary community care settings by Level 1 and 2 specialist trained General Practitioners (GPs). The Irish College of General Practitioners (ICGP) provides training and regulates the Methadone Treatment Programme (MTP). Aim The study aimed to assess and compare GP perceptions of the scale of local illicit drug use, attitudes toward and obstacles in the provision of methadone treatment and preferred adjunct modalities. Methods In 2006 and 2015, an online survey was undertaken with all Level 1 and 2 registered GPs in the MTP. Results. The majority of participants were male, aged between 35 and 60 years, treated between 1 and 25 patients in urban areas. In 2015, 44.7% with registered methadone patients reported no obstacles to taking on more (32% in 2006). In relation to GPs with no current methadone patients, reasons for not taking patients in 2015 were similar to 2006, and centred on no referrals or demand, and concern for negative affect on private patients. Majority attitudes toward the MTP remained positive, with one exception relating to greater disagreement in 2015 with the statement that supervised daily dispensing prevents patients from working (p < .05). Preferred adjunct services remained constant; addiction counselling, in-patient detoxification, employment schemes and consultant psychiatric services. Conclusions. The study illustrates a generally positive attitude toward the Irish MTP. Efficient referral mechanisms for stabilised patients to primary care settings, and greater psycho-social, vocational and detoxification supports are warranted.

Published: Volume 18 • Issue N4 • August 2016 (pages: 51 - 54)

Title: Illicit Drug Related Suicide Mortality and Identification of Hidden Cases: Experience of Slovenia

Authors: Lovrečič M., Šelb J., Šelb K., and Lovrečič B.

Summary: Not Available

Published: Volume 18 • Issue N5 • October 2016 (pages: 5 - 14)

Title: Evaluating Methadone Maintenance Treatment. The Sant'arsenio Methadone Clinic, in the Vallo Di Diano Region (Italy), as Case Study

Authors: Mautone S., Maremmani A.G., Gazzarrini D., and Maremmani I.

Summary: Introduction: The correspondence between scientific knowledge and healthcare practices is essential to meeting the need to provide Heroin Use Disorder (HUD) patients with qualitative improvements in well-functioning methadone clinics. Methods: In our search to identify quality control requirements, we evaluated, in January 2010, and again in January 2012, the outcomes of all patients registered in the methadone clinic of Sant'Arsenio, Salerno, Italy, in which Dole and Nyswander methodology is strictly applied. Out of 212 evaluated heroin-dependent patients, 85 had only the January 2010 evaluation (patients leaving treatment), 103 had both assessments (patients staying in treatment) and 24 had only the January 2012 evaluation (patients entering treatment). Results: In all the patients investigated, medical outcomes were positive. In general, patients leaving a treatment were older than patients entering one (p=0.028). Patients entering treatment showed a lower percentage of working people than patients staying in treatment ones (p=0.002), were more often at first treatment (p=0.008) and showed a more severe illness than their peers (p=0.002), and were still using CNS depressants more frequently (p=0.009). Patients staying in treatment more often declared an adequate income (p=0.049); at the follow-up 2 years later, there was a significant improvement in the frequency of people leaving their parents' family (p=0.001), in numbers of people presenting only a mild psychopathology (p<0.001), in achieving the status of being without legal problems (p=0.021), and in having reduced cannabinoid use (p=0.019). They did not show any significant differences in changes in the severity of illness (0.118), global improvement (p=0.508) or the therapeutic/side effect index (p=0.481). Conclusions: We propose three simple requirements in assessing the quality control of a methadone clinic: (1) HUD patients leaving the treatment must have obtained similar results to those of stabilized patients staying in treatment. (2) HUD patients staying in treatment must be able to show an improvement in outcome, if there is a follow-up scheduled at least biannually. (3) HUD patients entering treatment must have had only very limited previous treatment, and they must be younger than patients leaving treatment.

Published: Volume 18 • Issue N5 • October 2016 (pages: 15 - 22)

Title: How to Improve a Poorly Running Agonist Opioid Treatment. Part 2: trust

Authors: Ulmer A. and Meinhold C.

Summary: Background: Can trust help to improve the treatment of addiction diseases? Almost no scientific research and no discussion in daily practice exist on this topic in relation to Agonist Opioid Treatment (AOT), even though it seems to be of central importance in determining the quality of treatment. Mistrust is an early and central symptom in the relationships with addicts. There is no cure without sustainably overcoming the problem. We must be open to discussion if we are going to meet the patients entrusted to our care with the right attitude. Otherwise, a predominant attitude of mistrust might have to be considered a permanent sin against them. A detailed discussion and some practical hints may help to develop trust, in situations where trust initially seemed impossible. We have tried a first approach to evaluating data. Methods: 55 patients were asked how much importance they attach to this issue in a questionnaire. The development of 109 of 127 patients, who were asked about happiness and trust in their childhood from the beginning, was also evaluated. Results: In this evaluation, we found no correlation. Conclusions: Despite the absence of correlations, the answers given by patients to the questionnaire indicated that trust is a central topic for them.

Published: Volume 18 • Issue N5 • October 2016 (pages: 23 - 32)

Title: Pharmacotherapy for Methadone-Induced Erectile Dysfunction: A Meta-Analysis

Authors: Yee A., Loh H.S., Sulaiman A.H., and Ng C.G.

Summary: Background: Methadone is recognized as an effective maintenance therapy for opioid dependence. Of the many adverse events reported, sexual dysfunction is the most common. To date, however, no standard treatments have been made available to this subgroup of patients. Aim: We conducted a meta-analysis to assess 2 therapeutic options – adjunctive medication or switching to buprenorphine – for treating sexual dysfunction among male patients on methadone maintenance therapy. Methods: Pertinent English-language studies published from inception until January 2016 were identified by searching through PubMed, OVID, Embase, PsycArticles EBSCO, Cochrane Library, and Google Scholar databases. Studies were selected using previously defined criteria. Heterogeneity, publication bias, odds ratios, and effect size were all assessed thoroughly. Results: In all, 826 male participants selected from 11 eligible studies were identified in this meta-analysis. The effect size of treatment with adjunctive medication was at least 3.8 (95% confidence interval [CI] = 2.5–5.2, p < 0.0001) times greater than that before the intervention. The odds of erectile dysfunction occurring in men treated with methadone were 5.6 times greater (95% CI = 0.06–0.6, p < 0.01) than that in men treated with buprenorphine. Similarly, the odds of sexual desire being lost in men receiving methadone were 14.3 times greater (95% CI = 0.04–0.2, p < 0.01) than those in men receiving buprenorphine. Conclusions: Evidence shows that switching to buprenorphine or using adjunctive treatment reduces sexual dysfunction among male patients on methadone.

Published: Volume 18 • Issue N5 • October 2016 (pages: 33 - 42)

Title: The Experience of Pregnancy, Childbirth and Motherhood of Drug Using Women

Authors: Mejak V. and Kastelic A.

Summary: Background: Not many of the studies on the pregnancy, childbirth and motherhood of drug-using women that have been conducted in Central and Eastern Europe, including Slovenia, have demonstrated the marginal position such groups hold in research. There is not much knowledge about experiences of drug-using mothers, their needs or risk behaviours, as almost all studies focus on the harm undergone by new-born children. Aim: The goal of this study was to explore and better understand the experiences of women using illicit drugs during pregnancy, childbirth and motherhood, and to recognize their needs and the obstacles they have to face. Methods: The in-depth semi-structured interviews with fifteen mothers who had used opioid drugs during their pregnancy and labour served as the source of information. All subjects were included in various addiction treatment programmes. The methodology used was qualitative. Results: Apart from the problems that are physically linked with drug use, pregnancy involves various psychosocial risks. The pregnancies of most of the mothers in this study (all of them were opioid users) had been unplanned and were detected at quite a late stage. When the mothers realized they were pregnant, they began to follow various harm reduction strategies that they believed would benefit their child, such as discontinuing illicit drug use and taking part in an agonist opioid maintenance treatment. The involvement of supportive partners and other relatives, as well as the comprehensive management of pregnancy and drug use, demonstrated positive effects on prenatal care. However, prejudice and various stereotypes prevented care and health workers, governmental and non-governmental institutions alike and individuals from applying effective strategies. This study has investigated severe features of these women's lives when they came to the term of their pregnancy and then childbirth. Conclusions: Pregnancy is a period that allows changes to happen in pregnant women's lives, and therefore calls for support strategies to benefit both mothers and their children.

Published: Volume 18 • Issue N5 • October 2016 (pages: 43 - 48)

Title: Diagnosis of Neonatal Abstinence Syndrome: Substance Use During Pregnancy

Authors: Thomas J. and Wolff K.

Summary: Introduction: Internationally the misuse of prescribed medications is becoming a significant public health problem. The misuse of opioid analgesics is especially problematic with their use in pregnancy a growing but under reported problem. The Case: A male neonate (3.485 kg) suffered poor feeding, gastro-intestinal disturbance, hypoglycaemia, and respiratory distress. During pregnancy his mother was prescribed a variety of psychoactive medications including an opiate analgesic (co-codamol), an antidepressant (citalopram), an antipsychotic (chlorpromazine) and a benzodiazepine receptor agonist (zolpidem). A diagnosis of Neonatal Abstinence Syndrome (NAS) was made following a postnatal disclosure of unquantified maternal tramadol misuse in pregnancy. Conclusions: It is important to recognise the risk of prescribed medication misuse during pregnancy and the impact these drugs may have on the fetus and neonate. A NAS following intrauterine exposure to opioid analgesics has been described clearly in the literature but evidence is limited to case studies and case series. The management of these neonates should include a full maternal medication history, supported by neonatal toxicology, with an applied understanding of the potential neonatal consequences of different intrauterine medication exposures.

Published: Volume 18 • Issue N5 • October 2016 (pages: 49 - 50)

Title: Suicide among Heroin Addicts in Opioid Agonist Treatment in Slovenia: The Impact of Age at Cohort Treatment Entry and Gender on Suicide

Authors: Lovrečič M., Šelb J., Šelb K., and Lovrečič B.

Summary: Not available

Published: Volume 18 • Issue N6 • December 2016 (pages: 5 - 12)

Title: Respiratory Health of Patients Receiving Opiate Substitution Treatment

Authors: Nelson P., Bartu A., Musk A.B., and Aboagye-Sarfo P.

Summary: Background: The recommended treatment for opioid dependent people is agonist opioid treatment (AOT). The pharmacotherapies used are methadone and buprenorphine. The effects of methadone are similar to other opioids such as morphine and include sedation and respiratory depression. There is good evidence that polydrug use, particularly tobacco, cannabis and alcohol, is common among opioid dependent people on AOT programs. These drugs have also been linked to impaired lung function. The aims were to examine gender differences (a) tobacco and cannabis consumption, and (b) respiratory symptoms and lung function of opioid dependent people receiving AOT. Methods: The sample (n=149) were recruited from two Western Australian drug and alcohol clinics from March 2009 to July 2012 from a pool of ~350 patients receiving AOT. Data were obtained on current and past smoking, passive smoking, cannabis use, AOT medications, asthma, and respiratory symptoms. Forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC) and the FEV1 /FVC ratio were measured by spirometry. Results: Mean age ~40. Smoking prevalence (tobacco) was 89% males and 82% females, cannabis 47% males and 54% females. Over 60% were unemployed. The majority were treated with methadone. Breathlessness was associated with FEV1 (p=0.02) and FVC (p=0.02), asthma with FEV1 (p=0.04). COPD was detected in 27% of males and 24% of females. 51% reported shortness of breath when hurrying on level ground or walking up a slight hill and 30% gave a history of morning cough. As indicated by the FEV /FVC ratio <0.70, 27.3% of men and 24 % of women had COPD. Conclusions: The sample was relatively young but many men and women were exhibiting smoking related respiratory symptoms and ~25% had COPD. Declining lung function appears to be an important morbidity among patients on OST, particularly among women. Smoking cessation interventions should be included in AOT regimes.

Published: Volume 18 • Issue N6 • December 2016 (pages: 13 - 20)

Title: Analgesic Plus Prayer Versus Analgesic Alone. Effect of Prayer on Intensity of Postoperative Pain, Anxiety and Physiological Indices in Surgical Patients. A Randomized Clinical Trial

Authors: Hasanpour Dehkordi A., Fatehi D., and Solati K.

Summary: Introduction: Most surgical patients have a personal level of pain. Certain procedures are available for reducing postoperative pain (PoP). Prayer is one of the valuable methods that favour patient relaxation and reduce PoP; it is especially valuable because it neither causes additional tasks for hospitals, nor raises financial issues for patients. Purpose of this study was evaluation of the effect of prayer on PoP reduction in gastrointestinal surgical patients. Methods: In this clinical trial we selected 108 patients who were candidates for gastrointestinal elective surgery. Patients were randomly divided into two groups: the case group (n=54), who relied on analgesic plus prayer, and the control group (n=54), who relied on analgesic alone. Case group patients performed a specific prayer, starting 6hrs before surgery began and continuing until 24hrs after the operation. Vital signs, anxiety and PoP intensity were evaluated at 3, 12 and 24hrs after surgery. Applying SPSS, data were analysed utilizing the T-test, Fisher's exact test, and the Chi-square test. Results: There were no differences between the two groups in terms of type of operation, gender, marital status, age, educational level, job, or income of the patients. A statistically significant difference was seen between the anxiety, physiological indices, and PoP intensity recorded for the two groups after 3, 12, and 24hrs (p<0.003). Furthermore, the quantity and type of the analgesic (morphine) drugs showed significant differences between the two groups (p<0.05). Amount of the analgesic for the control group patients was 1.2 times that of the case group. Conclusion: Prayer may increase pain threshold tolerance and the adaptation level of surgical patients. Hospitals could provide conditions in which elective surgical patients can perform their own prayer.

Published: Volume 18 • Issue N6 • December 2016 (pages: 21 - 28)

Title: Comparative Study on Sleep Quality and Disorders in Opiate and Methamphetamine Users

Authors: Khazaie H., Jalali A., Jozani Y., Moradi S., Heydarpour F., and Khaledi-Paveh B.

Summary: Background: Sleep problems are more widespread in psychoactive substance users than in the general population. The precise nature of sleep disorders differs between stimulant users, especially between those who use crystal methamphetamine and opioid addicts. The aim of this study was to compare sleep disorders and quality in opioid and methamphetamine dependents. Methods: The participants in this study were divided into two groups: opioid (n = 120) and methamphetamine dependents (n = 115). All of the participants completed the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and a demographic characteristics form. Results: The findings revealed that sleep quality was low in both groups; both were defined as poor sleepers by the PSQI. A comparison between opioid and methamphetamine dependents revealed that the former group had a lower sleep quality (p = 0.004). Moreover, considering the ESS score of more than nine, a higher level of daytime drowsiness was reported by opioid dependents. Conclusions: The findings indicated that there was a relationship between the type of substance taken and the sleep quality and disorders experienced by an individual.

Published: Volume 18 • Issue N6 • December 2016 (pages: 29 - 36)

Title: Randomized Controlled Pilot Trial of Auricular Acupuncture in Men with Schizophrenia and Co-Occurring Multisubstance Use Disorders

Authors: Gimelfarb Y., Goldstein E., Natan Z., Elwahidi S., Kaikov E., and Baruch Y.

Summary: Background: There is no empirical evidence to recommend auricular acupuncture treatment for patients with schizophrenia and co-occurring substance use disorders. The lack of data on the efficacy and safety of auricular acupuncture has led to the inappropriate use of this therapeutic intervention in this population. Aim: To investigate the effects of auricular acupuncture with Antipsychotic Drugs (APD) versus APD alone on changes in both psychiatric and addiction issues in dual diagnosis patients. Methods: Randomized, controlled open label trial with a study sample of schizophrenic men with multisubstance use disorders conducted between January 2007 and November 2012. There were 41 randomly selected participants, of whom 36 had been analysed. The study population, who attended auricular acupuncture sessions 4-5 times a week and APD, comprised 22 men (mean age 31.0+8.9 years; 20 (90.9%) with atypical APD), while the control population (APD alone) comprised 14 men (mean age 32.7+6.8 years; 10 (71.4%) of them with atypical APD). Outcome Measures: Antipsychotic efficacy was measured by Clinical Global Impression–Severity (CGI-S) and CGI-Improvement (CGI-I); craving was measured by Dartmouth Assessment of Lifestyle Inventory (Drug-DALI); treatment compliance was measured by Drug Attitude Inventory-10 (DAI-10). Results: There were no significant differences between the groups before the trial. There were no differences in CGI-I between the subpopulations during RCT (NS). A decrease was found in the mean DALI score in both subpopulations after 10 (p<.001) and again after 20 (p<.05) sessions. There was an increase in the mean DAI score in the study subpopulation after 10 sessions (p<.001). Conclusions: Auricular acupuncture with APD is likely to be associated with greater improvement in treatment compliance.

Published: Volume 18 • Issue N6 • December 2016 (pages: 37 - 42)

Title: Correlation between Duration of Treatment and Cortisol Plasma Level in Methadone-Maintained Patients

Authors: Ignjatova L., and Spasovska Trajanovska A.

Summary: Background. The various endocrine abnormalities reported in heroin addicts and patients in methadone maintenance treatment include: increased thyroxin, triiodothyronine and prolactin levels, and abnormalities in sexual hormone, ACTH and cortisol secretion. The pathophysiological mechanism that has been postulated does explain these findings, including the direct action of heroin or methadone along the hypothalamic-pituitary-adrenal axis. Aim. The aim of this study is to determine the correlation between duration of methadone treatment and cortisol plasma levels in patients treated with methadone maintenance therapy. Methods. The study was carried out at the Centre for Prevention and Treatment of Drug Abuse and Addiction, a part of the Skopje Psychiatric Hospital. The hormonal analysis was carried out at the Department of Clinical Biochemistry, Skopje University Hospital. It is an analytical, cross-sectional study that included 50 male patients in methadone maintenance treatment, divided into two groups. The first group consisted of 34 male patients who had been maintained on methadone treatment for over 2 years. The second group consisted of 16 male patients who had been maintained on methadone treatment for 2 years or less. To discover demographic characteristics we used medical records, and to determine cortisol plasma level we relied on the Chemiluminescence Immunoassay method. The results were analysed statistically by using a t-test for independents samples, χ² test, and Pearson coefficient of linear correlation. Results. The results show that patients treated with methadone for 2 years or less have significantly higher plasma cortisol levels than patients treated with methadone for over 2 years. Conclusions. Longer duration of methadone maintenance treatment tends to normalize the cortisol plasma level.

Published: Volume 18 • Issue N6 • December 2016 (pages: 43 - 50)

Title: Psychopathological Dimensions and Addictive Behaviours in Heroin Use Disorder Patients

Authors: Maremmani A.G.I., Rovai L., Bacciardi S., Massimetti E., Gazzarrini D., Pallucchini A., Rugani F., Pani P.P., and Maremmani I.

Summary: Background. Specific psychopathology of Heroin Use Disorder (HUD) patients has been proved to be independent of treatment location (outpatient facilities or therapeutic communities), detoxification status, and patients' lifetime psychiatric issues. It was able to successfully discriminate between depressed patients and HUD patients. It also influenced treatment outcomes during methadone and buprenorphine treatment. When the 13 addictive behaviours of HUD patients were examined, Dual Disorder (DD) HUD patients showed a particular addictive behaviour pattern correlated with finding and taking opioids to alleviate psychopathology. In this study we tried to typify these addictive behaviours according to the severity of HUD-specific psychopathology, by checking the influence of the severity of psychopathological dimensions on the addictive behaviours we had previously found in DD-HUD patients. Methods. We examined, in this naturalistic, observational, cross-sectional study, the correlations between psychopathological dimensions and addictive behaviours in 114 HUD patients, at Agonist Opioid Treatment entry. We used the nonlinear canonical correlation analysis. Results. Significant correlations were found between severity of ‘worthlessness-being trapped' and ‘panic-anxiety' symptomatology, and the tendency of patients to adopt risk behaviours, using syringes that don't look good or injecting everything they think ‘will work' in absence of heroin, and prizing heroin much more than anything else they ever enjoyed before. The severity of sensitivity-psychoticism symptomatology correlated with having trouble using anti-withdrawal pills and with being willing to put up with a lot of stress to get heroin. Behaviours related to obsessive craving, relief craving or cue-induced behaviours showed lower correlation with the severity of psychopathology. Conclusions. Typifying addictive behaviours in HUD patients on the basis of the severity of their psychopathological dimensions is possible only for depressed-anxious or sensitive-psychotic patients, who are characterized by risk behaviours and with finding and taking opioids to alleviate psychopathology. The majority of addictive behaviours we investigated were not related to the severity of the psychopathology shown.

Published: Volume 18 • Issue N6 • December 2016 (pages: 51 - 60)

Title: Heroin Addiction Patterns of Treatment-Seeking Patients, 1992-2013: Comparison between Pre- and Post-Drug Policy Reform in Portugal

Authors: Pombo S., and Félix da Costa N.

Summary: Background. The abuse of illicit drugs is a significant public health concern. In Portugal, a new drug policy was put into practice with the intent of preventing drug-related problems. Aim. This study was designed to evaluate the patterns of heroin addiction and drug treatment involvement in the periods of pre- and post-drug policy reform. Methods. A comparative study evaluated heroin treatment-seeking clients (N=627; 82.3% males and 17.7% females) at their first visit in one of the two periods 1992-1999 and 2002-2013. Data on drug treatment admissions were also analysed for comparison (N=2,323 cases entering treatment). Results. Comparison between the 1992-1999 and 2002-2013 periods showed that: treatment demand declined by 37%, whereas treatment engagement increased by 94%; drug users have aged, become better educated and reported more cocaine use. In general, men were more likely than women to receive treatment (82.3% to 17.7%), but the number of women accessing treatment increased (from 13.0% to 20.9%). Drug injection has decreased and heroin users are choosing to smoke heroin rather than injecting it. HIV infection decreased, too (28.0% to 19.6%). The prevalence of hepatitis C infection, alcohol use and abuse and a criminal history remain stable. Conclusions. Drug scene has changed in Portugal. The drug-use profile of heroin-addicted patients changed after the new policy on drugs was implemented. Heroin indicators are generally stable or trending downwards. Our clinical findings are discussed in view of the recent drug policy reform. Assessing trends in drug use among heroin-using patients can reinforce prevention efforts.

Published: Volume 19 • Issue N1 • February 2017 (pages: 5 - 12)

Title: Severe Trauma among Substance Users in Opioid Maintenance Treatment: Users' Assessment of Worst Trauma and Clinical Assessment of PTSD.

Authors: Kjøsnes R., Waal H., Hauff E., and Gossop M.

Summary: Background: PTSD is highly prevalent among heroin dependent patients. Achieving a better understanding of the association between trauma symptoms and substance use is important for treatment services. Aims: This study looks at severity of trauma among patients seeking opioid maintenance treatment (OMT), and at associations between types of trauma, substance use and PTSD. Methods: Patients seeking opioid maintenance treatment (OMT) in the Oslo region were interviewed voluntarily signing up for the study. Data were collected using the Life Event Checklist, SCID, PTSD, EuropASI and M.I.N.I. Results: The sample (N=61) reported a range of traumatic events, often on repeated occasions. Almost three quarters (72%) met clinical criteria for lifetime PTSD, and about half (48%) for current PTSD. Those whose worst trauma occurred before age 8 years were most likely to have current PTSD, and the worst trauma typically occurred before onset of heroin use. Conclusions: Symptoms of PTSD have implications for treatment of heroin dependence. The provision of effective treatments for substance users with PTSD remains a challenge to treatment services, which often do not sufficiently address this comorbidity.

Published: Volume 19 • Issue N1 • February 2017 (pages: 13 - 18)

Title: GDNF Serum Levels Are Decreased in Opioid-Maintained Patients

Authors: Groh A., Janke E., Rehme M., Schuster R., Lichtinghagen R., Frieling H., Bleich S., Hillemacher T., and Heberlein A.

Summary: Background: The neuropeptide GDNF (glial cell line-derived neurotrophic factor) has been shown to correlate with psychiatric diseases like depression, anxiety and addiction. We therefore investigated GDNF serum levels, craving and other affective variables in opioid-dependent patients who received either diamorphine or levomethadone, comparing them with healthy controls. Methods: We measured serum levels of GDNF in opioid-dependent patients who received diamorphine (n=6) or levomethadone (n=6), and in an age- and gender-matched control group (n=37). Results: The GDNF serum levels in the three groups differed significantly. They were significantly higher in the diamorphine-maintained patients than in the levomethadone-maintained patients. Serum levels in both groups were significantly lower than in the healthy controls. Conclusion: GDNF levels seem to be lower in opioid-dependent patients and may act as a biomarker for substance use disorders.

Published: Volume 19 • Issue N1 • February 2017 (pages: 19 - 26)

Title: Characteristics of Patients Accessing NHS Lanarkshire Addiction Services for the Treatment of Opioid Analgesic Dependence

Authors: Hill D.

Summary: Background: Reviewing patient characteristics of new patients attending NHS Addiction Services in Lanarkshire, an increase in new patients accessing treatment for opioid analgesics dependence (OAD) was identified.This article conducted to assist in the identification of the characteristics of OAD patients that are presenting to addiction services in NHS Lanarkshire by using data collected, on the Europad-RADARs surveillance form, at the first medical appointment on substances used in the 90 days prior to admission. Methods: A total of 217 patients had accessed the service in the time frame. Of these, 29 patients (13.3%) declared that their primary drug of misuse was a prescribed opioid analgesic. Results: The reported results demonstrated that 13 (45%) were female. Various routes of obtaining the medication were reported, including access to illicit markets and supplies.16 (55%) patients reported taking other medications in addition for a euphoric effect. In relation to chronic pain, as defined in the questionnaire, 10 (35%) of the patients reported to having chronic pain at some point in their life and 19 (65%) reported to have never attended a GP for chronic pain. Conclusions: The data collected demonstrates that there is a demand for addiction treatment services to be provided for patients who have been misusing prescribed opioid analgesic medications and the demand for these services appears to be increasing. As a result the services employed to address the issue and provide treatment for these patients may need to be adapted from the traditional illicit opioid user model.

Published: Volume 19 • Issue N1 • February 2017 (pages: 27 - 40)

Title: Understanding Diversion of Prescribed Opioid Agonist Medications in Birmingham, Uk—Prevalence and Predictors of Diversion

Authors: Ratcliffe K., Chopra B., and Day E.

Summary: Background: Opioid agonist treatment (OAT) is an evidence-based intervention but concerns persist regarding diversion. Aim: This study assessed the prevalence of and motivating factors behind OAT diversion and acquisition of illicit OAT self-reported by persons treated within OAT programmes or accessing needle and syringe programmes (NSPs) in Birmingham, UK. Methods: 511 people in OAT programmes and 105 NSP users completed anonymous questionnaires consisting of 25 open and closed questions. Logistic regression analysis was used to explore associations between OAT diversion and acquisition of illicit OAT. Results: 32.5% (95% CI 28.4-36.6%) of people in OAT programmes self-reported diversion at some point. 12.1% (n=62) had diverted at least once a week. 25.2% (n=129) reported current diversion, with giving it away (n=64, 49.6%) more common than selling (n=21, 16.3%); 44 (34.1%) reported both reasons. In NSPs, most was purchased (67/74, 90.5%). In OAT programmes, the likelihood of diversion was higher in those who continued to use illicit drugs (OR=3.65, 95% CI 1.76–7.56, p=0.0005) and in people not taking the full dose of OAT. Rates of diversion appeared to be similar among all subgroups of illicit drug users. No difference in the risk of diversion of methadone and buprenorphine was found. OAT acquisition was common in OAT programmes (63.6%, 95% CI 59.4–67.8) and highly associated with continued illicit drug use and long-duration in treatment, and common in NSPs (70.5%, 95% CI 61.8–79.2%). Conclusions: Diversion and acquisition rates of OAT were high but consistent with previous European studies. The predictors identified offer important clues to reduce these activities, and point to the importance of optimised OAT with awareness of diversion potential, side effect profile, and effective supervision.

Published: Volume 19 • Issue N1 • February 2017 (pages: 41 - 44)

Title: Directly Observed Rivaroxaban Therapy for Recurrent Venous Thromboembolism Integrated into Methadone Maintenance. A Case Report.

Authors: Weichert I.

Summary: Background: Intravenous drug use is associated with venous thromboembolism and poor compliance with medication. This puts patients at risk of recurrence of a potentially life-threatening disease and creates a significant challenge for clinicians. In the same patient group, adherence to treatment for HIV, hepatitis c, and tuberculosis improves when combined with methadone maintenance and in directly observed therapy but this approach is generally not employed in the management of other conditions. Case Report: A drug user, with a history of thrombophilia and repeated thromboembolism, presented with a recurrence of pulmonary embolism after not adhering to anticoagulation. Rivaroxaban was restarted in directly observed therapy, combined with the already established methadone therapy. This led to compliance with anticoagulation without affecting the stabilisation treatment. Conclusions: This strategy, mainly used to improve compliance in the management of conditions that pose a particular risk to public health, should be considered to help drug users adhere to therapy for venous thromboembolism and indeed other medical conditions. This is the first published case where anticoagulation has been successfully integrated into directly observed methadone maintenance.

Published: Volume 19 • Issue N1 • February 2017 (pages: 45 - 54)

Title: Prevalence and Risk Factors for Hepatitis C Viral Infection Amongst a Cohort of Irish Drug Users Attending a Drug Treatment Centre for Agonist Opioid Treatment (AOT).

Authors: Keegan D., Crowley D., Laird E., and Van Hout M.C.

Summary: Background: Injecting drug use (IDU) is a major driver of the European hepatitis C virus (HCV) epidemic. National data on prevalence of HCV amongst Irish drug users remains confined to certain treatment sites and prison settings. Aim: To examine the prevalence of HCV infection and risk factors associated with infection among the 228 patients attending Opioid Substitution Treatment (OST) in a clinic in Dublin. Materials and Methods: A retrospective cross-sectional study was conducted using data collected from Health Research Board (HRB) forms and standardised written and electronic assessment forms routinely completed on OST initiation. Results: The prevalence of HCV infection was 63.6 % (n= 145) with no significant gender difference (p=0.717). Patients who were infected with HCV were older than those uninfected (41.1 ± 7.5 years versus 37.5 ± 8.5 years; p = 0.001), with prevalence significantly lower in younger adults (p=0.002). Multivariate analysis identified age of first drug use (p=0.002) and first injection (p=0.001), type of first drug used; cannabis (p=0.015), heroin (p=0.014) and cocaine (p=0.018) and early age of OST entry (p=0.001) as the most significant risk factors for HCV infection in this cohort. Those with no IDU had decreased odds of being HCV positive by 91.1%. Conclusion: Data for this Irish sample indicates high prevalence of HCV infection, and the need to consider age of first drug onset and injecting use, particular drug types and earlier commencement of OST to inform targeted HCV treatment and prevention interventions in Ireland.

Published: Volume 19 • Issue N1 • February 2017 (pages: 55 - 62)

Title: Towards Best Practice: Trends in the Management of Opioid Analgesic Dependence. Meeting Report.

Authors: Alam F., D'Agnone O., Bremner D., Tuckey G., Abbasi Y., and Littlewood R.

Summary: Background: Opioid analgesic dependence (OAD) may be a consequence of treatment for pain, or result from consumption of illegally acquired or diverted analgesic drugs, possibly related to underlying mental health problems such as anxiety. Affected populations and clinical management are different from street heroin dependence. Relevant evidence and guidelines review does not clearly define best practice in OAD decision-making. An expert-led approach integrated real world experience from clinical practice to define decision-making paradigm for OAD. This was presented to a symposium of experts at the 2016 meeting of EUROPAD. Meeting report: For OAD, treatment assessment often includes management of pain and potentially, other mental health problems such as anxiety or affective disorders. Treatment selection considers a broad set of interventions and outcomes/service user aims (for example: individual and society goals, work, social etc.). Other factors including minimising the risks of overdose, harm to children from inadvertent consumption of prescribed medications in the domestic setting, or potential for service users to participate in criminal behaviour may be important. Experience indicates that the integrated team approach with psychosocial interventions promotes success. An integrated medical treatment plan with options combining prescribed medicines indicated for dependence, other therapies, psychosocial interventions is described for OAD management. Options for treatment selection include: reduce current opioid analgesic medication, initiate medication assisted treatment, stop opioid analgesic medication in managed withdrawal. Success from clinical experience informs care choices for different types of people with OAD. This decision-making tool is a useful start in defining best practice in OAD care. Conclusion: Symposium participants concluded that the management algorithm was useful and that suggested planning in its treatment choice section were useful.

Published: Volume 19 • Issue N2 • April 2017 (pages: 5 - 16)

Title: Staff regard towards working with patients with co-morbid depression and substance misuse: an exploratory study

Authors: Nutt R., Gilchrist G., Marsa-Sambola F., and Baldacchino A.

Summary: Background. Patients having co-morbid mental health and substance misuse experience poorer treatment outcomes than those treated for either condition alone. Studies suggest health professionals regard towards these patients is a factor. Aims. To compare regard towards patients with co-morbid depression and substance misuse across different health professions and services, relative to independent conditions (depression, diabetes, alcohol and/or drug misuse). Methods. A cross-sectional comparative exploratory study of regard towards five patient groups conducted on multi-disciplinary staff (general practitioners, psychiatrists, psychologists, nurses and social workers. Total n=113) in three Scottish NHS board regions – NHS Fife, Tayside and Forth Valley. Services from three main treatment entry points were recruited in each region - 10 primary care services (43.5%), 7 mental health (70%) and 4 specialist addiction (100%). Descriptive statistics were calculated for regard towards each patient group. Multifactorial between subjects ANOVA examined influences on Medical Condition Regard Scale (MCRS) scores. Results. Regard towards patients with co-morbid depression and substance misuse was frequently lower than towards patients with independent conditions. Male professionals held lower regard towards these patients than female (p=0.03). Addiction services held the highest regard and general practice lowest (p <0.001). Over-45's held the lowest regard towards these patients (p=0.02). Health professional's satisfaction with working with these patients was also low (mean 1.98, sd 1.22) compared to other conditions. Conclusions. Regard towards patients with co-morbid depression and substance misuse is lower than either condition independently, particularly among older, male professionals and those in general practice.

Published: Volume 19 • Issue N2 • April 2017 (pages: 17 - 24)

Title: The Role and Function of Heroin-Assisted Treatment at the Treatment System Level

Authors: Uchtenhagen A.

Summary: Introduction: Prescribing opium, morphine and heroin to opiate addicts has a long history, as an approach to prevent negative consequences from excessive and uncontrolled use. It rarely reached the majority of this target population. During the 20th century, moral concerns mainly led to control measures and total prohibition (except for medicinal use and research). Other opioid agonists replaced opiates for maintenance therapy; Methadone and Buprenorphine maintenance became the preferred approaches to reach out effectively heroin addicts and to allow for significant improvements in health and social status of patients. Their role for the treatment system is essential. Aim: to describe the revival, role and function of heroin-assisted treatment (HAT), and to review critical concerns against this approach in the light of research evidence. Methods: research reports, reviews and monographs on opiates, agonist maintenance treatment and HAT. Results: The extent of HAT in countries where it is available is modest, in comparison to other agonist maintenance treatments for opiate dependence. Within the European Union, the role of HAT is marginal. A range of therapeutic, safety, prevention and economic concerns about potential negative effects of HAT, for patients and for the treatment system, are discussed in the light of relevant research evidence. None of the concerns is justified. Positive effects for the treatment system and for public order prevail. Conclusions: the present model of HAT has good outcomes for previously treatment-resistent heroin addicts, is a safe and cost-effective therapy and a useful element in a comprehensive treatment system for heroin addicts.

Published: Volume 19 • Issue N2 • April 2017 (pages: 25 - 42)

Title: Effectiveness of Pharmacotherapies in Increasing Treatment Retention and Reducing Opioid Overdose Death in Individuals Recently Released from Prison: A Systematic Review.

Authors: Crowley D., and Van Hout M.C.

Summary: Background: Opioid dependence is common amongst the prison population, with increased risk of fatal overdose in the immediate post-release period. Aim: The study aimed to review the effectiveness of pharmacotherapies (Methadone (METH), Buprenorphine (BUP), levo-alpha acetyl methadol (LAAM), Naltrexone (NLT) and Naloxone (NLX)) in reducing overdose deaths and increasing treatment retention in opioid dependent prisoners on release. Methods: A systematic review of studies on recently discharged opioid dependent prisoners receiving METH, BUP, LAAM, NLT and/or NLX was conducted. Factors of interest regarded post-release treatment retention, non-fatal overdoses (NFODs), overdose mortality, and continued heroin and/or other illicit drug use. Searches were conducted using MESH terms; opioid related disorder, prisoner, NLT, NLX, METH, BUP, LAAM, overdose. Exclusion criteria were applied as per PRISMA guidelines. Quality, outcome and risk of bias assessments were applied across studies. Results: Eight randomised control trials (RCT), one non-randomised trial and five observational studies formed the data set. Agonist Opioid Treatment (AOT) (METH, BUP, LAAM) initiated pre-release was associated with significant post-release treatment retention on discharge into the community, and post-release reduction in heroin use. Prisoners on BUP or METH on discharge had significantly reduced mortality risks in the immediate four weeks post-release. There was insufficient evidence supporting a reduction in NFODs and continued other illicit drug use. Conclusions: The review underscores the need for prisoners on AOT to be supported with continued treatment on release into the community. Further research is warranted to investigate potential utility of long-acting NLT formulations and take-home NLX (THN) in pre –release opioid dependant prisoners.

Published: Volume 19 • Issue N2 • April 2017 (pages: 43 - 48)

Title: Ten Years of Psychological Research on Heroin Addiction and Related Problems at the New Bulgarian University: An Overview

Authors: Todorov O., Psederska E., and Milcheva A.

Summary: Background: Heroin abuse and dependence constitute a significant public health problem that Bulgarian society now has to face. There has been a sizeable increase in the number of heroin-dependent individuals during the last few decades, which raises the issue of the importance of early identification, prevention and effective treatment programmes for this type of addiction. Methods: In the following review we wish to share some empirical findings related to the psychological factors that play a role in heroin dependence. The data presented here have been accumulated over the last ten years through various empirical studies conducted by graduating psychology students and their academic supervisors from the clinical psychology unit at the New Bulgarian University. Results: These studies generally fall into one of the three following categories: assessing environmental factors related to the outbreak and maintenance of drug abuse and addiction; the personality (temperament and character traits) of users; and characteristic psychological states and diagnostic profiles. Conclusions: The reviewed studies hopefully might be used as a further support in assessing the topical issue of psychological factors in the vast field of heroin addiction studies.

Published: Volume 19 • Issue N2 • April 2017 (pages: 49 - 58)

Title: Psychological Changes among Male Drug Dependent Offenders in a Prison-Based Therapeutic Community Programme

Authors: Powis B., Randhawa K., and Gossop M.

Summary: Background. Therapeutic communities have been found to be an effective intervention for drug dependent prisoners but little is known about the psychological mechanisms for change during treatment. Aims. The study investigates changes in locus of control, and in attitudes and beliefs about criminal behaviours among drug dependent offenders in a prison-based therapeutic community programme. Methods. Prospective, longitudinal study of 406 adult male, drug dependent offenders who entered a prison hierarchical TC programme. The programme duration was approximately 12 months, with 3 phases, induction, primary, and re-entry. Data were collected on demographics, substance use history, severity of drug dependence (SDS), criminal history, and risk of reoffending: main measures were Locus of Control (LOC), and Criminal Sentiments Scale-Modified (CSS-M). Results. Statistically significant reductions were found across each stage of the TC programme with regard to personal responsibility (LOC), and for antisocial cognitions (CSS-M). No differences in responses were found between the heroin-dependent and cocaine-dependent offenders. No difference was found between heroin-dependent and cocaine-dependent offenders in programme completion rates. Conclusions. Psychological changes occurred sequentially as drug-dependent offenders progressed through the TC phases, which are consistent with the TC model of change and programme goals and the study provides encouraging evidence about the impact of prison-based TCs. Relatively little is known about the processes that are responsible for change during treatment, and the present findings add to this literature. Identifying and measuring changes in the individual during treatment is important when examining the factors that promote effective interventions.

Published: Volume 19 • Issue N2 • April 2017 (pages: 59 - 68)

Title: Psychosocial Determinants in the Treatment of Opioid Use Disorder with Buprenorphine: an Overview of the Literature

Authors: Phelan J.

Summary: Background: The use of buprenorphine for the treatment of opioid use disorders has increased significantly in the past 10 years indicating a rapidly changing course of treatment. Methods: In order to see what extent psychosocial domains have been measured at baseline and at ending points with patients taking buprenorphine, an overview of the literature was conducted. Results: The reports that were eligible for review were promising as they yielded evidence of improved psychosocial outcomes including psychological, family, social, legal, employment, environmental ones in relation to buprenorphine treatment. Reductions in sexual risk behaviors were also found in some reports. The majority of participants were also engaged in some form of psychosocial intervention combined with buprenorphine treatment. Conclusions: Although more research is needed, the data available implies more attention be given to outcomes of treatment and the psychosocial needs of patients diagnosed with opioid use disorder/dependence, making a case for increased access to care.

Published: Volume 19 • Issue N2 • April 2017 (pages: 69 - 74)

Title: How to Improve a Poorly Running Agonist Opioid Treatment. Part 3: realistic Goals

Authors: Ulmer A., and Meinhold C.

Summary: Background: Each treatment needs a goal. Patients have often reported that unrealistic goals were being pursued, when the treatment of an addiction disease was running poorly. Methods: In response to that situation, we conducted a survey involving 53 Agonist Opioid Treatment (AOT) patients from our practice: “Do you too experience this problem in our treatment?” Results: At least 32.1% of the interviewees answered in the affirmative, predominantly by referring to their past experiences. They most frequently had to do with the consumption of alcohol and the dosage, but also dealt with benzodiazepines, employment, education and other topics. The most interesting aspect was that many answers were much more extensive. Common goals require cooperation in a partnership, while experiencing a feeling of dignity. Several patients went as far as to use the term ‘trust'. Conclusions: We should always be aware that single patients are a personal responsibility for us, as should be true of all other patients, not just being perceived as a number in a programme.

Published: Volume 19 • Issue N3 • June 2017 (pages: 5 - 10)

Title: Association between Serum Concentrations of Natriuretic Peptides and Perceived Withdrawal Symptoms in Opiate Maintenance

Authors: Schuster R., Glahn A., Heberlein A., Rehme M.-K., Kleimann A., Lichtinghagen R., Koopmann A., Bleich S., and Hillemacher T.

Summary: Background: Volume-regulation peptides indirectly influence the hypothalamic–pituitary–adrenal (HPA) axis and thereby also the strength of craving, withdrawal symptoms and the potential risk of relapse. Aims: The primary objective of the present study was to examine the serum levels of atrial and brain natriuretic peptides (ANP and BNP) in patients undergoing different opiate-based maintenance treatments. Methods: We compared two groups of patients receiving levomethadone (n=55) or else diamorphine (n=28) treatment, with a third, healthy control group (n=51). Results: We found a potential association between withdrawal symptoms measured with the Short Opiate Withdrawal Scale (SOWS) and serum levels of ANP and BNP in opiate-addicted patients undergoing diamorphine maintenance treatment. Conclusions: Differently from methadone maintenance, diamorphine seems to be unable to suppress natriuretic peptides levels, which, in our patients, reflect the amount of opioid withdrawal symptomatology.

Published: Volume 19 • Issue N3 • June 2017 (pages: 11 - 20)

Title: Enhancing Knowledge and Reducing Barriers Improve Hepatitis C Management in Methadone Maintenance Treatment Patients

Authors: Peles E., Adelson M., Sason A., Katchman H., Bruck R., Levit S., Schreiber S., and Shibolet O.

Summary: Background: Lack of knowledge and bureaucratic obstacles may prevent hepatitis C virus (HCV) treatment among methadone maintenance treatment (MMT) patients. Aims: to improve knowledge and enhance HCV treatment. Methods: HCV seropositive patients were invited to attend a lecture on HCV disease. Participants completed Virus-knowledge and Depression questionnaires before and after the lecture, and were then referred to evaluation and treatment in Liver Unit. Results: Of all the 80 eligible patients invited, 48 attended the lecture and scored significantly better on knowledge about HCV than the non-attendees. Having attended a lecture predicted referral to treatment (Odds ratio (OR) = 13 (95% Confidence Interval (CI) I 3.9-44.9 P < 0.0005)). Of the 41 referrals, only 21(51.2%) actually presented at the Liver Unit; they were characterized by lower depression scores (OR=0.2, 95%CI 0.06-0.9 P = 0.03). Despite administrative barriers, 15 (71.4%) underwent evaluation, 12 (80%) initiated anti-HCV treatment with pegylated interferon, ribavirin with (G1) or without (G2 and G3), a first generation protease inhibitor. Nine patients (75%) achieved sustained virologic response (one was a non-responder and two stopped treatment due to adverse events). Of the 59 who were referred, but did not arrive at the Liver Unit, 14 (23.7%) were followed up elsewhere, but only one of them (7.1%) started treatment. Conclusions: The fact of attending a single lecture led to improved knowledge and enhanced HCV treatment initiation among MMT patients, although the attendees and non-attendees alike still continued to show a certain degree of depression. Interventions to reduce administrative barriers and improve patients' knowledge about HCV disease, together with treatment of depression when needed, are recommended in MMT patients infected with HCV.

Published: Volume 19 • Issue N3 • June 2017 (pages: 21 - 36)

Title: Methadone Maintenance Therapy Users' Knowledge and Attitudes toward the Methadone Maintenance Therapy: A Meta-Analysis

Authors: Yee A., Loh H.S., Tan J.T., Tan A., and How M.Y.

Summary: Background: Methadone maintenance treatment is effective against opioid dependence. Despite its efficacy, its one-month dropout rate had been reported to be as high as 24%. Studies have associated poor treatment compliance with poor knowledge of and attitude towards treatment. Aim: Our meta-analysis aims to examine the topics of knowledge of and attitude to MMT. Methods: A total of 3,979 participants were recruited from 16 eligible studies, published from inception till August 2015, identified by searching through the PubMed, OVID, EMBASE and EBSCO databases. Results: Our study showed that participants generally had poor knowledge and experience of MMT, and poor attitudes to it. In 7 papers, associated factors of poor attitude to and knowledge of MMT were reported to include: no history of prior or current use of methadone, failure to provide sufficient information, excessive youth, including those who are still too young to qualify when initiating opioid use, depression or stress, admission to detoxification centres, and incarceration. Conclusions: Despite its methodological limitations, this meta-analysis may offer insight to clinicians about poor knowledge, attitudes and perceptions as factors contributing to poor treatment compliance and failure to provide solutions.

Published: Volume 19 • Issue N3 • June 2017 (pages: 37 - 48)

Title: Drug Addiction and Emotion Dysregulation in Young Adults

Authors: Parolin M., Simonelli A., Cristofalo P., Sacco M., Bacciardi S., Maremmani A.G.I., Cimino S., Trumello C., and Cerniglia L.

Summary: Background: It is widely acknowledged that drug addiction is characterized by emotional dysregulation. Relatively few studies in this field, however, have focused on early adulthood. Aim: The present study aims to assess emotional functioning in young adults (aged 18-24) with drug addiction who have already been admitted to residential treatment. Methods: A group of young drug addicts admitted to residential treatment (N=41) was compared with a group of young adults without Substance Use Disorder (N=27). A series of psychological self-report questionnaires on emotional functioning, Toronto Alexithymia Scale-20 item, Sensation Seeking Scale–VI, Emotional Quotient Inventory and Observer Alexithymia Scale were administered. Descriptive and nonparametric analyses (Pearson's chi square test, Mann-Whitney U test, and McNemar test) were performed. Results: High rates of alexithymia emerged from the administration of the observer scale, in contradiction with the self-report evaluation; also, past experiences related to sensation seeking and inadequate emotional intelligence abilities were identified as characteristics of this clinical group. Conclusions: Our results suggest that drug dependence in young adults is characterized by difficulties in emotional regulation, indicating the importance of specific and new treatment methodologies.

Published: Volume 19 • Issue N3 • June 2017 (pages: 49 - 56)

Title: Neuropsychological Deficits in Young Drug-Addicts

Authors: Parolin M., Simonelli A., Cristofalo P., Mapelli D., Bacciardi S., Maremmani A.G.I., Cimino S., Babore A., and Cerniglia L.

Summary: Background: Adolescence is a highly vulnerable age for experimenting with drugs; increasing evidence attests that several substances might have detrimental effects on cognitive functioning in this developmental phase, when prefrontal brain areas are still immature and may actually be the main target of the neurotoxic effects of drugs. There are still, in any case, too few studies that specifically address early adulthood. Aim: The present study aims to investigate neuropsychological performance in young drug addicts in residential treatment (aged 18-24). Methods: 41 young drug addicts, after admission to residential treatment, were compared with 27 subjects in the control group. A battery of neuropsychological tests (Brief Neuropsychological Exam-2) was administered to detect possible cognitive impairments. Descriptive and non-parametric statistics (Pearson's chi square test) were performed. Results and conclusions: Findings suggest that drug dependence in youth is distinguished by neuropsychological deficits, in particular, attention and executive function impairments – issues that now call for tailored and innovative treatment approaches.

Published: Volume 19 • Issue N3 • June 2017 (pages: 57 - 64)

Title: The Influence of Comorbid Personality Disorder on Patients in Heroin-Assisted Treatment: Pilot Data on Clinical Outcome

Authors: Dammann G., Gerber H., Denier N., Schmid O., Huber C., Riecher-Rössler A., Wiesbeck G.A., Borgwardt S.J., Gremaud-Heitz D., and Walter M.

Summary: Background: The diagnosis of a comorbid personality disorder (PD) is very common in patients with drug dependence. However, it is unclear whether differences between opioid-dependent patients with and without co-occurring PD influence diamorphine-assisted substance abuse treatments. Methods: Twenty-six patients with a diagnosis of opioid dependence (according to DSM-IV) in a stable heroin-assisted treatment (HAT) were included in this pilot study. The SCID II was used to assess the personality disorder diagnosis. At baseline, history of substance abuse (ASI), depressive symptoms (BDI) and childhood trauma (CTQ) were measured. At a 12-month follow-up, the clinical course was assessed with the Opiate Treatment Index (OTI), and substance abuse as well as depressive symptoms were newly assessed. Results: Fifty percent (n = 13) of the patients were diagnosed with at least one personality disorder. Patients with co-occurring PD experienced more depressive symptoms at baseline (p <0.05), were more traumatized (p <0.01) but had a shorter treatment history of heroin-assisted treatment (p <0.05) and less cannabis abuse (p<0.05) than those without a PD. At the 12-month follow-up, patients with comorbid PD showed worse overall psychological adjustment (p <0.01). Conclusion: Patients with co-occurring PD had more severe psychopathological symptoms. These findings indicate that even within a heroin-assisted treatment group, patients with opioid dependence suffering from an additional PD may represent a sicker clinical subgroup, which could benefit from disorder-specific treatment.

Published: Volume 19 • Issue N3 • June 2017 (pages: 65 - 72)

Title: Incidence of Cancer and Cancer Related Mortality in Opiate Dependent Patients Treated with Methadone, Buprenorphine or Implant Naltrexone as Compared with Non-Opiate Using Controls

Authors: Kelty E., Dobbins T., and Hulse G.

Summary: Background: Cancer has been identified as a common cause of mortality in opiate dependent patients. Aim: To examine and compare the incidence of cancer and cancer mortality in opiate dependent patients treated with methadone, buprenorphine or implant naltrexone to a cohort of controls taken from the general population. Methods: The study was a retrospective longitudinal follow up using routinely collected cancer and mortality data. Participants included opiate dependent patients treated for the first time with methadone (n=2,227), buprenorphine (n=1,954) or implant naltrexone (n=958) between 2001 and 2010 in Western Australia (WA) and a sex and age matched cohort of controls selected from the WA electoral roll. Incidence of cancer and cancer related mortality in the four groups were analyzed using Cox proportional hazard regression. Results: Rates of cancer in opiate patients treated with methadone (HR:0.81, CI:0.49-1.34), buprenorphine (HR:0.74, CI:0.41-1.33) and naltrexone (HR:0.65, CI:0.28–1.50) participants were not significantly different to the control cohort. Rates of respiratory cancer were elevated in patients initially treated with methadone (HR:7.53, CI:1.46–38.93) and naltrexone (HR:7.65, CI:1.07–54.48). Mortality rates in patients diagnosed with cancer were significantly elevated in patients treated in methadone (HR:3.19, CI:1.07–9.53), while both buprenorphine (HR:3.07, CI:0.78–12.15) and naltrexone (HR:3.73, CI:0.77–18.02) were not dissimilar to the controls. Conclusions: While rates of cancer were not significantly different to the control, poor survival may attribute to high rates of cancer related mortality.

Published: Volume 19 • Issue N4 • August 2017 (pages: 5 - 12)

Title: Substantial Improvement in Outpatient Opiate-Free Exits Using a Novel Resource-Efficient Lofexidine and Buprenorphine-Based Protocol (‘Detox-in-a-Box') – a Service Evaluation Study

Authors: Iosub R., Seeger I., Law F., Wallbank N., and Melichar J.

Summary: Background: Due to relatively poor outpatient opiate detox success rates locally and limited access to inpatient opiate detoxification beds, we introduced a novel two week long structured opiate detoxification regime using five key principles: 1) Four outpatient visits over the two week regime. 2) Buprenorphine frontloading: long-acting partial agonist with less severe withdrawal symptoms. 3) Lofexidine: an α2-adrenoceptor agonist for opiate withdrawal symptoms, with significantly less sedation and hypotension than clonidine. 4) “Well-being medication”: symptomatic relief for insomnia, abdominal symptoms, etc. 5) Naltrexone: offered for relapse prevention. Aims: We assessed the efficacy of this regime in our outpatients setting (annual numbers coming into treatment 120-150/year) compared to previous years when client-led opiate replacement dose reduction regimes were used solely. Methods: Electronic patient management software was used by data analysts to filter our caseload and calculate the number of ‘opiate-free' discharges yearly 2010 – 2014. Results: In the first year after its introduction the number of patients achieving abstinence quadrupled. ‘Detox-in-a-Box' was rapidly embraced by both key-workers and patients, and continued to prove highly successful over the subsequent four years leading to a dramatic improvement in the number of patients exiting drug-free from our services. This dramatic improvement cleared the backlog of highly motivated clients awaiting a detox. Conclusions: Compared to other community opiate detox strategies used, ‘Detox-in-a-Box' proved to be a highly efficient, successful, structured and resource efficient protocol. It continues to be used by services and is gradually being rolled out elsewhere.

Published: Volume 19 • Issue N4 • August 2017 (pages: 13 - 24)

Title: Novel Approach to Predicting the Likelihood of Sustained Abstinence in Heroin Addicts Treated with Naltrexone and Naltrexone-Behavioural Therapy

Authors: Knežević Tasić J., Karleuša Valkanou M., Đukanović B., Banković D., and Janjić V.

Summary: Background: Factors determining heroin addiction treatment outcome have not been studied extensively, despite their practical and theoretical significance. It is uncertain whether we are able to predict the odds of sustained heroin abstinence, or to influence the factors that increase the likelihood of recovery. This study has aimed to identify factors that either individually or in synergy support sustained multiannual abstinence. Methods: In this translational, ambidirectional cohort study, we have evaluated two groups of heroin addicts that underwent the same therapeutic procedures but with different outcomes (133 abstainers and 56 relapsers), using a non-standardized questionnaire to study: a) the history of addiction, b) motivation for the treatment, c) parental attitudes and control, d) job satisfaction, e) social and emotional relationships, f) alternative satisfactions, g) use of other substances during treatment and h) treatment characteristics. The chi square analysis was used to determine specific significant factors that act individually. Binary logistic regression provided a mathematical model of the synergistic effects of significant factors. Results: The study found a new variable, an ‘abstinence marker', which was defined by the synergistic effect of the following factors: a) use of tramadol before treatment (p = 0.011), b) non-use of benzodiazepines (p = 0.001), c) length of naltrexone use (p <0.0005), d) non-use of cannabis (p = 0.002), e) non-compulsive exercise (p = 0.009), and f) employment and job satisfaction (p <0.0005) during recovery. Conclusions: This study reports a mathematical model that predicts multiannual sustained abstinence as an outcome of heroin addiction treatment.

Published: Volume 19 • Issue N4 • August 2017 (pages: 25 - 34)

Title: Effectiveness of Cognitive-Behavioural Stress Management on Self-Efficacy and Relapse of Substance Use Disorders Symptoms

Authors: Solati K., and Hasanpour-Dehkordi A.

Summary: Background: Substance use disorders (SUDs) lead to serious problems, including health disorders, and social and occupational complications. Relapse prevention plays an important role in treating affected individuals. Aim: The present study was conducted to study the effects of cognitive-behavioural stress management (CBSM) on self-efficacy and relapses into a form of SUD. Methods: The present semi-experimental study was conducted on 40 individuals enrolled from addiction rehabilitation centres; they were matched on the basis of demographic characteristics and randomly assigned to two groups, labeled “case” and “control” group, respectively, each comprising 20 members. The questionnaires, which covered demographic data, self-efficacy, and the Relapse Prediction Scale, were distributed to the participants. After a pretest had been administered to the two groups, eight sessions of 60 minutes (two sessions a week) were held to provide CBSM training to the case group only. The test was then readministered immediately afterwards, and again two months after the completion of training and after all the data had been analysed using SPSS 17. Results: Analysis of covariance indicated a significant difference in self-efficacy and relapse showing SUD symptom recurrence; this emerged from the comparison between the case and control groups for pretest and post-test, and for pretest and follow-up (p>0.001). Conclusion: CBSM training contributes positively to increasing self-efficacy and lowering the risks of relapse into once again showing SUD symptoms. In the light of these findings, the training approach adopted can be recommended as a way to resolve SUDs.

Published: Volume 19 • Issue N4 • August 2017 (pages: 35 - 40)

Title: Exploring Predictors of Response to Methadone Maintenance Treatment for Heroin Addiction: The Role of Patient Satisfaction with Methadone as a Medication

Authors: Alcaraz S., Trujols J., Siñol N., Duran-Sindreu S., Batlle F., and Pérez de los Cobos J.

Summary: Background: Patients' degree of dissatisfaction with methadone is correlated with their response to methadone maintenance treatment (MMT), as patients who do not interrupt compulsive use of substances during MMT are less satisfied with methadone than their counterparts who do. Aim: To examine the satisfaction of heroin-dependent patients with methadone as an independent predictor of response to MMT. Methods: Participants (n = 185) were heroin-dependent patients who had been receiving MMT for at least the previous three months. Of these, 152 were considered non-responders due to current substance use disorders (SUD) requiring inpatient detoxification treatment, and 33 were considered responders due to sustained full remission of SUD. Satisfaction with methadone as a medication was measured with the Scale to Assess Satisfaction with Medications for Addiction Treatment – methadone for heroin addiction (SASMAT-METHER). The SASMAT-METHER subscales assess three domains: Personal Functioning and Well-Being; Anti-Addictive Effect on Heroin; and Anti-Addictive Effect on Other Substances (e.g., cocaine). We also evaluated other possible predictors of response to MMT: sociodemographic variables, heroin use, use of non-opioid substances, MMT characteristics and patients' views on methadone dose adjustment. Differences between non-responders and responders were tested individually; only those variables that reached statistical significance (p ≤ .05) were included in a subsequent binary logistic regression analysis. Results: On the regression model, two factors were independently associated with the likelihood of non-response to MMT: 1) a low level of satisfaction with the Anti-Addictive Effect (of methadone) on other substances and 2) current benzodiazepine treatment. Conclusions: Our results suggest that heroin-dependent patients' degree of satisfaction with methadone may be an independent predictor of MMT response. Prospective studies are now needed to confirm this finding.

Published: Volume 19 • Issue N4 • August 2017 (pages: 41 - 46)

Title: Clinical Determination of Carbohydrate-Deficient Transferrin (Cdt) in a Random Sample of General Population in Naples

Authors: Reccia L., Morelli R., Boccella S., Iovine R., Zaia D., Crinisio A., Leone A., Marabese I., Scala G., Guida F., Cante D., De Novellis V., and Stella L.

Summary: Background. Alcoholism has become one of the main medical and social problems in Western society. Among different indicators, carbohydrate-deficient transferrin (CDT) can be considered the main marker in both clinical and forensic environments for alcohol addicts. Aim. The present study aims to report an accurate estimate of CDT levels in a sample of chronic alcoholic subjects, while comparing that with a control group. Methods. We administered the CDT dosage to 993 subjects from a random sample of the general population and in patients from the Addiction Treatment Service (SERT, double diagnosis in two different samples of population in Naples). Among them, 423 belonged to a ‘random' sample from the control group and 570 alcohol addicts indicated as the Chronic Alcoholic group. To this end, serum CDT levels in both groups were measured by high-performance liquid chromatography (HPLC). Results. The analyses from the different groups revealed significantly higher percentages of CDT levels in the Chronic Alcoholic group than in the control group. Conclusions. Our findings add new data on CTD dosage in a significant sample of the territory pertaining to the Local Health Authority within Naples known as ASL Napoli 2 North.

Published: Volume 19 • Issue N4 • August 2017 (pages: 47 - 52)

Title: Experience of Drug Overdose at an Urban Addiction Clinic in Ireland

Authors: Barry T., Crowley D., Benton A., Barron E., and O'Reilly F.

Summary: Background: Drug overdose is a significant health problem that carries with it potentially fatal consequences. Overdose prevention and management strategies should be a key concern for settings that provide services to drug users and in particular to opioid injectors. The service user perspective is an important consideration in overdose prevention and management. Aim: To examine the experience of drug overdose among service users at a single addiction clinic, and thus inform future overdose prevention and management strategies. Methods: An anonymous census of all service users at a single urban addiction clinic was conducted in order to establish the experience of personal or witnessed drug overdose within the preceding year. Following this census, questionnaire-based interviews were conducted to examine the service user experience of drug overdose in greater detail. Results: A census response rate of 96% (216) was achieved. Eighteen service users participated in a follow up questionnaire-based interview. Almost one-third of service users (31%) had either witnessed or personally experienced an overdose in the previous year. A quarter of the population (25%) had witnessed but not experienced an overdose. Service users who were interviewed, were willing to intervene in overdose situations but many were unaware of the opiate antidote naloxone. Conclusions: A significant proportion of service users at this single clinic had recent experience of drug overdose. Overdose prevention and management strategies are relevant to this population. Training and equipping addiction clinic service users for overdose management may save additional lives.

Published: Volume 19 • Issue N4 • August 2017 (pages: 53 - 56)

Title: Patterns of Prescription Drug Use and Misuse in Spain: The European Opioid Treatment Patient Survey

Authors: Fonseca F., Torrens M., Farré M., McBride K.E., Guareschi M., Touzeau D., Villeger P., Benyamina A., Dagnone O., Somaini L., Maremmani I., and Dart R.C.

Summary: Aim: The present study aims to evaluate the patterns of prescription drug misuse in a medication-assisted treatment centre (MAT) in Spain. Methods: Launched in October 2014, this study is based on patient self-report data collected at treatment programme intake past 90-day use and injection history for European market prescription opioids, prescription stimulants, prescription cannabinoids, heroin, and other prescription drugs, as well as basic demographic information, treatment history, and health care worker status. Results: A total of 101 surveys have been collected so far in Spain (69% males, 42±10 years). The main drugs reported at intake were heroin (51%), cocaine (26%), cannabis (11%), amphetamines (4%), benzodiazepines (3%), prescription opioids (3%), in addition to other substances (3%). The main routes of administration were smoking (34%), injection (30%), snorting (27%), and oral consumption (7%), while 2 subjects used transdermal patches (2%). A majority of subjects (63%) were abusing more than one substance. Conclusions: Initial data show that, in Spain, there is widespread concomitant abuse of prescription drugs, mainly benzodiazepines, prescription opioids and cannabis. A thorough knowledge of drug use patterns can provide information that will be useful in developing effective forms of prevention and treatment.

Published: Volume 19 • Issue N5 • October 2017 (pages: 5 - 14)

Title: Erectile Dysfunction (Ed) among Men in Agonist Opioid Treatment (Aot) Programmes

Authors: Segrec N., Kastelic A., and Pregelj P.

Summary: Background: Agonist opioid treatment (AOT) with full and partial agonists of opioid receptors should be considered one of the key forms of treatment for heroin and other opioid addictions. Sexual dysfunction is a common side-effect of opioids. Symptoms of erectile dysfunction (ED) among patients enrolled in a variety of AOT programmes has been reported. The prevalence of ED has, however, so far never been reviewed separately or systematically. Aim: The main purpose of the present study is to review the existing literature according to the criterion of the prevalence of ED among patients receiving AOT medications for opioid addiction (methadone, buprenorphine, S-R morphine). Methods: A comprehensive computer literature search conducted on studies published from 2000 to April 2016 regarding ED among patients treated in AOT programmes for opioid addiction was performed by searching through the databases PubMed and Web of Science. Following the protocol, one preliminary screening operation was to divide the papers into two main clusters according to assessment of sexual dysfunction, with the first exploring the prevalence of ED and the second dedicated to other topics. At that point, all the studies not directly exploring the prevalence of ED were excluded. Results: A total of 131 records were screened, among them 18 studies with prevalence rates for ED between 12% and 93% (more exactly, 13% to 93% for methadone and 12% to 43% for buprenorphine). However, the methodological approaches adopted were highly variable, and included the use of methadone or buprenorphine, while excluding S-R morphine. Conclusions: ED is a common sexual dysfunction among men receiving AOT medication for opioid addiction, and it seems that condition is more frequent among patients treated with methadone than among those treated with buprenorphine. Further comparative studies are needed, especially those involving slow-release morphine.

Published: Volume 19 • Issue N5 • October 2017 (pages: 15 - 22)

Title: The Benzodiazepine Prescribing Support Tool - a Small Scale Pilot Study

Authors: Gibson L., Bowden K., Hill D., and Towle I.

Summary: Introduction: Those patients suffering from substance misuse problems are often vulnerable to other drugs of addiction, and mental health issues such as anxiety and depression. Often these patients can find themselves prescribed both agonist opioid therapy (AOT) and benzodiazepines. Dual prescribing of these drugs is high risk and significantly increases overdose risk. However guidance and support tools to help mitigate this risk are currently lacking. Methods: This is a small scale pilot study which aims to develop a benzodiazepine prescribing support tool, to help improve the safety of benzodiazepine prescribing in substance misuse patients. This tool has been developed from guidance within national and local guidelines. Prescribers caseloads from NHS Lanarkshire Addiction Services were used to assess the tool. Results: It was found the tool provided a simple and quick template for which to audit prescribers benzodiazepine prescribing and to help guideline development, and it could be adapted and used in other organisations. Conclusions: Although small in scale with limitations, this pilot study is a good proof of concept for the further development of the benzodiazepine support tool in substance misuse patients.

Published: Volume 19 • Issue N5 • October 2017 (pages: 23 - 28)

Title: Violence against Working Personnel in Slovenian Drug Addiction Rehabilitation Centre Network

Authors: Gabrovec B., Jelenc M., Prislan K., and Lobnikar B.

Summary: Introduction: Healthcare workers are frequently a target of patients' violent behaviour. Increased workplace violence towards health care professionals has been reported by several studies. The purpose of the present study has been to identify the prevalence of violence towards employees in the Slovenian drug addiction rehabilitation centre network. Methods: For the purpose of this study, a non-experimental sampling method was employed, using a structured questionnaire answered by rehabilitation centre employees (n = 54). Data were analysed by means of descriptive statistics, correlation analysis and linear regression, with a significance threshold of p < 0.05. Results: Employees in the Slovenian drug addiction rehabilitation centre network are subject to a high risk of violence. In the last 12 months employees were most often faced with verbal abuse (83.3%), while one in 5 became the target of physical violence (22.2%), which indicates that work-related risks are not being properly managed. Conclusion: This study could serve as a basis for a comprehensive approach to managing violence within the drug addiction rehabilitation centre network, while it also provides clear pointers to guidelines for the design of further research. Some Slovenian psychiatric health care facilities have already introduced certain measures in this field, leading to reductions in workplace violence that demonstrate that the incidence of aggressive outbursts by patients can be reduced.

Published: Volume 19 • Issue N5 • October 2017 (pages: 29 - 34)

Title: Benzodiazepine Use in a Group of Heroin Addicts under Opioid Agonist Maintenance Treatment in a Public Service in Rome

Authors: Casella P., Zangaro S., Ricci M., Rosa A., Lupi A.M., Camposeragna A., Garofalo M.S., and Triunfo F.

Summary: Background: Benzodiazepines (BDZs) are widely commercialized for use in the treatment of several psychopathological conditions. Their extended and unnecessary use can lead to medical complications, problematic use, abuse and addiction. The aim of the present study is to evaluate the characteristics of a sample of Drug Addict (DA) subjects – some using BDZs, others not – in treatment with opioid agonist drugs, to identify possible differences between the two populations (of those with and without BDZ consumption). Methods: All the patients that were in treatment provided by the Public Treatment Service (PTS) for drug dependence and that presented to the PTS over a two-week period were interviewed in December 2014 on the basis of a semi-structured brief questionnaire administered by staff members. Results: Along with the older age of heroin addicts using BDZs, the higher frequencies of concomitant psychoactive therapies, the higher incidence of previous imprisonment, and the explanation provided by addicts for their use of BDZs are features consistent with the fact that BDZ use is more due to relief than to reward. Opioid medication and primary substance abuse do not influence the use of BDZs. Conclusions: The fact that opioid medication and primary substance abuse does not influence BDZ use further supports the hypothesis that the use of BDZs by heroin addicts is more a reflection of the severity of the addictive illness than a result of treatments and/or the concomitant abuse of other substances.

Published: Volume 19 • Issue N5 • October 2017 (pages: 35 - 44)

Title: Engagement in an E-Health Tool (Orion) Predicts Opioid-Dependent Patient Likelihood of Behavioural Change

Authors: Humphris G., Carra G., Frisher M., Neufeind J., Cecil J., Scherbaum N., Crome I., and Baldacchino A.

Summary: Background: An eHealth computer-based tool named ORION was constructed to assist patients in the clinic to appreciate the factors responsible for risks of drug overdose. The aim of this study was to investigate the associations between risk perception of overdose, engagement in the ORION tool and willingness to alter overdose risk factors. Methods: 194 opioid dependent patients participated from 4 countries (UK, N=39; Germany, N=99; Italy, N=40 and Denmark, N=16). A structural equation model was fitted (AMOS version 17) to summarise the predicted associations between perceived risk and willingness to change risks of opioid overdose. The degree of engagement with the tool (time spent and number of changes to overdose risk factors) was explored. Results: A variety of models were fitted and the most parsimonious model provided a non-significant difference between the raw data and the specified model: Chi Sq = 16.87, df10, p = .077 chi sq/df = 1.688. The fit indices: CFI = .991, RMSEA = .066. Pre and post self-assessments of risk towards known factors linked with overdose were highly correlated. A significant path was found between engagement in the tool and the willingness to change one or more risk factors (stand. coeff. = 0.16, p = .04). In addition, the final assessment of the risk factors was associated with engagement (stand. coeff. = 0.18, p = .02). Conclusion: The encouragement of drug users to engage in exploring changes to their overdose risk when presented on a computer screen appears to increase willingness to change risky behaviour.

Published: Volume 19 • Issue N5 • October 2017 (pages: 45 - 54)

Title: Effects of Non-Scheduled Urine Drug Tests among All Students at a Private High School in the USA

Authors: Adelson M., Linzy S., Ray B., Kreek M.J., Schiffman P., and Peles E.

Summary: Background: Adolescence is the most vulnerable period, the period of greatest susceptibility to the development of addiction, for all those who are exposed to psychoactive substances. Despite a substantial experience of psychoactive usage prevention programmes (including educational work and even random urine tests), their success has so far been limited. Aims: To describe the results of educational and urine testing drug programmes among all the students and staff at in a private high school in order to identify and curtail drug use in its early stages and so save lives. Methods: During six years (April 2008 to April 2014) of studies in a private high school, urine samples for substance abuse (cannabinoids, cocaine, heroin, morphine, oxycontin, methadone, benzodiazepine, amphetamines, and ethanol) were collected and tested among all grades (9th-12th) and staff. The tests were done every few months in a random manner, and involved everyone. Positive tests were re-checked and were defined as positive if no medical prescriptions had been written. Results: During this period we performed 19 tests (about three per year) among all available students on each occasion (with numbers of participants ranging from 37 to 137). Reviewing all the 19 test times during the six years, only four students showed positive results for cannabinoids (two of them only once, the other two more than once). Conclusions: The programme results indicated minimum substance usage among adolescent children. Our finding was limited to a private high school with a selected population group, where all students and staff members agreed to participate in the programme when registering for admission to the school or, for staff members, when taking up employment. Based on our observational non-controlled study, future programmes, including controlled studies, can now be recommended.

Published: Volume 19 • Issue N5 • October 2017 (pages: 55 - 62)

Title: The Substance Abuser's Partner: Do Codependent Individuals Have Borderline and Dependent Personality Disorder?

Authors: Knapek É., Balázs K., and Kuritárné Szabó I.

Summary: Background: Little is known about the personality of codependents, despite the fact that it should be taken into consideration in the treatment of illicit drug users. Codependency has a strong positive correlation with borderline and with dependent personality disorder (BPD, DPD), which should be taken into account when trying to explain the relationships so far discovered between codependency and anamnestic data, together with psychopathological (e.g. child) abuse, depression, and insecure attachment. Aim: To identify whether ‘pure' codependent individuals exist. By ‘pure' codependency we mean the condition of codependent individuals without BPD and/or DPD. Methods: Our sample consisted of 131 codependents and 276 non-codependent individuals, as assessed by the Codependent Questionnaire; they were recruited in self-help groups and in the general population. Borderline and dependent traits were assessed by SCID-II. Results: According to our data, probably every 2nd codependent person meets the five criteria required for a BPD diagnosis in DSM-IV-TR, and every 7th codependent meets the criteria set out there for a DPD diagnosis. 31% of codependent individuals have borderline traits; in addition, 31% of codependents have dependent traits. On the other hand, 16% of codependent individuals seem to be classifiable as ‘pure' codependents. Conclusions: The overlap areas between codependency, BPD and DPD have significant treatment and research implications. Since ‘pure' codependents were identified by us, the codependency concept cannot be rejected.

Published: Volume 19 • Issue N5 • October 2017 (pages: 63 - 72)

Title: Crime Issues in Substance Use Disorders: Need for a Medically-Based Algorithm

Authors: Pacini M., Maremmani A.G.I., Patricio L., Barra M., and Maremmani I.

Summary: On political grounds, the liberalization and decriminalization of treatment instruments, as long as they are used for medical purposes, have become a priority in improving treatment standards. Scientifically based interventions should never be hampered by restrictive regulations targeting substance classes, let alone specific medical preparations. Pathways to recovery should also be made easier by lessening the restrictions on work and travel that are generally applied to substance users or offenders against laws on drugs. In other words, the figure of the patient should be allowed to prevail in legal contexts over that of the offender, as long as treatment can guarantee a positive outcome. For non-responders, alternative sanctions or ‘decriminalization' may be considered too, although the need to prevent social harmfulness may justify restrictive measures. Decriminalization should stop being a substance-related matter, and become a diagnosis-related one. Categories of mentally ill patients (addiction being one main issue) should be decriminalized in so far as their offence can be considered a result of their addictive behaviour. Intoxication-related behaviour may, therefore, be decriminalized when it springs from addiction, and generically sanctioned when it is independent of addiction or other brain disorders. In terms of social security, decriminalization should be distinguished from depenalization. The person in question should not be charged with legal responsibility, as long as he/she is addicted or mentally ill, but restrictions may be applied when there is no other way of preventing social harm. The definition of categories of abuse, addiction and mental illness is a medical matter. One consequence is that the most reasonable way to allow ‘pathologic' offenders to be given treatment is to check whether each offender belongs to a decriminalized category. The physician should become the central figure in assessing and handling social risk related to psychiatric disorders, because he/she is able to give medical criteria and knowledge priority over laws targeting generic substance use, trading in substances or substance-related crime.

Published: Volume 19 • Issue N5 • October 2017 (pages: 73 - 78)

Title: Effects of Naltrexone Treatment on Hypothalamic-Pituitary-Adrenal Axis Activation and Gaba Release in Rats

Authors: Stella L., Oliva P., Boccella S., Scafuro M.A., Giordano C., Scala G., Guida F., Leone A., Marabese I., and de Novellis V.

Summary: Background: Narcotic antagonists, such as naltrexone (NTX), are effective not only in the treatment of opiate addiction, but also of alcohol dependency. Repeated treatment with NTX is, however, associated with several side-effects, including insomnia, anxiety, panic attacks and ‘hyperexcitability', which are often responsible for treatment withdrawal. Previous findings reported that such behavioural alterations are associated with changes in GABA levels in the brain that are responsible for an overactivated hypothalamic-pituitary-adrenal axis. Aim: The aim of this study has been to evaluate the effect of the benzodiazepine prazepam on the biochemical changes induced by NTX treatment. Materials and Methods: We have evaluated GABA levels following NTX treatment alone or in presence of prazepam in three brain regions (globus pallidus, posterior hypothalamus and hippocampus) in freely moving rats. In addition, the concentrations of ACTH and corticosterone have been measured. Results: Acute or chronic NTX treatment reduced extracellular GABA levels in the brain and increased blood concentrations of ACTH and corticosterone in a dose-dependent manner. Prazepam (PRZ) administered prior to treatment significantly prevented these effects. Conclusions: This study demonstrates that PRZ is able to prevent the biochemical changes believed to be associated with NTX-induced behavioural changes. Moreover, our data suggest the use of NTX combined with PRZ as a new pharmacological tool in the treatment of patients addicted to opioids.

Published: Volume 19 • Issue N6 • December 2017 (pages: 5 - 12)

Title: New Psychoactive Substances and Drug Addiction Rehabilitation Centre Networks in Slovenia

Authors: Gabrovec B.

Summary: Introduction: In 2015/2016, several young men went missing in Slovenia and the media implied that they had disappeared when they were under the influence of new drugs. The police did not confirm this, but they did confirm that the use of psychoactive substances and hallucinogenic drugs was on the rise. New psychoactive substances are more easily available than other illicit drugs. The Drug Addiction Rehabilitation Centre Network is the most comprehensive network for drug prevention and drug addiction rehabilitation, and consequently the best point of access for everybody working in the field of addiction, including addiction with psychoactive substances. The purpose of this study has been to establish to what extent the employees of the Drug Addiction Rehabilitation Centre Network in Slovenia believe that their current rehabilitation programme is also suitable for users of the new psychoactive substances, and that they have the right kind of knowledge to be able to identify substance abusers and offer them counselling and help. Methods: For the purpose of this study, a non-experimental sampling method was employed, using a structured questionnaire on rehabilitation centre employees in Slovenia (n = 54). Data were analysed by means of descriptive statistics, correlation analysis and linear regression, with a significance threshold of p < 0.05. Results: Employees gave a low score in responding to all the questions and statements on the appropriate provision of care in combating the effects of new, emerging substances in the Drug Addiction and Rehabilitation Centre Network. Except for doctors and psychologists, they have a low degree of knowledge about these emerging substances. Conclusions: Due to the increasing use of this type of drug among users, and considering the wide range and territorial presence of the Slovenian Drug Addiction Rehabilitation Centre Network, it would be reasonable to upgrade employees' knowledge in preparation for the daily work to be done at the Centre, as well as preventive work in the field.

Published: Volume 19 • Issue N6 • December 2017 (pages: 13 - 20)

Title: Further Evidence of a Psychopathology Specific to Heroin Use Disorder. Relationships between Psychopathological Dimensions and Addictive Behaviours

Authors: Della Rocca F., Maremmani A.G.I., Rovai L., Bacciardi S., Lamanna F., and Maremmani I.

Summary: Background: addictive behaviours are the behavioural expression of addiction, a chronic relapsing brain disease that is expressed through symptoms related to the onset of tolerance and dependence phenomena, social maladjustment, somatic complications and symptoms of psychopathology related to the presence or absence of a Dual Diagnosis. Recent studies suggest that specific psychopathological dimensions appear to be the psychopathological expression of Substance Use Disorders beyond the presence or absence of a Dual Diagnosis. High-level correlation between psychopathological dimensions and addictive behaviours would be further evidence of the existence of a psychopathology specific to Substance Use Disorder. Methods: 207 patients, with a diagnosis of heroin dependence according to DSM-IV-R and DSM-5 criteria, were included in the study. Of these, 163 (78.7%) patients were males and 44 (21.3%) females. At the time of the evaluation, average age was 35.20 ± 10.7 years (minimum 16, maximum 65). For data collection, we used three questionnaires: DAH-Q for demographic and drug addiction history; SCL-90 for psychopathological symptomatology; and CRAV-HERO for addictive behaviour. Correlations between the psychopathological dimensions of SCL-90 and CRAV-HERO were studied, at the multivariate level, by means of canonical correlation analysis to identify and measure the associations that may connect the two separate sets of variables. Results: Canonical correlation analysis showed only a variate linking psychopathology and addictive behaviour (Statistics: Wilks L=0.72; F=2.70 p <0.001). The psychopathological set was saturated negatively by the violence-suicide, somatic symptoms and panic anxiety dimensions and positively (at a very low level) by the sensitivity-psychoticism dimension. The addictive behavioural set was saturated negatively by time items, exchange items, risk items and cue-induced/environmental stimuli items related to relief-obsessive craving and positively (at a very low level) by cue-induced/environmental stimuli items related to reward craving. Conclusions: The high-level correlation between psychopathological dimensions and addictive behaviour stands as further evidence, at least in Heroin Use Disorder patients, of the existence of a psychopathology that is specific to addiction.

Published: Volume 19 • Issue N6 • December 2017 (pages: 21 - 30)

Title: Substance Use Typology in Psychiatric Patients Admitted to an Emergency Room, in Italy

Authors: Falchi S., Spera V., Maiello M., Gazzarrini D., Belcari I., Ceglie R., Ciapparelli A., and Maremmani I.

Summary: Background: In the USA, emergency room (ER) visits for Substance Use Disorders with or without Dual Diagnosis become more frequent in the last decade. This is particularly true of opioid overdoses and opioid withdrawal symptomatology, and also of psychotic episodes related to the use of cannabinoids and stimulants. Methods: To verify the degree to which this phenomenon is valid for Italy, we assessed, in an observational comparative study, substance use and psychopathological symptoms in patients admitted to an Italian psychiatric emergency room over during a six-month period. We divided subjects into Substance Use Disorder patients with (DD patients) and those without (SUD patients) dual disorder. As control group we used subjects with all other kinds of psychiatric diagnosis (NSUD patients). Results: We evaluated 54 patients (23 males and 31 females, mean age 45.69±13.2, 19-77 ranged). Ten patients were classified as DD patients, 8 as SUD patients and 36 as NSUD patients. Tobacco proved to be the main substance abused (81.5%), followed by caffeine (51.9%), alcohol (46.3%), SNC stimulants and depressants (both at 27.8%). The use of opioids (7.4%) and energizers (7.4%) appeared to be much less common. 13 subjects showed the prevalently combined use of stimulants, cannabinoids, alcohol and opioids; 24 subjects showed a more frequent social drug use and 17 subjects most frequently used a combination of SNC depressors (BDZs) and energizers. SUD patients were characterized by the more frequent use of alcohol and stimulants. Cannabinoid use was more frequent in DD patients. A strongly polyabuse typology was observed both in SUD and DD patients, whereas a higher frequency of social drug use was found in DD patients. Regarding psychopathology, DD patients showed more severe excitement and activation. Conclusions: In this study, what commonly happens in the USA does not seem to apply to Italy. The majority of psychiatric urgencies are not due to a Substance Use Disorder, with or without DD, and opiate use is not predominant in ER SUD patients. Only excitement and activation sustained by cannabinoid use seemed to be present in DD patients.

Published: Volume 19 • Issue N6 • December 2017 (pages: 31 - 38)

Title: Viral Infection, Psychopathology, and Autonomic Modulation among Methadone Users in Taiwan

Authors: Huang W.-L., Chang L.-R., Kuo T.B.J., Lin Y.-H., Yang J.-L., Chen Y.-Z., and Yang C.C.H.

Summary: Aim: We aimed to explore the impact of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infection on autonomic modulation in heroin users. Methods: Fifty-nine subjects were divided into three groups: no infection group, HCV infection group, and HIV infection group (IG). Heart rate variability of all participants was measured. Results: The high frequency power (a parasympathetic index) and the total power (a combined autonomic index) of the IG were significantly lower before and after taking methadone. Above finding could not be explained by psychopathology. Conclusions: The results indicated that early HIV infection may play a role in autonomic dysregulation in heroin users.

Published: Volume 19 • Issue N6 • December 2017 (pages: 39 - 48)

Title: Opiates Versus Other Opioids – Are These Relevant as Diagnostic Categorizations?

Authors: Monwell B., and Gerdner A.

Summary: Background: For more than three decades, the international diagnostic systems have used the term ‘opioids', including opiates, yet research publications continue to use an older terminology. In 2010, new Codes of Statutes for “opiate replacement therapy” (ORT) was brought into effect in Sweden, stating that only those “dependent on opiates” – explicitly specifying heroin, morphine or opium – were eligible. Those addicted to other opioids were then denied access. This study examines the relevance of the distinction of opiates vs. other opioids. Are there differences in the severity of opioid dependence or concerning other substance-related diagnoses? Methods: Ninety-nine individuals participated in two groups: 1) the opiate group (n = 69), and 2) the other opioids group (n=30). Structured interviews covered the ICD-10 criteria of nine different types of addictive substances. For opioids, questions were asked separately in relation to opiates versus other opioids. Results: The two groups fulfilled the criteria for opioid dependence to the same extent, with most participants meeting all six criteria, so indicating a severe opioid dependence problem. Both opiates and other opioids had contributed to their development of opioid dependence, and both groups, to the same high degree, showed comorbidity affecting other dependence conditions. Conclusions: This study reveals that the two categories of opioids used contribute to the development of opioid dependence and that the term ‘opioids' can be suitably used to convey (opioids are well suited as) a unitary concept in diagnostic terms. There were no scientific grounds for treating the two groups differently. The study calls for more stringent use of terminology in accordance with the international diagnostic systems.

Published: Volume 19 • Issue N6 • December 2017 (pages: 49 - 56)

Title: Completion of Opioid Agonist Treatment – an Observational Prospective Study

Authors: Verthein U., Götzke C., Strada L., and Reimer J.

Summary: Background: Studies on the process of regular completion of opioid agonist treatment (OAT) are scarce. Little is known about the patients aiming to terminate OAT, their current life circumstances, and factors associated with successful completion. In the present naturalistic prospective study, we monitor the process of OAT termination and aim to identify factors associated with the successful completion of OAT. Methods: The patients recruited to this study came from primary care settings and specialized clinics, and were likely to complete OAT within the next year according to the medical assessment of physicians. Patients filled out questionnaires every 3 months over a 12-month period and at 6-month follow-up. Simultaneously, physicians documented the process of OAT treatment and patients' health. Results: Out of 972 OAT patients in seven participating clinics, 97 patients met the eligibility criteria, of which 78 agreed to participate in the study (8.0% of the total population of OAT patients). Eight patients (10.3%) successfully completed OAT during the 12-month study period, 12 patients (15.4%) dropped out prematurely, and 74.4% stayed in OAT. No prognostic factors for OAT completion could be identified. Conclusion: Only a few patients are considered eligible for OAT completion and a very low number of patients successfully complete treatment. Prognostic factors for OAT completion remain largely unidentified, which underlines the complexity of this issue. Further research on this issue with larger samples and longer observation periods is urgently needed.

Published: Volume 19 • Issue N6 • December 2017 (pages: 57 - 64)

Title: How to Improve a Poorly Running Agonist Opioid Treatment (Aot). Part 4: dosage Splitting

Authors: Ulmer A., Klein M., and Meinhold C.

Summary: Introduction: Since the beginning of methadone maintenance therapies it has been standard to provide methadone once a day (QD). Providers want to be re-ally sure that methadone is being swallowed. Therefore not many studies with the usual standard have examined if it wouldn't be better to split the daily dose. This is only consensus for pregnant women. But the overall results of methadone treatments are still too often disappointing. If we look closely, we recog-nize that many patients come to their methadone intake in a bad and hardly suf-ferable condition. It's impressive, how they describe the difference between before and afterwards. That can't be physiological. It's certainly complicit in the limitation of good results. Methods: We have interviewed 97 patients about the-se differences. Results: The answers indicate significant differences between QD- and intake twice or more times daily. Withdrawal symptoms of QD intaking patients were reported in nearly double intensity. Conclusions: There is a clear plea for split dosing, at least of methadone and levomethadone, but better of all AOT medication.

Published: Volume 19 • Issue N6 • December 2017 (pages: 65 - 72)

Title: Relationship between Impulsivity and Antisocial Personality Disorder, Severity of Psychopathology and Novelty Seeking in a Sample of Inpatients with Heroin Use Disorder

Authors: Umut G., Evren C., Alniak I., Karabulut V., Cetin T., Agachanli R., and Evren B.

Summary: Introduction: Although the strong association between antisocial personality disorder (ASPD) and impulsivity is well known, the question of which impulsivity dimensions are most closely associated with ASPD has not been answered. The aim of the present study was to evaluate the relationship between impulsivity and dimensions of impulsivity with ASPD, while testing the effects of psychopathology and novelty seeking in a sample of inpatients with heroin use disorder (HUD). Method: Participants included 232 inpatients with HUD. Participants were evaluated with the Symptom Checklist-90-R (SCL-90-R), the Short Form of Barratt Impulsiveness Scale (BIS-11-SF), novelty-seeking subscale of the Temperament and Character Inventory (TCI) and with the relevant section of the Structured Clinical Interview for DSM-III-R-Personality Disorders (SCID-II) for antisocial personality disorder. Results: Severity of psychopathology, novelty seeking and impulsivity were higher among those with ASPD. Presence of ASPD predicted motor and attentional impulsivity, together with the severity of novelty seeking and psychopathology, but not non-planning impulsivity – a factor that was, instead, predicted by the severity of novelty seeking and psychopathology. Conclusion: These findings suggest that impulsivity (particularly its motor and attentional dimensions) is related to the presence of ASPD, together with the severity of psychopathology and novelty seeking among patients with HUD. Measurement and detection of these factors may contribute to directing patients with HUD to the most appropriate psychotherapy option available as an addition to the medication.

Published: Volume 19 • Issue N6 • December 2017 (pages: 73 - 80)

Title: Exploring Irish Travellers' Experiences of Opioid Agonist Treatment: A Phenomenological Study

Authors: Claffey C., Crowley D., MacLachlan M., and Van Hout M.C.

Summary: Background: The Irish Travelling community are identified “as a people with shared history, culture and traditions including, historically, a nomadic way of life”. The core of Travelling culture is strong family bonds which support resilience, however changing social circumstances and dislocation have contributed to significant mental and physical health issues accompanied by a steep rise in substance abuse and addiction. Aim: To explore and describe Irish Travellers' experiences of drug use and opioid agonist treatment (OAT), with a view to improving service delivery and expanding the limited research base. Materials and Methods: A phenomenological approach using semi-structured interviews was conducted with seven opioid dependent Irish Travellers (two females/five males) currently on OAT at an outpatient clinic in Dublin, Ireland. Results: All participants described the complexities arising from drug use, with significant life events often accompanied by depression and drug use (street, prescribed and over the counter) as a means of self-medication. Barriers to accessing treatment included shame and stigma, fears around being shunned by the community, and a negative attitude towards OAT. All participants and particularly women reported that stigma related physical violence came from community elders if suspected of drug use or association with drug users. Despite initial strong reservations about OAT, experiences were largely positive with acceptance by and support from staff viewed as instrumental. Conclusions: The development of culturally appropriate, gender sensitive and integrated OAT and mental health support services, designed with input from addiction and mental health specialists, alongside community members is warranted.

Published: Volume 20 • Issue N1 • February 2018 (pages: 5 - 6)

Title: Treatment Expansion for Opioid Use Disorders in the United States

Authors: Parrino M.

Summary: Not available

Published: Volume 20 • Issue N1 • February 2018 (pages: 7 - 12)

Title: Capgras Syndrome in a Heroin Addict. A Case Study

Authors: Lovrecic M., and Lovrecic B.

Summary: Background: Capgras syndrome is an extremely rare clinical manifestation. A Capgras delusion can be associated with psychiatric or neurological disorders, with drug therapy or toxicities, metabolic conditions, or nutritional deficiencies, and it is difficult to diagnose. In addition, substance use can mimic or mask symptoms of other psychiatric disorders and can lead to the misdiagnosis or underdiagnosis of other psychiatric conditions. Case Report: A drug user with a history of several compulsory hospital admissions to psychiatric hospitals due to violence and physical attacks on others, failed to comply with prescribed treatment in the community, was restarted in directly observed daily therapy combined with stabilization methadone treatment and antipsychotic treatment. Conclusions: Although heroin addiction is a treatable condition, both heroin addiction and methadone treatment are still strongly stigmatized by the lay public, general opinion, patients, patients' family members, and those with professional qualifications such as health professionals. This is the first published case of Capgras syndrome in a heroin addict where daily directly supervised methadone treatment helped the drug user to adhere to outpatient antipsychotic treatment integrated with methadone in such a way as to improve compliance and make it possible to manage conditions involving severe risks.

Published: Volume 20 • Issue N1 • February 2018 (pages: 13 - 20)

Title: Opioid Maintenance Therapy with Methadone and Levomethadone - Sexual Dysfunction and Treatment Satisfaction

Authors: Schoofs N., Häbel T.H., Bermpohl F., and Gutwinski S.

Summary: Background: Sexual dysfunction (SD) is a common adverse effect of opioid maintenance therapy (OMT). Little is known about its impact on treatment satisfaction. Aim: To explore SD and its impact on treatment satisfaction and wish for advice on that subject in patients receiving OMT compared with a group of patients with other substance use disorders (control group). Methods: 95 patients with opioid dependence receiving OMT and 90 patients with other substance use disorders were included. A self-rating instrument as well as the International Index of Erectile Function (IIEF) and the Female Sexual Function Index (FSFI) were applied. Results: In the OMT group, 69.1% of the patients reported to suffer from SD, in contrast to 18.2% in the control group (p<0.001). With 40.7%, OMT was the most quoted reason for SD. 55.6% of the patients in the OMT group reported to be willing to quit OMT because of SD. Significantly more patients in the OMT group claimed a wish for advice on SD (p=0.004). In the OMT group, 15.6% of the patients reported to have been interviewed by a doctor concerning this subject, in the control group 4.9% did so (p=0.052). Regarding the IIEF, the patients in the OMT group were significantly less satisfied with their sexual life than patients in the control group (p=0.023). The FSFI revealed no differences. Conclusion: SD is common in OMT in comparison with other substance use disorders and may have a pejorative influence on treatment satisfaction. Despite the patients' wish, advice on the subject was often not provided.

Published: Volume 20 • Issue N1 • February 2018 (pages: 21 - 30)

Title: On the Long-Term Status of Treatment-Seeking, Heroin Addicted Patients: A 22-Year Follow-up Study on Mortality and Drug Use in Portugal

Authors: Pombo S., and Félix da Costa N.

Summary: Background: Evidence showed that problematic drug users, in particular heroin users, have a higher risk of re-engagement in drug use and consequent death than the general population. Aim: Our aim was to perform a descriptive follow-up analysis to assess mortality and current drug use by reviewing over two decades of treatment admissions. Methods: We considered the cohort sample of heroin treatment-seeking patients from 1992 to 2013 that completed the clinical protocol (N= 627 patients). A total of 222 cases (35.4%) of heroin users were traced. A telephone post-treatment 22-year follow-up interview was then performed for each of these cases to allow assessment of current drug use in relation to mortality. Results: The follow-up analysis estimated a percentage frequency of mortality of 13.1%, with attribution of the main cause of death revealing a connection with HIV/AIDS. Comparative analyses suggested the potential impact of some clinical conditions on drug-related mortality, namely, HIV infection, intravenous drug use, sharing of needles, unemployment and a greater number of years of heroin and other drug consumption when compared with the population of survivors. Among those who were alive, 17.4% reported that they had been using heroin and 15.5% cocaine in the previous 30 days. Our baseline and follow-up data confirm that around 10% of the heroin-addicted population presented a drinking problem. Conclusions: Our long-term study clearly shows the burden that HIV infection and intravenous drug use have imposed on the country in terms of mortality and morbidity. Moreover, the rate of alcohol and drug use over the follow-up period suggests that many aging heroin users are in need of continuous clinical attention.

Published: Volume 20 • Issue N1 • February 2018 (pages: 31 - 36)

Title: Methadone Versus Torture: The Perspective of the European Court of Human Rights

Authors: Junod V., Wolff H., Scholten W., Novet B., Greifinger R., Dickson C., and Simon O.

Summary: For the first time, the European Court of Human Rights in Strasbourg has addressed the issue of whether persons with a heroin dependence syndrome in custodial settings are entitled to receive opioid agonist treatment (OAT). The court relied on Article 3 of the European Convention on Human Rights, which prohibits torture as well as inhuman or degrading treatment. It concluded that member states of the Council of Europe that refuse access to OAT have the burden of proving that an alternative medical approach would, in the case of an individual patient, be as effective as OAT. Such proof needs to be based on an independent medical opinion. This paper discusses the scope and limitations of the European Court of Human Rights' judgment.

Published: Volume 20 • Issue N1 • February 2018 (pages: 37 - 44)

Title: Characteristics of Methadone-Related Overdose Deaths and Comparisons between Those Dying on and Off Opioid Agonist Treatment (OAT): a National Cohort Study.

Authors: Van Hout M.C., Crowley D., Collins C., Barry A., Lyons S., and Delargy I.

Summary: Background: Opioid users, particularly those with a history of injecting and dependence, have a high risk of fatal polysubstance and methadone related overdose. Aim: To describe characteristics of methadone related overdose deaths and assess if differences exist between those dying on and off opioid agonist treatment (OAT). Methods: A descriptive study of all persons dying of drug overdose involving methadone on the Irish National Drug Related Deaths Index (NDRDI) in 2012 and 2013. Results: A total of 182 methadone implicated deaths were recorded . 78% (n=142) were male; with a mean age of 36 years. Of the cohort, 61% (n=111) were not in receipt of opiate agonist treatment (OAT) at the time of death, 15.9% (n=29) had a previous history of non-fatal overdose and 24.7% (n=45) a history of alcohol dependence. Analysis and interpretations are limited by incomplete data on other characteristics but where available show that 89% (n=73) were injecting drug users, with 57.8% (n=26) injecting drugs at the time of death. History of mental illness was recorded in 96.3% (n=77) of cases, with 94.7% (n=107) having history of substance dependency treatment. Polysubstances were implicated in 86.8% (n=158) of deaths. The majority died in a private dwelling (74.7% n= 127) and were not alone 67.4% (n=114). Conclusions: Methadone related fatal overdose is a significant cause of death in young Irish, who share many characteristics with other drug related deaths. Improved monitoring, risk assessment and OAT retention strategies is warranted to inform national drug overdose plans and overdose prevention.

Published: Volume 20 • Issue N2 • April 2018 (pages: 5 - 11)

Title: Methadone Dose as a Determinant of Infant Outcome During the Peri and Postnatal Period

Authors: Wang M., Stapleton J., and Wolff K.

Summary: Background: Methadone remains the mainstay pharmacotherapy for heroin dependent women across Europe although treatment is not standard and neonatal outcomes vary. Aim: We studied pregnant opioid dependent women to compare outcomes during the peri- and postnatal period in infants exposed to methadone in utero. We hypothesized that doses <30 mg methadone/day would contribute to poorer infant outcomes when compared to doses ≥30 mg methadone/day. Methods: A retrospective case note study of methadone maintained mother and infant pairs were evaluated. Cases from an inner city Specialist NHS Substance Misuse Service were categorized according to the methadone dose received at delivery: ≤ 30 mg (detoxification dose) or >30 mg methadone/day. Infant outcomes included gestation, birth weight, and mode of delivery, prevalence of Neonatal Withdrawal Syndrome (NAS) and parenting. Results: Nearly twice as many infants in the ‘≤ 30 mg' group were treated for NAS (40% Vs 22.7% respectively). Mothers in the >30 mg' group were significantly more likely to use; crack cocaine (59.1% Vs 20%, p < 0.044); drugs by the intravenous route (49.1% Vs 6.7%, p < 0.054) and; be referred to Social Services (100% Vs 73%, p < 0.043). Half of their infants were placed under protective care. Conclusions: Our study suggests differences in outcomes for infants according to the maternal dose at delivery. More detailed assessment during pregnancy and in the perinatal period of the addict lifestyle may be crucial in optimising neonatal outcomes. Further research is needed in this area.

Published: Volume 20 • Issue N2 • April 2018 (pages: 13 - 22)

Title: Affective Temperaments in Non-Depressed Patients with Alcohol and Opiate Addictions. Is the “Dark Side” Associated with Current Depressive Symptoms?

Authors: Kałwa A., Siwy-Hudowska A., and Niznikiewicz M.

Summary: Background: Studies investigating affective temperament in alcohol and opiate addiction indicate association between those addictions and affective temperaments of the “dark side”. Aim: The present study aimed to investigate relations between depressive symptoms and particular affective temperament types in patients who were not depressed at the time of investigation, and had no diagnosis of mood disorders. The study hypothesized that depressive symptoms in non-depressed patients would be associated with affective temperaments other than hyperthymic. Methods: Eighty one patients: 65 individuals with alcohol addiction (54 males and 9 females) in their last stages of hospital detoxification and 16 subjects with opiate addiction (13 males and 3 females) from outpatient methadone maintenance program, were evaluated. Affective temperament was assessed with the TEMPS-A 110-item questionnaire. Current depressive symptoms were assessed using Hamilton Depression Rating Scale (HDRS), which was also the method of pre-assessment. Results: Low intensity of the irritable temperament was higher relative to other temperament types in patients with alcohol addiction. In the alcohol group, significant correlations were found between higher HDRS score and cyclothymic, anxious and irritable, but not depressive temperaments. No such associations were found in the opiate addiction group. Both groups did not significantly differ in the intensity of affective temperaments or mean HDRS score. Conclusions: The association between “dark side” temperaments and depressive symptoms in alcohol addicted patients seems to have a different profile relative to the opiate addiction individuals.

Published: Volume 20 • Issue N2 • April 2018 (pages: 23 - 29)

Title: Heroin Deaths in Norway in 2000 and 2009: A Comparative Study of Polydrug Use

Authors: Karinen R., Konstantinova-Larsen S., Normann P.T., Mørland J., Christophersen A.S., and Arnestad M.

Summary: Background: Norway has a high number of deaths following heroin use, often involving the use of additional drugs. In 2000, most of the overdose deaths reported with heroin present turned out to be cases of polydrug use. Aims: In this study we have looked for changes in the polydrug use pattern among the deceased in 2000 and 2009, a period during which heroin-related deaths declined markedly. Methods: Blood samples from autopsy cases were analysed for the possible presence of heroin metabolites: 6-monoacethylmorphine (6-MAM) and morphine; as well as codeine, amphetamines, cocaine and cannabis (THC), methadone, benzodiazepines, a selection of antidepressants, antipsychotics and miscellaneous drugs, and ethanol. 6-MAM was analysed separately in urine samples. Results: Cases with detection of heroin declined from 264 (15%) to 125 (9%) out of 1,794 and 1,435 forensic autopsy cases analysed in our laboratory in 2000 and 2009, respectively. A large number of these cases were also positive for alcohol, illicit drugs or medicinal drugs. The number of additional drug findings rose from 2000 to 2009, and a change in drug use pattern was seen. In comparing all the results for 2000 and 2009, findings of CNS stimulants, cannabis, benzodiazepines, and methadone became more common, whereas findings of ethanol fell, and the prevalence of additional drug findings rose in general. Similar changes in drug use patterns were found in the two gender groups. Conclusions: The results demonstrated that the significant reduction of heroin-related deaths in Norway between 2000 and 2009 was accompanied by a sharp increase in the number of other drugs discovered in those who had died.

Published: Volume 20 • Issue N2 • April 2018 (pages: 31 - 33)

Title: Refractory Bipolar Patient Treated with Oral Methadone: Does Methadone Act as Mood Stabilizer?

Authors: Etaee F., Shirdel S., Azarhomayoun A., Nasiri K., and Komaki A.

Summary: Methadone is routinely used in the context of a Methadone Maintenance Treatment Programme (MMTP). There are some reports of methadone's effects in improving the condition of patients with affective disorders. The present paper reports the case of a refractory bipolar patient who was responsive to methadone syrup. The patient had previously received routine treatment for bipolar disorder without any obvious improvement in his symptoms. After methadone administration he made dramatic improvements, and was able to return to normal life. In this report we give a description of the patient and review the studies in the literature that are pertinent to this case.

Published: Volume 20 • Issue N2 • April 2018 (pages: 35 - 40)

Title: Excess Suicide Mortality in Heroin Use Disorder Patients Seeking Opioid Agonist Treatment in Slovenia and Risk Factors for Suicide

Authors: Lovrecic M., Lovrecic B., Maremmani I., and Maremmani A.G.I.

Summary: Background: Heroin Use Disorder (HUD) patients are more endangered by suicide than the general population. Excess suicide mortality and the risk factor for suicide in HUD patients seeking Opioid Agonist Treatment (OAT) in Slovenia were both assessed. Methods: Record-linkage study of a well-defined cohort of 3,949 HUD patients seeking OAT in Slovenia in the period from 1st January 2004 to 31st December 2006, and General Mortality Register for ascertained vital status in cohort till 31st December 2011. Results: In the 2004-2011 period there were 31 suicides among 3,949 HUD patients seeking OAT. Standardized mortality ratio (SMR) for suicide in HUD patients was 4 (95% CI: 2.8-5.6) times higher than that of the general Slovenian population of the same age over the same period of time. SMR for male HUD patients was 3.7 (95% CI 2.6-5.4) times higher than that of Slovenian males of same age and 2.2 times higher than that of females. SMR for female HUD patients was 7 (95% CI: 2.6-18.7) times higher than that of Slovenian females of the same age. Higher age at cohort treatment entry is an important risk factor for suicide; hazard risk for suicide was significantly higher in patients entering the cohort when older (HR=1.08, 95% CI: 1.02-1.13, p=0.003), whereas those at their first OAT episode seem to be protected from suicide (HR=0.139, 95% CI: 0.019-1.036, p=0.054), while male gender, unemployment and a living alone status do not constitute a statistically significant risk factor for suicide in HUD patients seeking OAT. Conclusions: Specific suicide prevention interventions tailored to the needs of HUD patients are required.

Published: Volume 20 • Issue N2 • April 2018 (pages: 41 - 50)

Title: How to Improve a Poorly Running Agonist Opioid Treatment (Aot). Part 5: Higher Dosage

Authors: Ulmer A., and Meinhold C.

Summary: Long term mental problems, especially restlessness and inner stress, remain in a relevant number of AOT patients, often connected with the use of other addictive substances. This indicates, in nearly all cases, that the treatment is improvable. Opioids are pacifying substances. If patients show the mentioned symptoms, we can interpret it as a hint that the opioid dosage is inadequate. The dosage is not optimal, if more is experienced as better. We find many reports in references of better results with higher dosages. We have, therefore, prescribed increasingly higher dosages in the last years. The dosage exceeded 250 mg Methadone or equivalent 125 mg Levomethadone in 27 patients. That's 11.3% of the 239 patients, whose development we could document in charts. Average maximal dose was 359.7 mg (179.8 mg Levomethadone). A parallel alcohol problem was one of the main reasons in 16 of them. 10 of these could overcome this problem completely in connection with the high dose. We registered an extensive stabilization in the sense of a comprehensive normalization in 20 (74%) of the 27 patients. A clear increase of the dosage appears to be an effective instrument for the improvement of a poorly running AOT. It should be used much more often, also influencing the general setup, which will be discussed in detail.

Published: Volume 20 • Issue N3 • June 2018 (pages: 5 - 12)

Title: The Second to Fourth Digit (2d:4d) Ratios in Patients with Heroin Use Disorder

Authors: Canan F., Sogucak S., Karaca S., Tegin C., Gecici O., and Kuloglu M.

Summary: Background: The ratio between the length of the second and fourth fingers (2D:4D ratio) has been linked with prenatal testosterone concentrations, but also with alcohol and tobacco misuse. Aim: We aimed to investigate any possible association between 2D:4D ratios and heroin use disorder, and whether such a relationship might be independent of impulsivity. Methods: A group of 150 men with heroin use disorder, consecutively admitted to a detoxification and therapy unit, completed the Barratt Impulsiveness Scale-version 11 (BIS-11) and had their 2D:4D ratios measured, along with a group of 266 male controls of similar age and education. Results: Men with heroin use disorder had lower 2D:4D ratios on their right hand when compared with those without heroin use disorder. Results from logistic regression indicated that 2D:4D ratios were not significant independent predictors of heroin use disorder when attentional and non-planning impulsivity were considered. Conclusions: These findings suggest that high prenatal testosterone levels, as measured indirectly by 2D:4D ratios, are not independently associated with heroin use disorder among males.

Published: Volume 20 • Issue N3 • June 2018 (pages: 13 - 24)

Title: Novel Psychoactive Synthetic Cannabinoids and Synthetic Cathinones: The Never-Ending Story of Potential Clinical Toxicity

Authors: Lovrecic B., and Lovrecic M.

Summary: Background: Over the last ten years, there has been an unprecedented increase in the use of new psychoactive substances (NPS) that are not yet under international control. This poses an emerging and demanding challenge to public health, clinical work and researchers worldwide. Synthetic cannabinoids (SCs) and synthetic cathinones (SKs) are the substances most frequently involved in producing states of intoxication; acute toxicity due to SKs is the most problematic prognosis from the viewpoint of public safety and health. Aim: To raise awareness among clinicians regarding NPS (especially SC- and SK-related) signs, symptoms and clinical toxicities. Methods: An electronic search was carried out on the Medline/PubMed and Google Scholar databases to find selected search terms with a particular focus on reporting acute toxicity and psychopathology. Results: Acute toxicity due to SCs and SKs has been implicated in the emergence mostly of neuropsychiatric and cardiovascular clinical manifestations. A majority of emergency medical problems are minor to moderate poisonings; however, severe intoxication can lead to life-threatening adverse effects and death. These substances cannot be detected by conventional drug screening methods. Clinicians should maintain a high level of suspicion of finding synthetic toxicity in patients presenting with unexplained agitation or cardiovascular symptoms, especially in cases of altered mental status with acute onset, excited delirium, renal failure or sympathomimetic symptoms. Conclusions: The acute and chronic toxicity of many NPSs is still unknown, as data from poison centres should be interpreted within their limitations (absence of analytical confirmation, secondary reporting of clinical features). There is a need for evidence-based treatment recommendations for cases of acute intoxication.

Published: Volume 20 • Issue N3 • June 2018 (pages: 25 - 32)

Title: Relationship between Self-Mutilative Behaviour and Novelty Seeking, the Presence of Antisocial and Borderline Personality Disorders, and Severity of Psychopathology in a Sample of Male Patients with Heroin Use Disorder

Authors: Evren C., Karabulut V., Alniak I., Umut G., Cetin T., Evren B., and Agachanli R.

Summary: Background: Self-mutilative behaviour (SMB) is common among patients with heroin use disorder (HUD) and poses a severe threat to the safety and well-being of these patients. Aim: The main aim of the present study was to evaluate the relationship between SMB and novelty seeking (NS), while also carefully assessing the presence of antisocial (ASPD) and borderline (BPD) personality disorders and the severity of psychopathology in a sample of patients with HUD. Methods: Participants, in a group comprising 236 patients with HUD, were evaluated by applying the Symptom Checklist-Revised (SCL-90-R) and NS subscale of the Temperament and Character Inventory (TCI). In addition, BPD and ASPD were assessed with the Structured Clinical Interview for DSM-III-R-Personality Disorders (SCID-II). Results: Age, duration of education and marital status did not differ between those with a history of SMB (n=116, 49.1%) and those without (n=120, 50.9%). Age at first heroin use and percentage of those who were employed were lower among those with a history of SMB. Severity of psychopathology, ASPD, BPD and NS scores were higher among those with a history of SMB. In logistic regression analysis, high NS, together with the presence of both BPD and ASPD, together with severity of general psychopathology, in particular hostility, predicted patients' history of SMB. Conclusions: These findings suggest that the history of SMB is related to the severity of NS, while the severity of psychopathology, particularly the hostility dimension, and the presence of BPD and ASPD may have additional effects on SMB among male patients with HUD.

Published: Volume 20 • Issue N3 • June 2018 (pages: 33 - 40)

Title: Impact of Employment and Marital Status on Lapse Risk Situations among Addicted Patients in Methadone Maintenance Treatment

Authors: Abed M.

Summary: Background: Identifying risk situations for lapses into substance abuse plays a central role in planning appropriate treatments and predicting the possibility of lapse and relapse. Materials and Methods: In the present study, 160 addicted male patients in Methadone Maintenance Treatment (MMT) were chosen from four randomly selected MMT centres in Isfahan. The inclusion criteria were being male opioid users who were in MMT treatment and were willing to participate in the study. Of these 160 participants, 82 were single and 78 married; in addition, 90 of them were employed and the other 70 unemployed at the time of the study. For data collection, patients were asked to complete the Inventory of Drug-Taking Situations (IDTS), a self-report questionnaire for risk situations. Results: The results of MANOVA analysis indicated that Physical Discomfort and Pleasant Times with Others were risk situations for the employed participants, whereas Pleasant Emotions, Urges and Temptations to Use, Social Pressure to Use and Testing Personal Control were the main risk situations for the unemployed ones. Considering marital status, Unpleasant Emotions, Physical Discomfort and Conflict with Others were the risk factors for the married participants, whereas Pleasant Emotions, Pleasant Times with Others, Urges and Temptations to Use, Social Pressure to Use and Testing Personal Control were the situations at risk for the single ones. Conclusions: Occupational activities are essential for lapse/relapse prevention, since they facilitate the establishment of non-substance abusing social networks; moreover, while married participants had fewer risk situations, it is likely that married life is open to influence from an addicted partner.

Published: Volume 20 • Issue N3 • June 2018 (pages: 41 - 49)

Title: How to Develop and Implement an Exercise Programme in a Heroin-Assisted Treatment Setting

Authors: Staub L., Gerber M., Vogel M., Dürsteler-Macfarland K., Strom J., Schoen S., Pühse U., and Colledge F.

Summary: Background: Individuals in treatment for substance dependence suffer more frequently from a variety of psychiatric and physical comorbidities in comparison with the general population. In the past, it has been shown that exercise can be beneficial as an adjunct therapy in the treatment of these diverse comorbidities; however, in substance dependence treatment, compliance with exercise programmes is inadequate. Aim: The aim of this study was to gather the perspectives of patients on how an exercise programme should be developed and implemented in an outpatient setting dedicated to treating substance dependence. Methods: The study was carried out in a clinic offering heroin-assisted treatment (HAT) in Switzerland. A survey, focus group and interviews were administered before and after a 3-month exercise programme. Results: Participants in the focus group (n=12) and survey (n=28) reported that they were eager to participate in an exercise programme, and recognized that it would be beneficial for their well-being. The exercise programme was adapted to offer parallel sessions for differing ability levels. Feedback from the programme indicated that a varied multisport programme was most favoured, and that special attention was required to ensure that participants would not lose touch with each other through miscommunication. Final interviews (n=14) indicated that patients wanted the programme to become a fixed part of treatment. Conclusions: It is essential to take patients' views into account when implementing an exercise programme in an outpatient substance use treatment setting. Clear and repeated communication, programmes which adapt to patients' abilities, and continuous assessment of the programme are important in motivating participation.

Published: Volume 20 • Issue N3 • June 2018 (pages: 51 - 58)

Title: Diversion of Buprenorphine: Scope of the Problem and the Measures Taken to Address It

Authors: Tripathi R., and Sarkar S.

Summary: Background: Opioid dependence is a matter of public health concern globally. Opioid substitution therapy is recommended as one of the most effective treatment strategies to manage opioid use disorder. As a partial opioid agonist, buprenorphine is widely used all over the world for opioid substitution therapy. Clinical use of buprenorphine is often coupled with instances of diversion and misuse of this medication. There can be multiple reasons and motives for diversion. Methods: In this paper, we assess the various reasons for, and the effects of diversion, along with the range of mitigation strategies adopted to reduce /that diversion. Results: The potential methods that can be utilized for reducing diversion include improving medication adherence, adequate dosing, supervision of dosing, being cautious of possible diversion at clinical visits, termination of treatment in selected cases, provision of confidential treatment in specific situations, random urine screening, prescription monitoring, utilizing alternative formulations of buprenorphine, and scaling up of opioid substitution (treatment. Conclusion: The concerns often expressed about diversion should not be allowed to become a deterrent against the rational use of buprenorphine for opioid substitution, though reflective and corrective measures are needed once diversion has been detected.

Published: Volume 20 • Issue N4 • August 2018 (pages: 5 - 11)

Title: Multidisciplinary Settings in the Treatment of Drug-Addiction: An Experimental Evaluation

Authors: Cicatelli P., Borriello M.T., De Vivo C., D'Oriano V., Fuscone A., Moccia E., and Siconolfi M.

Summary: The present paper provides a detailed description of a protocol based on the application of multidisciplinary settings; its primary aim is to discuss the issue of what kinds of treatment should be given to drug-addicted patients already receiving pharmacological therapy. The proposed model includes settings that provide patients with coordinated assistance from a staff of operators with different professional profiles. In these settings the therapeutic criteria are implemented by applying one or more of the following practices: ● Contemporary presence of professionals with different skills at times when medications are being administered; each professional interacts with patients on the basis of his/her own specific competence; ● Psychological monitoring of patients currently receiving pharmacological therapy; ● Activation of group settings chaired by staff members belonging to the medical and/or psychological areas. In the following, the context hosting this experimentation is presented, and some details regarding the method are discussed. Lastly, results are reported on the treatment of 85 subjects chosen from a sample of 189 patients of the Ser.T. D.S.B.30 A.S.L. Na1 in the time interval under consideration.

Published: Volume 20 • Issue N4 • August 2018 (pages: 13 - 18)

Title: A Review of Literature Assessing Public Opinion of Heroin Assisted Treatment

Authors: Berrigan P.

Summary: Background: A result of the growing prevalence of synthetic opioids, the incidence of overdose is increasing in many jurisdictions. As opioid overdose is associated with significant morbidity, mortality, and resource use, strategies for managing opioid addiction are becoming increasingly important. Literature suggests that for patients who do not respond to conventional treatment, a harm reduction strategy including physician prescribed heroin, represents a reasonable treatment strategy. Despite its potential benefit, given its controversial nature, adoption of physician prescribed heroin without public support is politically unviable. Aims: The purpose of the present study is to conduct a review of literature assessing public opinion of heroin assisted treatment for the treatment of patients with opioid addiction. Methods: PubMed, Embase, Cochrane Library, and Google Scholar were searched for studies reporting data on public opinion surveys of heroin assisted treatment with no publication date restrictions. PubMed, Embase, and the Cochrane Library were searched using the terms “Heroin assisted treatment” OR “Prescribed heroin” AND “Public opinion”. Google Scholar was searched first using the terms “Heroin assisted treatment” and “Public opinion” and then using the terms “Prescribed heroin” and “Public opinion”. Results: In total, 10 studies were identified referencing 22 surveys, 20 of which were unique, from 10 countries. The present study highlights significant variability in public support for HAT ranging from 19.5% to 74.6%. Conclusion: Given the degree of variability both between and within countries regarding public support for heroin assisted treatment, further research is required to help guide decision-makers assessing the treatment.

Published: Volume 20 • Issue N4 • August 2018 (pages: 19 - 28)

Title: Predictors of Retention and Mortality among Patients on Methadone Maintenance Therapy

Authors: Teoh J., Yee A., and Danaee M.

Summary: Background: Methadone maintenance therapy (MMT) was started as a pilot project in Malaysia in 2005, and many individuals have benefited from it. Aim: This study aimed to examine the retention rate among patients enrolled in a tertiary hospital MMT programme in Malaysia, as well as factors predicting retention and mortality among these patients. Methods: A total of 164 patients were enrolled in a MMT programme implemented at a tertiary centre in Malaysia between 2005 to 2013. During enrolment, sociodemographic data, blood investigations and urine toxicology were recorded, along with Opiate Treatment Index (OTI) and World Health Organisation Quality of Life (WHOQOL)-BREF scores. Data, including the most recent follow-up date of patients and their daily methadone dose, were obtained retrospectively, in 2015. Retention rate was ascertained on the basis of living patients who stayed in the MMT programme up to 2015. Factors predicting retention rate and mortality were ascertained using Cox's proportional hazards regression analysis. Results:. The retention rate for MMT at its implementation 10 years ago was 70.1%. Methadone dose ≥ 80 mg/day significantly predicted better retention, while HIV risk-taking behaviour significantly predicted poorer retention in MMT. Mortality was found to be significantly lower among patients of Malay ethnicity and higher among patients who had been found to have HIV and other medical illnesses. Conclusions: MMT retention rate at a tertiary centre in Malaysia was high, but more effort is required to enhance retention among patients with HIV risk-taking behaviour, while also attempting to improve the health of patients with HIV and other medical illnesses.

Published: Volume 20 • Issue N4 • August 2018 (pages: 29 - 35)

Title: Impact of Hepatitis B(Hbv)/C(Hcv) Virus Co-Infection on the Long-Term Survival of Patients with Schizophrenia and Co-Occurring Substance Use Disorders

Authors: Gimelfarb Y., Ligay A., and Ben Tzarfati M.

Summary: Background: The high rates of patients with schizophrenia and co-occurring substance use disorders signal a challenge to both clinicians and policy makers. This study aimed to examine the impact of HBV/HCV coinfection on long-term survival of subjects with schizophrenia and co-occurring substance use disorders. Methods: Charts of 263 subjects admitted from January 1, 2002 to September 30, 2006 were assessed. The Kaplan-Meier survival analysis was used to estimate the cumulative survival rates. The association between HBV/HCV and mortality was estimated using the Cox proportional-hazard regression models, with adjustments for potential confounders. Median observation time was 10.8 years. Outcome measure was all-cause mortality. Results: In patients with HBV/HCV co-infection, the all-cause mortality rate was significantly higher than that in patients with either HBV or HCV monoinfection. In Cox regression, the HBV/HCV co-infection is an independent predictor of the low survival frequency of schizophrenic patients with co-occurring substance use disorders. Conclusions: Dual infection by HBV and HCV is associated with a higher risk of low long-term survival than each infection alone, suggesting a synergism between HBV and HCV. For more accurate results, prospective studies are required. It is essential that adequate resources and strategies should now be focused on schizophrenic dual disorder patients with HBV/HCV.

Published: Volume 20 • Issue N4 • August 2018 (pages: 37 - 43)

Title: The Cost-Effectiveness of Naloxone Programmes for the Treatment of Heroin Overdoses ‘on the Street': A 2-Year Data Collection by the Street Unit of the Villa Maraini Foundation

Authors: Barra M., Direnzo G.F.M., Patruno F.V., Patti M., Rodoquino G., Rossi E., Santoro R., and Badiani A.

Summary: Introduction: The mortality rate of opioid users is 5 to 10 times greater than that of the general population, and the most common cause of death in that case is an overdose. When treated in a timely fashion with the opioid antagonist naloxone, an opioid overdose is rarely lethal. Unfortunately, many opioid overdoses occur in isolated, hidden, inaccessible locations. To circumvent this problem, the Villa Maraini Foundation in Rome has created a rescue team called ‘the Street Unit' to provide basic life support and administer naloxone for the treatment of opioid overdose in urban environments. The aim of this paper is to review the cost-effectiveness of our Street Unit. Methods: We compared the cost of 90 overdose interventions provided by the Street Unit with the cost of those provided by the Accident & Emergency departments of the Italian National Health System. Results: The Street Unit not only successfully treated all overdoses, but also provided a dramatic reduction in costs, ranging from €123,367.05 (best-case scenario) to €203,377.05 (worst-case scenario). Conclusion: This finding suggests that the treatment of opioid overdose in the street context offers a safe, cost-effective strategy for the reduction of opioid overdose-related mortality.

Published: Volume 20 • Issue N4 • August 2018 (pages: 45 - 54)

Title: Personality Profiles and Aggressive Behaviour of Heroin Use Disorder Patients Compared with Non-Substance-Use Peers

Authors: Conversano C., Belcari I., Marchi L., Maremmani A.G.I., and Maremmani I.

Summary: Background: Personality characteristics and aggressive behaviour have long been considered factors that pre-exist addiction. Cattell's 16-Personality Factor Questionnaire and the Buss-Durkee Inventory have been used in psychosomatic medicine, and in psychiatric as well as Substance Use Disorder patients, to study psychological profiles and aggressive behaviour. Methods: In this study, we verified the existence of the factors that pre-exist heroin. Using Cattell's 16PF Questionnaire and the Buss-Durkee Inventory, we have, at both the univariate and multivariate level, compared 73 Heroin Use Disorder (HUD) patients with a sample of 45 Substance Non-User (SNU) peers, selected after matching their respective socio-demographic data. Our expectation was, that among the characteristics that show the most evident deviance from the general population, those that differentiate HUD patients most sharply from their SNU peers should be considered as factors pre-existing heroin addiction. Results: HUD patients and SNU peers, regarding psychological profiles, differ from the general population in the same way. As to the significant univariate differences, the 8-Sensitivity and 6-Rule-Consciousness factors are the only deviants from the general population in all individuals (higher scores in 8-Sensitivity and lower values in 6-Rule-Consciousness). Conversely, the 4-Dominance factor and 2-Reasoning factors are deviant only in the HUD patients, while 10-Abstractedness was not deviant in all our subjects. Differences in the 4-Dominance factor did not enter into the multivariate analysis. Being introverted, expedient in rule consciousness, abstracted in abstractedness, but less sensitive and more concrete in reasoning, are the prominent characteristics that allow HUD patients to be differentiated from their SNU peers. Regarding aggressive behaviour, HUD patients are deviant in all factors, whereas their SNU peers are deviant in only two elements: 2-Indirect Aggression and 6-Suspiciousness. These two factors do not, however, have a high profile at the multivariate level, and HUD patients can be distinguished by the higher values recorded for the 1-Assault and 4-Negativism factors. Conclusions: Psychological profiles that show deviance from those of the general population are unable to differentiate HUD patients from their SNU peers, with the sole exceptions of rule-consciousness and sensitivity, which, in any case, show greater deviance in their SNU peers. Assault and Negativism are not deviant in SNU peers and can be considered as probable consequences of heroin use.

Published: Volume 20 • Issue N5 • October 2018 (pages: 5 - 11)

Title: Addiction and self-reported associated sociodemographic factors in a small province of Iran

Authors: Sedaghat Z., Fararouei M., Shahraki G., Karimzadeh Shirazi K., and Haghighi R.E.

Summary: Background: Drug addiction is a chronic brain disorder caused by drug use. It is one of the most important social and health problems, as it is responsible for the serious deterioration of health, mental health and the socioeconomic status of individuals and the community. Aims: The aim of this study was to understand the views of drug users on the factors putatively involved in their initiation of substance use and in their propensity to make attempts to quit drug use in Yasuj, Iran. Methods: Using a self-administered questionnaire, 362 male addicted participants (selected through snowball sampling) provided us with the information required. Results: Among all participants, 83.6% reported that they were not aware of the health or social consequences of addiction. Also, 33.13% referred to their friends as being the main reason for their addiction and 69.46% declared that they had been introduced to drugs by a friend. Opium was reported to be the most prevalent (92.44%) substance at first drug administration, the most common route being via eating. The most common place for drug use was a friend's home (29.52%). Among the participants, 82.34% were smokers who had started smoking when as young as 17.57±4.90 years of age. Family members were the main factor encouraging participants to attempt to quit (63.91%). Conclusion: Based on the information provided by the addicted participants, friendship is the most important initiating factor in addiction. Friends encouraged patients and provided them with drugs and a safe place to first administer them. On the other hand, family members and family relationships seem to help patients financially and emotionally to quit substance use. As a result, keeping or restoring family relationships may be helpful factors in predicting and treating addiction.

Published: Volume 20 • Issue N5 • October 2018 (pages: 13 - 17)

Title: An evaluation of community pharmacist perception of the misuse and abuse of over-the-counter co-codamol in Cornwell and Devon, UK: a cross-sectional survey

Authors: Barrett R., and Costa D.

Summary: Background: Codeine containing preparations have the potential to cause harm and dependence. Recent UK regulatory changes to the pack-size and printed warnings have been instituted to reduce this potential. However, there is a reported increase in the misuse of codeine containing analgesics in countries where it is available over-the-counter. This is a challenge for pharmacies and pharmacists globally. Aim: To evaluate the perceptions of community pharmacists on the nature and management of Over-The-Counter (OTC) co-codamol (paracetamol and codeine combination preparations) misuse and abuse. Methods: A self-report, postal survey was developed and posted to 65 pharmacies in Cornwall and 85 pharmacies in Devon (n=150) in the UK. Qualitative and quantitative data was analysed using descriptive statistics, hypothesis testing and thematic analysis. Results: Most pharmacists perceived their patients and community as having some challenges with the misuse of co-codamol. Pharmacists think that co-codamol is not harmful if used as indicated. The behaviours pharmacist associated with misuse were frequent to purchase and misinformation provided by the patient during consultation. Counselling and referral are the main interventions utilised by pharmacist in such circumstances. Pharmacists who have received training on co-codamol abuse know where to refer customers. Conclusions: Community pharmacists face a difficult challenge when suspecting misuse. However, pharmacists believe co-codamol abuse can be reduced by increasing the public's awareness of the addictive potential of co-codamol.

Published: Volume 20 • Issue N5 • October 2018 (pages: 19 - 28)

Title: Switching between lyophilized and sub-lingual buprenorphine formulations in opioid-dependent patients: Observations on medication transfer during a safety and pharmacokinetic study

Authors: Reed K., Knight A., Baillie S., Bogdanowicz K., Bell J., and Strang J.

Summary: Background: A new lyophilized, rapid-disintegrating buprenorphine tablet (“bup-lyo”) has been developed to potentially enhance adherence compared to conventional sublingual tablets (“bup-SL”) but with a higher bioavailability of buprenorphine. Aim: To examine the pharmacokinetics, efficacy and safety of switching between formulations. Materials and Methods: Within a randomized trial of opioid-dependent subjects, one arm received “bup-lyo”. After 2 weeks of treatment, all subjects switched back to standard sublingual “bup-SL” over 1-4 days in preparation for transfer back to their treating clinician. Observations were made of any change in clinical situation on transfer, or need for dose adjustment. Measurements included dose titration, treatment retention and within-subject comparisons of; pharmacokinetics (buprenorphine and norbuprenorphine), subjective scores of medication hold and dose adequacy, and safety assessments. Results: Subjects (N=23) were titrated to an effective and safe daily dose of “bup-lyo” (10.8 ± 4.85 mg) (N=22) and then returned to the same dose of “bup-SL” (N=21). There had been no significant difference in dose, medication hold and dose adequacy between formulations on optimized treatment. Bloods were provided by 5 “bup-lyo” subjects for pharmacokinetic analysis: despite within subject similar dosing, buprenorphine Cmax and AUC0-3hr (mean ± SD) were significantly higher with “bup-lyo” than when switched to “bup-SL” (relative Cmax 185.8 ± 88.2%, AUC0-3hr 169.8 ± 62.0 %). However, for norbuprenorphine which is more associated with respiratory depression, the differences were not significant (relative Cmax 109.6 ± 42.2%, AUC0-3hr 105.0 ± 39.4 %). Adverse event incidence and profile was comparable between formulations. Conclusion: Switching from “bup-lyo” to “bup-SL” did not require clinical adjustment of daily dose despite observed higher buprenorphine levels with “bup-lyo”. The bioavailability of the metabolite norbuprenorphine, which is a more potent respiratory depressant than buprenorphine, was comparable between formulations. This may explain the absence of clinical difference in vital signs or other adverse events observed on switching formulations.

Published: Volume 20 • Issue N5 • October 2018 (pages: 29 - 34)

Title: The SCL90-Based psychopathological structure may be applied in substance use disorder patients independently of the drug involved, even in heroin, alcohol and cocaine monodrug users

Authors: Carbone M.G., Maiello M., Spera V., Manni C., Pallucchini A., Maremmani A.G.I., and Maremmani I.

Summary: Background. Using the SCL90 checklist, we previously showed that a cluster of five psychopathological symptoms could be found in Heroin Use Disorder patients. This aggregation demonstrated a high degree of stability, as it proved to be independent of addiction-related conditions such as treatment chosen, intoxication status, and presence of psychiatric problems. It was also applied, in patients with polysubstance use, independently of the drug involved (alcohol, cocaine or heroin). In this study, we have restricted the analysis to patients using only one substance of abuse by excluding patients with polysubstance use. Methods. 256 subjects with alcohol (AUD), heroin (HUD), or cocaine use disorder (CUD) and without a secondary substance of use were assigned to one of the five clusters (worthlessness-being trapped, somatic symptoms, sensitivity-psychoticism, panic anxiety, and violence-suicide). Differences between AUD, HUD and CUD patients in their psychopathological typology and its severity were analysed at univariate and multivariate level. Results. Despite some demographic distinctions, no differences were observed regarding psychopathological typology or its severity among AUD, HUD and CUD patients. Conclusions. This study further supports the independence of the proposed SCL90 five-dimensional structure of the various substances considered.

Published: Volume 20 • Issue N5 • October 2018 (pages: 35 - 49)

Title: Comparing neurocognitive function in individuals receiving chronic methadone or buprenorphine for the treatment of opioid dependence: A systematic review.

Authors: Hill D., Garner D., and Baldacchino A.

Summary: Introduction: Agonist Opioid Treatments (AOT) have been, in comparison to healthy controls, associated with neurocognitive impairment in different domains. This review identifies differences in neurocognitive function as a result of treatment with either buprenorphine or methadone. Method: A qualitative and systematic literature review of published articles from 1946 to 29/2/2016 on neurocognitive function of patients prescribed buprenorphine or methadone and compared with healthy patients utilising the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Results: The limited data demonstrate buprenorphine as presenting with fewer neurocognitive impairments, in cognitive impulsivity, cognitive flexibility and attention domains when compared with methadone. However both treatments modalities presented with more impairments in neurocognitive function domains, including short term memory, attention, cognitive flexibility, cognitive impulsivity, motor impulsivity and non planning impulsivity, when compared with healthy control groups. Discussion: The lack of published papers in comparing neurocognitive impairment between the treatment modalities limit interpretation of this systematic review. Further methodologically rigid and higher quality research into the neurocognitive effects of these treatment modalities in the opioid dependent populations, especially when in treatment, is urgently required.

Published: Volume 20 • Issue N5 • October 2018 (pages: 50 - 53)

Title: Medicinal products detected as novel psychoactive substances: The case of intravenous use of tropicamide.

Authors: van Hout M.C.

Summary: Use and abuse of novel psychoactive substances (NPS) remains a public health and law enforcement challenge across Europe and bordering countries. Increasingly NPS detected on the drug market include those with legitimate use as medicines or active pharmaceutical ingredients in medicines. This Short Communication wishes to draw attention to reports on the concerning upward trend of intravenous (IV) use of eyedrops containing tropicamide by problematic opiate users. Since 2013, trends of diversion by IV route are identified as a new phenomenon in Europe. Sales in Russia and Eastern Europe in particular have increased significantly in the past five years. Key indicators of suspected misuse include online interest particularly from Russia, Ukraine and other Eastern European countries, and pharmacovigilance and clinical alerts from Turkey , Italy, France, Georgia, Russia, Tajikistan, and Kazakhstan. Tropicamide is injected as secondary to the primary opiate addiction, and reportedly occurs as self-sufficient means to get high amongst opiate injectors when primary opiates such as heroin are not available, and as poly-substitute to further enhance the opiate effect and manage heroin (and to a lesser extent methadone) withdrawals . Anecdotally, injection of tropicamide is known as the ‘seven monther' in relation to the length of time it takes to kill the user. The diversion of tropicamide is high risk, concentrated within problematic drug user networks, and conducted by individuals who may not be engaging with social and medical systems. Aside from dependence and physical/psychiatric harms, the risk pertaining to this injecting phenomenon as potential contribution toward virus transmission (HIV, Hepatitis C) within injecting networks are present. The Short Communication presents extant literature on the topic, and discusses implications for drug policy and service delivery.

Published: Volume 20 • Issue N6 • December 2018 (pages: 5 - 15)

Title: The Pros and Cons of Supervised Urine Tests in Opioid Maintenance Treatment: A Study of Patients' Experiences

Authors: Monwell B., Bülow P., and Johnsson B.

Summary: Background: In opioid replacement therapy (ORT), drug testing is performed continuously to ensure that patients are taking their prescribed medication, and to detect whether they have taken other, non-prescribed, substances. Typically, supervised urine testing is conducted, and in Sweden such testing is often an ORT precondition. Aim: This study investigates ORT patients' experiences of and views on supervised urine testing. Methods: Structured interviews were conducted with 90 Swedish ORT patients. During the interview, patients were asked to say what they thought about the supervised urine tests required. The answers were then analysed through content analysis. Results: Three main themes with sub-themes were found in the patients' statements. 1) The consequences of the test results (sub-themes: external control can provide assurance; proven drug intake may have negative consequences for patients; proven drug abstinence can yield advantages for patients), 2) The testing procedures (sub-themes: supervised urine testing is humiliating and causes harm; how you are treated is important; clinical culture and attitudes differ; stress, pressure and anxiety – tests can be difficult to perform), and 3) The structure of the testing (sub-themes: structure is needed in life; inflexible testing schemes can interfere with treatment goals; gathering people with similar problems can be counterproductive). Conclusions: Most interviewees found the testing functional as support or as proxy control in case of personal loss of control. However, supervised urine testing also constitutes a severe invasion of privacy. Less demeaning testing methods need to be developed and implemented.

Published: Volume 20 • Issue N6 • December 2018 (pages: 17 - 25)

Title: ‘You Should Be Helping Him, He's Trying to Do Something About It': The Dilemma of Heroin Use, Agonist Opioid Treatment and Employment

Authors: Emmerson O., Parkman T., Akhtar S., Lowe E., and Day E.

Summary: Background: Approximately 20% of people starting an episode of specialist drug treatment in England are in work, but few gain employment as treatment progresses. Although much has been written about the barriers to employment, less research has been conducted on people who do manage to work on opiate substitution treatment (AOT). This study set out to explore the interaction between heroin use, AOT and employment. Methods: We conducted semi-structured interviews with 10 individuals receiving AOT in full-time employment recruited from a community drug treatment centre in the English West Midlands. All interviews were transcribed, and data relating to employment, treatment and illicit drug use were systematically coded using the Iterative Classification process and subjected to thematic analysis. Results: AOT was considered an important factor in allowing this group to obtain full time employment, but the majority were still using some heroin. AOT and the income derived from working had allowed them to pick and choose when they used drugs, but their reliance on their income from employment meant that they couldn't devote significant time to detoxification and rehabilitation strategies. At the same time, promotion opportunities were limited by the perceived stigma of AOT. Conclusions: These findings suggest a different approach is required to help employed opiate users receiving AOT than for those who are unemployed. More work with employers to increase the understanding of AOT and overcome the stigma of drug use may be required.

Published: Volume 20 • Issue N6 • December 2018 (pages: 27 - 34)

Title: Sleep Problems among Intravenous and Non-Intravenous Opioid-Dependent Patients: The Role of Modality of Use

Authors: Khazaie H., Jalali A., Cheraghi K., Mojtaba Ahmadi S., and Khaledi-Paveh B.

Summary: Background: Sleep is one of the most basic needs and complex behaviours of human beings. Although many studies have been conducted on sleep disorders in opioid users, very few have carried out a comparative analysis of how sleep disorders in this group are affected by the method of substance use. Aim: The main aim of the present study is to compare sleep problems among individuals with intravenous and non-intravenous opioids dependency. Methods: This analytical cross-sectional study was conducted on a statistical population consisting of all the opioid-dependent people in Kermanshah in 2015 who had been admitted to voluntary addiction treatment programmes and rehabilitation centres. A total of 173 male opioid users were chosen through convenience sampling, and assessed using the Berlin Sleep Questionnaire, the Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS). Results: The results showed no statistically significant differences between the two groups in terms of the risk of apnea and the components of sleep quality, except for daytime dysfunction and state of sleepiness, in which the groups did differ significantly (P<0.05). Conclusion: The results showed that both groups of patients were in a poor condition in terms of the risk of sleep apnea, the quality of sleep and the level of sleepiness, and also that the intravenous opioid-dependent group was in a worse condition compared with the non-intravenous group.

Published: Volume 20 • Issue N6 • December 2018 (pages: 35 - 37)

Title: Outbreak of 'Novel Synthetic Opioids': A Deadly Threat to Public Health

Authors: Lovrecic B., and Lovrecic M.

Summary: In the period from 2012 to 2016 fourteen fentanyl analogues and three synthetic opioids belonging to other structural groups were reported to the UNODC from East Asia, Europe and North America. In just the last three years (2014-2017) the variety of the group of Novel synthetic opioids (NSOs) increased dramatically. Monitoring of the health consequences of exposure to NSOs is demanding, the consequences are underestimated. Further research on NSOs is needed in order to recognise their pharmacokinetic properties and effects (acute and long-term), while giving updates on drug testing protocols in clinical settings and postmortem forensic analysis. In cases of opioid toxidrome, naloxone, can be administered to treat/NSO overdoses, but higher or repeated doses of naloxone (doses of 10 to 20 mg) may be required. Challenges to routine surveillance of exposure to NSOs and NSO news highlights are reported.

Published: Volume 20 • Issue N6 • December 2018 (pages: 39 - 50)

Title: Personality Dimensions and Main Drug of Use in Dual Disorders

Authors: Hurtado Ruiz M.G., Fonseca F., Díaz Digón L., Martínez Riera R., Martínez Sanvisens D., Mateu Codina G.A., Farre Martínez A., Sauras Quetcuti R.B., and Torrens M.

Summary: Background: Personality dimensions such as ‘novelty seeking' (NS) and ‘impulsivity' (I) have been reported as risk factors for drug experimentation, escalation of use, substance of choice, and maintenance of substance use disorder (SUD). The high prevalence of dual disorders signifies the need to study the influence of personality traits in these patients. Aim: To assess the relationship between personality dimensions and drug consumption types in patients with dual disorder. Methods: A sample comprising 215 patients was recruited from a dual disorder unit. Cloninger's Revised Temperament and Character Inventory was administered for personality assessment. Results: Statistically significant differences in NS were observed between the number of SUD diagnoses and between the drug type groups both for the general sample and for the subgroup of personality disorders (PD) (where statistically significant differences were found in I). An increase was observed in the likelihood of: cocaine use if NS was high (1.67: CI 95% [1,20,2,3]) and cooperation low (1.379: CI 95% [1.026, 1.854]); opioid use if self-directedness was low (3.373: CI 95% [1.049, 10.845]) and I reduced (0.427: CI 95% [0.187,0.974]); and cannabis use if NS was high (1.80: CI 95% [1.047, 3.094]). Conclusions: The highest NS was associated with cocaine, cannabis, and polysubstance use, with more altered personality patterns, and greater SUD severity. Drug type groups only presented differences in impulsivity in the PD subgroup. When I was elevated, the risk of opioid use was reduced.

Published: Volume 21 • Issue N1 • February 2019 (pages: 5 - 10)

Title: Improving Response Capacities in Opioid Overdose Management

Authors: Cozzolino E., D'Egidio P.F., De Facci R., Leonardi C., Nava F., Stella L., and Maremmani I.

Summary: The recreational use of opioids is increasing in Italy as elsewhere in Europe and so the prevention of opioid overdose (OD) deaths remains a major challenge for addiction services. In Italy, the availability of the opiate antagonist naloxone, the standard treatment for OD, is generally limited to the emergency and first aid system with an uneven distribution of Take Home Naloxone programmes (THN). Naloxone rapidly counteracts opiate overdose; it is non-addictive and generally safe with no side effects. The availability of naloxone in the shortest possible time is directly associated with subject survival. The new intranasal formulation of naloxone offers an easier and safer administration compared with previous injectable formulations. It has a rapid onset of effect and its pharmacokinetic profile is similar to intramuscularly administered naloxone. However, it is more acceptable due to the elimination of needles for administration and this also eliminates the concept of restriction of expanded access based on the provision of needles. The OD epidemic is fought not only by distributing naloxone, but also through complex educational and social strategies. THN programs have overcome legal barriers in many countries. The intranasal formulation has the potential to further simplify the process of access. This paper discusses the existing barriers to wider access of naloxone, including misconceptions about naloxone. It describes how the advent of intranasal naloxone can help to simplify the delivery process by providing a more effective and appropriate solution to OD. In turn, this may also facilitate the implementation of THN programmes that reach more affected individuals and help to save more lives. More extensive distribution of naloxone (including of the intranasal spray formulation) to target groups and populations has the potential to reduce mortality and other consequences of OD.

Published: Volume 21 • Issue N1 • February 2019 (pages: 15 - 20)

Title: An Analysis of Psychological and Physical Problems Faced by Drug (Barsh) Addicts in Khyber Pakhtunkhwa, Pakistan

Authors: Jan S.U.K., and Ali A.

Summary: Background: In most countries throughout the world, including Pakistan, especially in Khyber Pakhtunkhwa, illicit drug use behaviour is thriving in terms of a rapid increase in the number of users. Aim: The aim of the current study was to analyse the psychological and physical impacts of a highly addictive opium-based narcotic drug substance known as ‘Barsh' that is prepared locally. Methods: An exploratory study was conducted by selecting 100 respondents; the abusers were traced through snowball sampling. A chi-square test was applied to determine the association between dependent and independent variables. Results: At univariate level the results showed that the best represented aged group. (n=30, 30%). The respondents increased the dose taken with the passage of time. At bivariate level, a highly significant (p=0.05). A relationship was found between the use of ‘Barsh' and psychological & physical problems, i.e. a memory problem, constipation, nausea, a dysentery problem, convulsions, kidney problems, physical weakness, teeth/gum problems and weight loss. In addition, a highly significant (p=0.05) relationship was found between psychological & physical problems and Barsh withdrawal, i.e. body pain, cramps, insomnia, aggressiveness, headache, watery eyes, dysentery, shivering, cold sweating, constipation, rectal bleeding/haematuria, runny nose, sexual dysfunction, diarrhoea. Conclusions: Barsh is a strongly narcotic drug that leads to many problems, such as tolerance, psychological problems, physical problems, craving and withdrawal syndromes.

Published: Volume 21 • Issue N1 • February 2019 (pages: 21 - 28)

Title: Practitioners' Experiences of Working with Dual Users of Heroin and Crack Cocaine. A Thematic Analysis

Authors: Heidebrecht F., and Macleod M.B.

Summary: Background: Crack/cocaine use is highly prevalent among individuals accessing pharmacological treatment for heroin dependency. Quantitative research studies have shown that dual users of heroin and crack/cocaine have worse treatment outcomes in Agonist Opioid Treatment (AOT) programmes compared to heroin-only users, however, no specific psychosocial interventions have been proposed. Aim: The aim of this study was to explore the experience of substance misuse practitioners of providing treatment to heroin and crack/cocaine users. Methods: The study was conducted in three community services in London, UK. A thematic analysis was performed on semi-structured interviews with seven practitioners from diverse ethnic backgrounds, two females, three currently in leading positions, with an average age of 40 years (27-49), and average work experience of 12 years (2-20). Results: Two themes with several sub-themes were identified: The high and the low (Reasons for drug use, Patterns of heroin and crack use, Behaviour); Facilitating change (Worker-client relationship, Working with the drug use, Working with additional issues). The participants highlighted the importance of exploring the use of both drugs, associated personal constructions, and the experience of pleasure. They discussed the medication as a supporting rather than a main intervention, and the need for workers to be creative and skilled in engaging clients with a constantly-changing presentation, using flexible rather than structured interventions. Practitioners identified several patterns of using heroin and crack/cocaine, and discussed suitable interventions. Conclusion: Psychosocial interventions need to be better integrated with AOT, and tailored to individual needs according to the pattern of dual use.

Published: Volume 21 • Issue N1 • February 2019 (pages: 29 - 34)

Title: Early Maladjustment Schemas in Opioid Abstainers, Opioid Abusers and Normal Individuals

Authors: Veiskarami H.A., Mirdrikvand F., Khodarahimi S., and Rahmian Bougar M.

Summary: Background: In accordance with the developmental, cognitive, metacognitive and diathesis-stress theories of mental disorders, this study suggests that childhood negative experiences produce some EMSs (Early Maladjustment Schemas) which may subsequently influence the occurrence of opioid addiction in adults. Aim: This study set itself the objective of inquiring into early maladjustment schemas among opioid abstainers, opioid abusers and normal individuals in an Iranian sample. Methods: Participants included 180 young adult males (20-30 years old) who were opioid abstainers (N=60), opioid abusers (N=60) or belonged to the normal control sample selected from the population of Shiraz, Fars province, Iran (N=60). These three groups were matched with respect to their age, marital status, occupation and level of education. The Young Schema Questionnaire-Short Form (YSQ-SF) was used for the measurement of early maladjustment schemas in the present study. Results: The data obtained showed that patients with opioid abuse had significantly higher scores in the emotional deprivation, defectiveness, failure, dependence, vulnerability, enmeshment, self-sacrifice, emotional inhibition and insufficient self control maladjustment schemas, while also showing greater disconnection and rejection, impaired autonomy and performance as well as impaired limits in schematic domains, than individuals in the opioid abstainers and the control group. Conclusions: This study demonstrated the incidence of significantly higher levels of some EMSs in males with opioid addiction.

Published: Volume 21 • Issue N1 • February 2019 (pages: 35 - 45)

Title: Hepatitis C Virus (Hcv) Screening in People Who Inject Drugs (Pwid) and Prisoners - a Narrative Review of Extant Literature

Authors: Crowley D., Cullen W., Lambert J., and Van Hout M.C.

Summary: Background. Injecting drug use (IDU) is the major driver of Hepatitis C Virus (HCV) infection in European and other developed countries. People who inject drugs (PWID) and prisoners, both marginalised and underserved populations are recognised as key groups to target for HCV screening and treatment. Aim: To review the most up to date published literature on HCV screening in PWID and prisoners. Methods: Electronic data base (Medline, PubMed, Cochrane library and Embase) and relevant website search using key search terms related to the topic. Results: Data on HCV screening in these two groups is incomplete. Over half of PWID and a quarter of prisoners globally have been exposed to HCV. Multiple personal and institutional barriers, including; lack of knowledge, fear, stigma , complex testing procedures and competing priorities , have been identified to the upscaling of screening in these two groups. Focussed screening at targeted locations, increasing screening methods including the use of dried blood spot testing (DBS), peer-worker involvement and opt-out screening in prisons has the potential to enable uptake. Reflex-RNA testing streamlines identification of active infection and improves linkage to care. Supporting community linkage on prison release is critical to optimise HCV management. Active case finding in PWID and prisoners, provided within an ethical and human rights framework, increases diagnosis, assessment, and treatment, reduces transmission and is cost-effective. Conclusion: Optimising HCV screening in PWID and prisoners underpins any public and prison health strategy aimed at HCV elimination but requires political will and targeted resources to be successfully implemented.

Published: Volume 21 • Issue N1 • February 2019 (pages: 47 - 56)

Title: How to Improve a Poorly Running Agonist Opioid Treatment (Aot). Part 6: psychosocial Care

Authors: Ulmer A., and Meinhold C.

Summary: Introduction: Psychosocial approaches are important, besides what can be achieved by medical treatment alone, in the attempt to optimize a poorly running Agonist Opioid Treatment (AOT). The German system puts pressure on physicians and patients: no payment of AOT expenses is permitted without professional psychosocial care. It's surprising to discover how many patients miss their appointments for such care. Methods: Not much published evidence has been made available on this topic, but we have asked our patients how important psychosocial care is to them. Results: We were impressed by how high a grade of appreciation was displayed by their answers; 65% said that this kind of care was essential to them. We also discussed the view that all forms of care would become much more effective if the treatment were organized in a decentralized manner, so aiming more directly at the integration of patients into normal settings. The number of patients with a job or training post under the widely unregulated, decentralized type of treatment being offered 27 years ago was 85.7%. Currently, in the opposite situation of an organized offer of treatment, that figure has fallen to 31% (including those with a regular job, who account for 29%). Conclusion: The optimum is, therefore, the best possible organization of AOT treatment, which gives normality the top priority, as well as a comprehensive psychosocial offer, with special emphasis dedicated to its psychotherapeutic components.

Published: Volume 21 • Issue N2 • April 2019 (pages: 5 - 19)

Title: Hepatitis C Treatment and Prevention in Pwid and Prisoners: A Narrative Review of the Extant Literature.

Authors: Crowley D., Cullen W., Lambert J., and Van Hout M.C.

Summary: Background. Hepatitis C is a curable and preventable disease. People who inject drugs (PWID) and prisoners are at-risk groups for acquisition of Hepatitis C Virus (HCV) yet treatment rates remain low. Opioid substitution treatment (OST) and needle syringe programs (NSP) reduce HCV transmission, yet coverage, particularly in prisons, is inadequate. ‘Treatment as prevention' is a key public health strategy to help achieve the World Health Organisation (WHO) goal of HCV elimination by 2030. Aim: To review the recent literature on HCV treatment and prevention in PWID and prisoners. Methods: Electronic data base (Medline, PubMed, Cochrane library and Embase) and key website search using search terms related to the topic. Results: HCV related disease burden in PWID and prisoners is greater than the general population, yet treatment rates remain low. Direct acting anti-virals, mobile elastography, integration of treatment into community and prison settings and less restrictive treatment guidelines have removed many treatment barriers. Treatment adherence and outcomes, among PWID (even current injectors) and prisoners are equivalent to the general population. HCV treatment in both groups is cost-effective but is dependent on up scaling treatment levels, continuing treatment on prison release and preventing re-infection. The public health strategies of treatment as prevention and micro-elimination along with adequate coverage of OST and NSP has the potential to achieve the WHO goal of HCV elimination by 2030. Conclusion: Up-scaling HCV treatment levels and increasing OST and NSP coverage among PWID and prisoners remains a challenge but is an essential public health strategy to reduce the increasing HCV burden.

Published: Volume 21 • Issue N2 • April 2019 (pages: 21 - 26)

Title: Over the Counter (Otc) Analgesic Misuse: One Patient's Journey

Authors: Hill D., and Stewart E.

Summary: This case study is to demonstrate the journey experienced by a patient who had developed a dependency on large quantities of opioid analgesics they purchased from community pharmacy. It sets out to describe the patient's dependency, the quantities consumed (96 tablets most days), how they obtained the medication (both logistically and technique) and how they were treated once the dependency was disclosed. The article includes the patients thoughts on actions that they feel should be taken and the signs that health care professionals should be aware of that are used by patients who have developed a dependency on opioid analgesics. The case study also demonstrates that patients can successfully be treated for opioid analgesic dependency, despite large quantities being used but there may be a need to use treatment alternatives and ensure the care provided is patient centred.

Published: Volume 21 • Issue N2 • April 2019 (pages: 27 - 32)

Title: Early Age of First Drug Misuse Is Associated with Increased Risk of Suicide Attempt by Overdose Amongst Patients with Heroin Addiction in Medication-Assisted Treatment Programmes

Authors: Kastelic A., Pregelj P., Zaman R., and Segrec N.

Summary: Aim: The aim of the present study was to examine whether there is any association between receiving medication-assisted treatment for opioid dependence (MAT) with the duration of substance abuse. Methods: Data were collected using self-rating questionnaires in Slovenia from 1997 to 2007. Results: Of the 2,853 patients included, 2,494 provided valid data (87%; cases where data were missing: 359; 13%). Of those 2,494, 2,075 (83%) patients were assigned to the group with no previous history of overdose, 356 (14%) to the group with at least one previous overdose, without involving any suicide attempt, and 63 (3%) to the group of patients with previous suicide attempt(s) by overdose. Using multivariate logistic regression, the two risk factors associated with suicide attempts by overdose were: age (OR = 1.05, 95% CI = 1.01–1.09) and age at first PAS use (OR = 0.86, 95% CI = 0.77–0.96), //while / and// the three risk factors associated with overdose without suicide attempts were: age (OR = 1.03, 95% CI = 1.01–1.06), age at initial PAS use (OR = 0.95, 95% CI = 0.91–0.99) and unemployment (OR = 1.77, 95% CI = 1.23–2.55). Conclusion: These findings suggest that it is not the years of PAS usage, but the patient's age at first use that was an important risk factor associated both with suicide attempts by overdose and the finding of overdose without any suicide attempts. We suggest that special attention should be directed to suicidal behaviour with a primary focus on patients with heroin addiction, in particular to cases of non-fatal overdose and those of suicide attempts by overdose among individuals with heroin addiction who initiated drug misuse at an early age.

Published: Volume 21 • Issue N2 • April 2019 (pages: 33 - 40)

Title: Hepatitis C Screening in Inpatient Addiction Treatment Settings in Istanbul Turkey: Implications for Integrating Treatment Services

Authors: Alaei A., Mishkin K., Alaei K., Bilici R., Altintas M., and Altice F.

Summary: Background: While drug use is increasing in Turkey, little research had documented Hepatitis C (HCV) infections among drug users. Because the country has low HCV screening practices, we conducted a HCV screening assessment of all patients entering a large governmental addiction treatment hospital in Istanbul, Turkey. Aim: This paper presents results from HCV screening of people seeking drug treatment in Turkey, including analysis of factors associated with HCV infection. Methods: Data were collected from 936 patients who received a HCV test while seeking drug treatment at Erenköy Mental Health and Neurology Training and Research Hospital from January 1, 2014 to December 30, 2015. Chi-square tests and logistic regression models iden-tified variables significantly associated with HCV status. Results: Of the sample, 14% were HCV-positive. HCV was highly prevalent among injection drug users (IDU) (38%) and heroin IDU (98.3%). In addition to IDU and heroin use, HCV status was associated with sex (p=0.03), age (p<0.0001), living location (p=0.006), prior treatment (p<0.0001), drug use method (p<0.0001), and Hepatitis B status (p=0.0002). The number needed to screen for HCV was highest among non-heroin users. Conclusions: HCV is highly prevalent among injection drug users who use heroin in Turkey. Pub-lic health interventions focused on incorporation of HCV screening into drug rehabilitation clinics in Turkey should target heroin injection drug users.

Published: Volume 21 • Issue N2 • April 2019 (pages: 41 - 46)

Title: Surviving in the Workplace: Conditions in Centres for the Prevention and Treatment of Drug Addiction

Authors: Ignjatova L.

Summary: Background. The European Commission has adopted a new Strategic Framework on Health and Safety at Work, 2014-2020 and the prevention of physical accidents has recently been expanded to include the prevention of mental accidents. Aim of this study is to show the workplace situation in centres for the prevention and treatment of drug addiction (CPTDAs). Materials and Methods. The survey was conducted in 2014/2015 in 12 CPTDAs in the Republic of Macedonia. The unstandardized, work-related questionnaires were prepared by staff at the CPTDAs, in each case with a related workshop, where 31 participants were asked to analyse data through group work. Results. The number of patients participating in the study was 1,314, their average methadone dose varied from 53 to 99 mg, with 0%-60% injecting drugs in the last 30 days; 0%-26% were employed and 0%-70% needed social help from the various centres involved. The staff complained that there were: aggressive patients, threats, offensive remarks, attempts by patients to blackmail staff members and their family, thefts carried out by patients, obstruction of the professional work being done by staff, incomplete teams, too few psychiatrists and doctors, an insufficient availability of medications for the treatment of comorbidity, an insufficient supply of buprenorphine, difficulties in referring patients to psychiatric and other hospitals, poor quality of security staff, large numbers of patients, poor quality work in packaging bottles for take-home therapy, too few screening tests, inflexible working hours, organizational problems, having to face a strong social stigma, insufficient support, work to be done over the weekend for prison staff only and insufficient rest. Conclusions. Adequate care of staff is needed if our aim is to adequately cure patients.

Published: Volume 21 • Issue N2 • April 2019 (pages: 47 - 52)

Title: Does Impulsivity Increase the Risk of Developing a Pathological Condition?

Authors: Conversano C., Marchi L., Ciacchini R., Bertolucci I., Micheloni T., and Maremmani A.G.I.

Summary: Background: With the term addiction, the scientific community refers to a psychopathological category related to a rather variable series of addictions to different substances and behaviors, among which we can find common generic elements. The most important part in the definition of addiction is represented by the continuous research for gratification. The psychopathological manifestation of the disease consists of three key symptoms: craving, relapse and loss of control (impulsivity). Discovering and studying a factor of vulnerability in the development towards this psychopathology would certainly represent a goal and would have both predictive and explanatory importance. Methods: This short review is an attempt to explore impulsivity concept and its relations with addiction, in particular cocaine addiction. Results: In literature, there are numerous studies that indicate the excessive amount of impulsivity and the non tendency to control impulses as pre-existing factors and possible predictors of vulnerability for the development of an addiction. Furthermore, some neurocognitive studies have shown how cocaine-addicted subjects show more impulsivity towards both movements (impulsive action) and, cognitively, in the decision-making capacity (impulsive choice). Conclusions: It is rather common to find higher impulsivity traits in gamblers than in the general population; therefore, this trait could represent an important risk factor and predisposition to the development of a clinical picture of dependence.

Published: Volume 21 • Issue N3 • June 2019 (pages: 7 - 16)

Title: Relationship between Syringe Sharing and Severity of Psychopathology, Antisocial Personality Disorder and Novelty Seeking in a Sample of Patients with Heroin Use Disorder

Authors: Alnıak İ., Karabulut V., Evren C., Çetin T., Umut G., Ağaçhanlı R., and Evren B.

Summary: Background: Patients with heroin use disorder (PWHUD) were reported to have different clinical features according to the route of heroin administration. People who share syringes may represent a relatively unique type of PWHUD. Aim: To evaluate the clinical characteristics of PWHUD who share syringes while investigating the predictive factors involved in syringe sharing (SS). Methods: A sample of 219 male PWHUD who were currently in opioid maintenance treatment participated in the study. All patients were evaluated using the Symptom Checklist-90-R (SCL-90-R) and Novelty Seeking (NS) subscale of the Temperament and Character Inventory (TCI). Antisocial personality disorder (APD) was assessed by holding a Structured Clinical Interview for DSM-III-R-Personality Disorders (SCID-II). Logistic regression analysis was conducted to evaluate variables that predict the presence of SS. Results: The prevalence of SS in our sample was 24.7%. The total scores assigned according to the rating scales were significantly higher in the SS (+) group than in the SS (-) group. SS (+) group members were more likely to have a criminal record, as well as a history of incarceration and probation. Multiple substance use, Hepatitis C virus seropositivity, history of suicide attempts and self-mutilation were significantly more common in the SS (+) group. Extravagance, interpersonal sensitivity and APD were found to be the main predictors of the presence of SS. Conclusions: Presence of APD, extravagant personality trait and interpersonal sensitivity appear to have a probable impact in discriminaing SS (+) patients from the others among PWHUD. Knowledge of the predictive risk factors for SS might help to prevent SS from happening, so reducing the potential burden of SS both on patients and society.

Published: Volume 21 • Issue N3 • June 2019 (pages: 17 - 26)

Title: Self-Reported Adverse Experiences and Age of Opioid Onset for First Time Admitted to Opioid Maintenance Treatment

Authors: Carlsen S.-E.L., and Torsheim T.

Summary: Background: Patients in opioid maintenance treatment might differ significantly on major life events, coping resources and living conditions. Aim: This study investigated patients' sociodemographic characteristics before first admission to opioid maintenance treatment, focusing on adverse experiences and their influence on age of opioid onset. Materials and Methods: Forty-seven participants were recruited from eight opioid maintenance treatment units in Bergen, Norway. Retrospective data on demographics, external potential adverse experiences and patients' history of drug use were collected using the National Quality Register for Substance Abuse Treatment. A Cox regression survival analysis was conducted to examine potential differences in sociodemographic characteristics compared to age of opioid onset and adverse experiences. Results: The mean age of opioid onset was 22.6 years (SD = 6.80). No significant differences between recruited patients were found for sociodemographic factors such as marital status, education level, living situation, parenthood and crime. Age of opioid onset use was strongly correlated to being in care (b = 0.87), family members that were or had been in prison (b = 0.83) and drop-out from school (b = 0.77). The participants' adverse experiences varied in number, with a mean exposure of 8.1 (SD = 4.0). Conclusions: Patients in this study had been exposed to many adverse experiences, yet these variated in both type and number. There was substantial variation in age of opioid onset. When new patients are enrolled in treatment, clinicians should consider this heterogeneity. It can be of importance in opioid maintenance treatment to distinguish between patients according to their number of adverse experiences.

Published: Volume 21 • Issue N3 • June 2019 (pages: 27 - 35)

Title: Using Medication Assisted Treatment to Treat Opioid Use Disorder: Learning from Past Experience to Guide Policy

Authors: Parrino M.

Summary: The increasing prevalence of opioid use disorder (OUD) in the United States has led to an ongoing public health crisis. At the present time, more than 150 Americans die each day of opioid-related overdoses. This epidemic of opioid overdose deaths, first characterized by prescription opioid misuse, has transitioned into heroin and fentanyl use. Medication assisted treatment with methadone and buprenorphine has been shown to be effective in helping individuals addicted to heroin or other opioids stabilize their lives and reduce their illicit drug use. Naltrexone also is an effective medication for some opioid addicted individuals as well as for those with alcohol dependence.(1) The OUD crisis has led to an increasing demand for medication assisted treatment through opioid treatment programs (OTPs) and office-based opioid treatment via the Drug Abuse Treatment Act of 2000 (DATA 2000). Treatment capacity, however, must be further expanded to meet the growing demand, especially in rural and other underserved areas. The American Association of Treatment of Opioid Disorders (AATOD) presents this policy paper to address some of the issues that impact the development of future policies in the use of medications in OUD treatment and the prevention of opioid overdose. These issues include: Should treating OUD be viewed as a public health intervention with the principal component of care and treatment being the utilization of federally approved medications (methadone, buprenorphine, and extended release injectable naltrexone)? Should resources be prioritized to treating OUD with medications and additional clinical services? Should there be coordination to organize service delivery to treat this illness through a continuum of service delivery components? Should there be a better connection/coordination between DATA 2000 practices and OTPs to address treatment capacity and facilitate interfacility referrals from one practice to the next? This paper provides a historical perspective of the nation's current policies for delivering medication assisted treatment for OUD. By understanding the system and principles of care that guide how medication assisted treatment is delivered today, policymakers can develop future policies that offer greater stability, are based on evidence, and reflect best practices.

Published: Volume 21 • Issue N3 • June 2019 (pages: 37 - 45)

Title: Low Mindfulness Trait Associated with High Perceived Stress Equally by Methadone Maintenance Treatment Patients and Medical Students

Authors: Claman A., Adelson M., Sason A., Barkay G., and Peles E.

Summary: Background: A poor mindfulness trait was reported in some studies among different types of individuals with substance use disorders; however, specific scores of patients in methadone maintenance treatment (MMT) have never been delineated. Aims: To study whether MMT patients have poor mindfulness, and may benefit from mindfulness-based interventions, a mindfulness trait and perceived stress were compared between MMT patients and two control groups. Methods: Perceived stress (Perceived Stress Scale, PSS) and the mindfulness trait (Five Facet Mindfulness Questionnaire, FFMQ) were assessed among 41 MMT patients and two additional groups that served as reference groups, 36 medical students (known to suffer from stress), and 27 patients with borderline personality disorder (BPD, known to be characterized by having a poor mindfulness trait). Results: High perceived stress levels (PSS ≥18, median) were present among 61% of the MMT patients and 50% of the medical students. The highest mindfulness score was observed among non-stressed MMT patients (153.5±17.2), followed by the stressed MMT patients and the non-stressed students (128.9±17.0 and 130.5±13.3, respectively), with the lowest score for stressed students (116.3±17.9). The PSS score and the mindfulness score were inversely correlated (R=-0.65, p < 0.0005). The BPD individuals had the lowest mindfulness score (103.4±25.3). Conclusions: MMT patients as a whole have a high mindfulness trait. A high prevalence of high perceived stress levels, as characterized by a poor mindfulness trait, was observed in both MMT patients and medical students, making them optimal candidates for mindfulness course interventions for reducing high perceived stress levels.

Published: Volume 21 • Issue N3 • June 2019 (pages: 47 - 51)

Title: Difficulties in Initiating Hepatitis C Treatment in Patients with Opioid Use Disorder: Patient's Perspective

Authors: Palma-Alvarez R.F., Ros-Cucurull E., Grau-López L., Martínez-Luna N., Rodríguez-Cintas L., Álvarez A.I., and Roncero C.

Summary: Introduction: The Hepatitis C Virus (HCV) is highly prevalent in intravenous drug users, however HCV treatment is scarce in them and there are difficulties to start it within this population. Aim: To explore the difficulties to initiate a HCV treatment from the perspective of the patient who goes to an outpatient drug addiction treatment center. Methods: A self-administered Ad Hoc questionnaire was designed to assess the reasons why the patient would not perform a treatment for HCV, then this questionnaire was administered to patients with opioid use disorder who were in an outpatient center for drug treatment. Results: 56 patients were assessed (82,1% men, 44,09 ± 8,33 years), 80,9% had a history of intravenous drug use and 76.4% had HCV. The most frequent reasons for not performing a HCV treatment were related to false beliefs and lack of information about the treatment itself. However, 72% would be interested in carrying it out. Conclusion: Given the false beliefs detected, educational interventions about the treatment of HCV in intravenous drug users should be performed.

Published: Volume 21 • Issue N3 • June 2019 (pages: 51 - 59)

Title: Towards a Specific Psychopathology of Substance Use Disorder: Comparison between Heroin Use Disorder and Chronic Psychotic Patients

Authors: Rugani F., Paganin W., Maremmani A.G.I., Perugi G., and Maremmani I.

Summary: Background: Addiction is a chronic relapsing condition in which psychiatric phenomena play a crucial role. Psychopathological symptoms in patients with Substance Use Disorders (SUDs) are generally considered to be part of the drug addict personality, or else to be related to the presence of a Dual Disorder (DD), raising doubts about whether patients with long-term SUD possessed psychopathological dimensions. Our research group at the University of Pisa has shed light on the possible definition of a specific psychopathy dimension in SUD. In Heroin Use Disorder (HUD) patients, by applying a PCA factor analysis to the 90 items listed in the SCL90 checklist, a 5-factor solution was identified for the first time and was then confirmed in Alcohol Use Disorder and Cocaine Use Disorder patients. The first factor reflected a depressive 'Worthlessness-Being Trapped' dimension (W/BT); the second factor picked out a ‘Somatic Symptoms' dimension (SS); the third identified a 'Sensitivity-Psychoticism' dimension (S/P); the fourth a 'Panic Anxiety' dimension (PA); and the fifth a 'Violence-Suicide' dimension (V/S). To confirm their specificity, these dimensions must be able to discriminate patients affected by addiction from those affected by other psychiatric diseases. Methods: In this study 40 chronic psychotic patients (CHR-PSY) were matched with 33 HUD patients according to age and gender, and compared, at univariate and multivariate level, regarding the severity and typology of the SCL90 five dimensions. Results: Low-level education was more frequent in HUD patients, but it was unrelated to psychopathological typology (2=8.83; p=0.065) and to severity (except for the SS dimension, F=5.94; p<0.05). Psychopathological typology was able to differentiate HUD from CHR-PSY patients 2=14.44; p=0.006). At univariate level, only PA severity was higher in CHR-PSY patients, whereas multivariate discriminant analysis was able to differentiate HUD significantly from CHR-PSY patients (Wilks' Lambda=0.69; 2=25.74; df=2; p<0.001), showing that 79.5% of the cases, as originally grouped, had been correctly classified. Conclusions: This study, being able to differentiate HUD from CHR-PSY patients, further supports the specificity of the proposed factorial dimensions of the psychopathology of SUD.

Published: Volume 21 • Issue N4 • August 2019 (pages: 5 - 14)

Title: Association of Drd2 Gene Polymorphism with Heroin Dependence.

Authors: Koijam A.S., and Haobam R.

Summary: Background: Dopamine receptors play a crucial role in the neuronal signaling of the mesolimbic system in the brain which regulates emotion, complex behavior along with rewarding effects. The variants rs6276 of DRD2, 120 bp indel of DRD4 and 12 bp repeat have been reported to have effects on receptor activity. Aim: To analyse the genetic association of DRD2 and DRD4 genes with heroin dependence. Methods: Genetic association (based on alleles, genotypes and haplotypes) analyses for three variants of DRD2 and DRD4 genes were performed using UNPHASED version 3.1.5. in 290 participants (157 controls and 133 cases with heroin dependence) from Manipur, India. Interactions among the markers were also analysed using MDR 2.0 beta 8.4. Results: The post-hoc statistical power of the study was 0.683 (68.3%). Significantly higher distribution of AA genotype (p= 0.005, OR= 2.27, CI= 1.21-4.27) of rs6276 (DRD2) was observed in cases with heroin dependence than in controls. Interestingly when analysis was made separately, genotypic association of rs6276 was observed in male subjects only (p-value= 0.006, adjusted p-value= 0.021) but not female subjects (p-value= 0.103). G-S haplotype of rs6276-120bp indel (case frequency= 0.214, control frequency= 0.309, p-value= 0.03) and S-L haplotype of 120bp indel-12 bp repeat (case frequency= 0.17, control frequency= 0.25, p-value= 0.02) were found to be significantly higher in controls than in cases. Conclusion: The study indicates evidences for genotypic association of rs6276 of DRD2 with heroin dependence. The ‘AA' genotype of rs6276 in an individual is a possible risk factor for heroin dependence.

Published: Volume 21 • Issue N4 • August 2019 (pages: 15 - 22)

Title: The Effect of Heroin, Cannabis and Cocaine Addiction on Sexual Functions and Depression of Women: A Comparative Cross-Sectional Study

Authors: Dişsiz M.

Summary: Background: The acute effects brought about by heroin, cannabis and cocaine increase the levels of dopamine, norepinephrine, and serotonin neurotransmitters that are associated with sexual activity. Continuous use of these substances causes mental disorders, while lowering the individual's interest in sexuality. Aim: This study aimed to determine the effects of heroin, cannabis and cocaine addiction on the sexual functions of women. Methods: This study is the outcome of comparative-descriptive and cross-sectional research. Women with a diagnosis of substance use disorder according to DSM-5 (n=97) were included in the patient group. Age-matched healthy women volunteers (n=105) were selected for the control group. A questionnaire form was carefully compiled by researchers. The data were collected using the Female Sexual Functioning Index (FSFI) and the Beck Depression Index (BDI). Results: Heroin-, cannabis-, and cocaine-addicted women obtained significantly higher scores, which were calculated from the FSFI scale total score and all subscales, including desire, arousal, lubrication, orgasm, satisfaction and pain (p<.05). Additionally, the orgasm, satisfaction, and total FSFI scores of the women in the cocaine group turned out to be significantly higher than those of the women in the cannabis and heroin groups (p<.05). According to the FSFI scale (<26.55), the sexual dysfunction was most common in the cannabis-addicted group (94.7%), which was followed by the heroin-addicted group (91.2%) and cocaine-addicted group (76.2%), respectively. Conclusion: In heroin-, cannabis-, and cocaine-addicted women, sexual functions are adversely affected and depressive symptoms appear to increase.

Published: Volume 21 • Issue N4 • August 2019 (pages: 23 - 26)

Title: Risk of Hepatitis C Virus Infection among Heroin and Methamphetamine Users

Authors: Okruhlica L., and Kamendy Z.

Summary: The objective of this study was to determine whether there is a difference in the prevalence of hepatitis C virus (HCV) infection between opiate and methamphetamine users. Patients and methods: We conducted a retrospective comparative study of 222 patients who requested treatment for dependence on opiates (101 patients) or methamphetamines (121). The average age of participants was 23 years old (standard deviation: 4.3), and 75/% were male. Results: We found that 65% of heroin users and 12% of methamphetamine users were infected with HCV. The prevalence among those who injected drugs was 69% and 28%, respectively. 93 % of opiate users and 35% of methamphetamine users had injected drug some time in their life. The HCV infection risk was significantly higher among the heroin users as compared to the methamphetamines users (odds ratio 13.75). Conclusions: The prevalence of injecting behavior and the risk of the HCV infection was lower in methamphetamine users compared to the heroin users. Still, the HCV infection prevalence in the methamphetamine group was much higher than in the general population. Because no substitution treatment is available for methamphetamine users, detoxification followed by a drug-free lifestyle are essential to reducing the risk of drug-related infectious diseases, in general, and of HCV, in particular.

Published: Volume 21 • Issue N4 • August 2019 (pages: 27 - 34)

Title: Cross-Sectional Study on the Need to Provide Contraceptive Services to Women Attending Opioid-Substitution Therapy

Authors: Olioff J., O Shea T., Horan A., Naughton A.M., and O'Brien D.

Summary: Background. Women with opioid use disorders who have unintended pregnancies face unique challenges. A common strategy for preventing unintended pregnancies among these women is to increase their use of long acting reversible contraception (LARC), especially the implant and intrauterine device. This study aimed to assess the pregnancy history, contraceptive use and access to contraceptive services of women attending Cork-Kerry Community Healthcare (CKCH) for opioid replacement therapy. The need for a contraceptive service within the Addiction Services at CKCH was evaluated. Methods. The study utilized a cross-sectional survey administered by healthcare providers to 39 women, ages 18-50, attending CKCH for opioid replacement therapy. Descriptive statistics were performed using IBM SPSS Statistics Data Editor. Results. 79.5% of participants had unintended pregnancies, and 23% had 3 or more unintended pregnancies. Of the participants' children, 35% lived with their mother, 37% lived in care, and 24% lived with another family member. 31% of participants reported never having used LARC. 18% of participants reported never having received information on pregnancy prevention and 21% reported never having received information on STI prevention. 92% of participants reported that they would use a contraceptive service if it were provided within the addiction services at CKCH. Conclusions. This study highlights the need to increase contraceptive services for women attending CKCH for opioid replacement therapy. Addiction services are ideal locations to also access contraceptive services because service-users already attend these clinics frequently for treatment, and thus have continuity of care with healthcare providers.

Published: Volume 21 • Issue N4 • August 2019 (pages: 35 - 39)

Title: Ethnicity and Specific Psychopathology of Addiction. Comparison between Slovenian and Italian Heroin Use Disorder Patients

Authors: Maremmani A.G.I., Lovrecic M., Lovrecic B., and Maremmani I.

Summary: Background: In Heroin Use Disorder (HUD) patients, by applying a PCA factor analysis to the 90 items listed in the SCL90 checklist, 5-factor psychopathology was identified for the first time and was then confirmed in other Substance Use Disorders. The first factor reflected a depressive 'Worthlessness-Being Trapped' dimension (W/BT); the second factor picked out a ‘Somatic Symptoms' dimension (SS); the third identified a 'Sensitivity-Psychoticism' dimension (S/P); the fourth a 'Panic Anxiety' dimension (PA); and the fifth a 'Violence-Suicide' dimension (V/S). We confirmed the dimensions' specificity, testing their independence from state-addiction conditions such as treatment typology, type of drug involved, concomitant psychiatric problems, active substance use, and stress reactivity. Methods: In this study, 66 Slovenian HUD (SLO-HUD) patients requesting Agonist Opioid Treatment (AOT) were matched with 66 Italian ones (IT-HUD) according to age and gender; the severity and typology of the five SCL90 dimensions were then compared between the two groups, at the univariate and multivariate levels. Results: Severity of psychopathology was able to differentiate SLO-HUD from IT-HUD patients. At univariate level, the S/P PA and V/S dimensions were more severe in SLO-HUD patients, whereas multivariate discriminant analysis was only able to poorly differentiate SLO-HUD from IT-HUD patients (Wilks' Lambda=0.90; 2=12.73; df=5; p<0.026), showing that only 62.9% of the cases, as initially grouped, had been correctly classified. At the other extreme, psychopathological typology was unable to differentiate between the two samples, SLO-HUD and IT-HUD (2=2.14; p=0.709). Conclusions: This study, by demonstrating the same psychopathological typology in SLO-HUD and IT-HUD patients, further supports the specificity of the proposed factorial dimensions that go to make up the psychopathology of SUD.

Published: Volume 21 • Issue N4 • August 2019 (pages: 41 - 44)

Title: Additional Comments to Staub Et Al., “How to Develop and Implement an Exercise Programme in a Heroin-Assisted Treatment Setting”

Authors: Muller A.E., and Roessler K.K.

Summary: Staub et al. recently reported on participant involvement in the planning and evaluation of an exercise intervention for patients in heroin-assisted treatment. Very few exercise interventions among people with opioid or other substance use disorders report surveying potential participants about their actual interests and preferences beforehand, and even fewer follow up afterwards to ask about barriers to participation. Their article should be considered a best practice, and our commentary is intended as a supplement to situate their important contribution within more recent research.

Published: Volume 21 • Issue N5 • October 2019 (pages: 5 - 6)

Title: The European Medical Agency and the Unfolding Destiny of Alcohol Use Disorder Patients

Authors: Maremmani I.

Summary: Not available

Published: Volume 21 • Issue N5 • October 2019 (pages: 7 - 12)

Title: Toward Diagnostic and Therapeutic Relativism in Psychiatry and Addiction Medicine

Authors: Mendelevich V.

Summary: This article is devoted to the analysis of the dual attitude towards patients who have a behavioural pathology, including personal, addictive, sexual and impulse disorders in psychiatry. On the one hand, these disorders are admitted as psychiatric diagnoses classified in ICD and DSM. At the same time, such patients are denied the opportunity to benefit from a patient's lawful rights (e.g. sick lists, disability). Attention has been directed to the medicalization of behavioural deviance with insufficient scientific validity to justify their inclusion in psychiatric classifications. The question is raised as to the necessity of discussing the removal of these diagnostic categories from the psychiatric classification.

Published: Volume 21 • Issue N5 • October 2019 (pages: 13 - 30)

Title: A Systematic Review of Methadone Maintenance Therapy Studies in Preventing Relapses in Addiction: Evidence from Asean Countries

Authors: Mohd Fahami N.A., Nazrun Shuid A., Abdullah A., Naina-Mohamed I., Chin K.-Y., Mohamed N., Masbah N., Haji Mohd Saad Q., Kamisah Y., and Muhammad N.

Summary: Background: Opioid abuse is a significant problem worldwide due to its associated healthcare and economic burdens. In ASEAN countries, methadone maintenance therapy (MMT) has been implemented for over a decade to replace forced detoxification programmes. However, the overall effectiveness of MMT programmes is still unclear in the region. Aims: We aimed to summarize the current evidence on the effectiveness of MMT in preventing relapses in drug addicts living in ASEAN countries. Methodology: A search through the literature for original research articles written in English and published between 1990 and 2016 was performed using PubMed, Scopus and Web of Science. Articles were screened and extracted by two independent reviewers. Results: The results showed that MMT alone or incorporation into other programmes was effective in reducing concurrent illicit drug use and withdrawal from treatment across ASEAN countries. Higher methadone doses were reported to have better retention effects than those due to lower doses. Conclusion: In summary, MMT is effective in preventing relapses into addiction behaviour from occurring in patients in ASEAN countries. Health professions should adjust the methadone dosage to suit the individual requirements of patients and ensure compliance.

Published: Volume 21 • Issue N5 • October 2019 (pages: 33 - 40)

Title: The Impact of Mindfulness-Based Relapse Prevention on Craving, Lapse and Mindfulness Fostering in Addicted Patients in Methadone Maintenance Treatment

Authors: Sarami Foroushani N.

Summary: Background: lapse or relapse is highly prevalent in substance abuse treatment; therefore, prevention programmes are of great importance. Aim: The present study has aimed to investigate the effects of Mindfulness-Based Relapse Prevention (MBRP) on craving, lapse and mindfulness fostering in addicted patients in Methadone Maintenance Treatment (MMT). Methods: For this purpose, using the Solomon four group design, 55 male addicted patients from three MMT centres were randomly selected and assigned to four groups (two experimental and two control groups). The experimental groups received eight sessions of MBRP besides while the control groups received only methadone. The data were collected by distributing the Heroin Craving Questionnaire (HCQ), the Five Facet Mindfulness Questionnaire (FFMQ) and urine tests. Results: The results of the analyses indicated that three out of the five subscales of HCQ, namely: desire to use, intention to use and anticipation of relief from withdrawal or dysphoria were significantly influenced by MBRP, while all the five facets of the mindfulness questionnaire, namely: observing, describing, acting with awareness, non-judging of inner experience and non-reactivity to inner experience were significantly influenced by this prevention programme. Furthermore, the results of the urine tests revealed a lower lapse/relapse percentage in the experimental groups. Conclusions: It can be concluded that MBRP might support longer lasting sustainability of treatment gains for individuals suffering from substance use disorders; clinicians will therefore do well to complement common medical addiction treatments with psychological programmes such as Mindfulness-Based Relapse Prevention.

Published: Volume 21 • Issue N5 • October 2019 (pages: 41 - 53)

Title: Cardiological Safety in Patients Receiving Methadone Treatment

Authors: Farina G., Mungai F., and Starace F.

Summary: Background: Long QT syndrome is a rare, potentially fatal cardiac condition caused by an alteration of the ventricular repolarization process requiring a longer time than normal. The anomalies of the ventricular repolarization are caused by alterations of proteins responsible for the transport of potassium and sodium ions through the membranes of the cardiac cells, which represents a fundamental process for the maintenance of normal electrical activity. Functional alterations of these channels may be genetic, but may be also caused by the action of some drugs. There are many drugs that can potentially cause a prolonged QT interval, methadone is among these drugs. Aim: This paper aims at summarizing the recommendations available and at providing advice to promote safer use of methadone. Methods: A systematic revision of available and internationally acknowledged guidelines for methadone treatment was performed and an analysis of the existing processes within the Healthcare Organization - Department of Mental Health and Substance Abuse (DMHSA) of Modena was carried out. Results: More than half of patients on methadone treatment considered in our sample presented at least one cardiological risk factor. Conclusions: A Care Pathways for methadone treatment was developed in order to guide professionals with the identification of the subjects at higher risk, the choice of safer opioid agonist and the cardiac monitoring of patients in treatment.

Published: Volume 21 • Issue N5 • October 2019 (pages: 51 - 58)

Title: How Probation Affects Treatment of Opioid Use Disorders: Comparison of Early Remission Rates between Opioid Use Disorder Patients Admitted to Medical Clinic Voluntarily and by Probation

Authors: Asan Ö., Şahiner İ.V., Şahiner Ş.Y., and Göka E.

Summary: Background: Probation is a well-intentioned approach that aims to bring substance abusers back into the community. In the literature there is a lack of studies dedicated to showing how probation affects the treatment outcomes of opioid use disorders. Aim: This study aims to explore the probation's impact on treatment outcomes of opioid use disorders by comparing the early remission rates of patients admitted voluntarily and by probation. Methods: 158 convicts on probation and 303 patients with opioid use disorder who applied voluntarily were included in the study. The sociodemographic characteristics and the early remission rates of the patients were compared. Based on DSM-5 criteria, early remission refers to the failure to meet any of the criteria of substance use disorder, other than craving or a strong desire, and the compulsion to use such substances for at least 3 months, but for a time period shorter than 12 months. Results: Early remission rate among patients who applied voluntarily (38.9%) was significantly higher than patients who were referred to us as convicts on probation (26.6%). Independent factors raising the probability of early remission were found to be voluntary referral to outpatient clinics (1.791-fold), being male (4.855-fold) and old age (1.090-fold), while being single (0.508-fold) and a long duration of substance use (0.981-fold) were found to be independent factors lowering the probability of early remission. Conclusion: The findings of the present study demonstrate that in patients suffering from opioid use disorder, the willingness and motivation of the individual to undergo treatment were more effective than motivations based on the threat of legal sanctions.

Published: Volume 21 • Issue N5 • October 2019 (pages: 61 - 66)

Title: Ethnicity and Specific Psychopathology of Addiction. Comparison between Migrant and Italian Heroin Use Disorder Patients

Authors: Carbone M.G., Tagliarini C., Ricci M., Lupi A.M., Sarandrea L., Ceban A., Casella P., and Maremmani I.

Summary: Background: In previous research projects of ours, we have succeeded in defining a psychopathology that appears to be specific to the substance use disorder, while remaining stable and independent of many factors and variables. The primary symptom dimensions considered were: W/BT, SS, S/P, PA, and V/S. Methods: Continuing this line of investigation, we tested the independence of this five-dimension psychopathology from ethnicity by assessing its five dimensions in migrant subjects with Heroin Use Disorder (M-HUD), and comparing them, after matching for age and gender, with Italian HUD patients (IT-HUD), selected from the Addiction PISA-DATASET in a naturalistic, case-control study. Results: Despite the differences regarding educational level, job typology and economic situation, M-HUD and IT-HUD patients showed the same severity and the same predominant typology in the five dimensions we consider specific to SUD. Conclusions: The present study once again shed light on a specific aggregation of psychopathological symptoms in SUD patients, a finding that strengthens the credibility of the five-factor solution.

Published: Volume 21 • Issue N6 • December 2019 (pages: 5 - 16)

Title: Gender Comparison in the History of Addiction, Specific Psychopathology, Behavioural Covariates of Heroin Craving, and Heroin Post-Traumatic Stress Disorder Spectrum During Agonist Opioid Treatment

Authors: Bronzina V., Conversano C., Maremmani A.G.I., Lamanna F., Pacini M., and Maremmani I.

Summary: Introduction: Gender health is an interdisciplinary issue of medicine, raised by the need to account for sex-related influences on physiology and pathophysiology, that is, how symptoms, prevention strategies and treatment should vary by sexual gender. Methods: The basic purpose of this study is to estimate the magnitude of differences between females and males regarding the natural course of heroin addiction, the psychopathology specific to HUD, the behavioural covariates of heroin craving and the Heroin-Post Traumatic Stress Disorder Spectrum (H-PTSD/S) during an Agonist Opioid Treatment (AOT). Results: Our female patients tend to have a higher educational level and live in a family context more often than their male peers. They achieve the same level of adjustment as males during treatment and have a similar addiction history, with the same baseline grade of severity of addictive symptoms. Nevertheless, they are more depressed along the “Worthlessness/Being Trapped” (W/BT) dimension, have prominent panic anxiety more often than males, and, most conspicuously, they react differently to traumatic and loss events. They report perception of loss in relation to a higher number of events, and their reactions are more intense, with higher severity of post-traumatic stress disorder symptoms, such as flashbacks and avoidant behaviour. They are also more likely to display a H-PTSD/S clinical picture such as that reported for L'Aquila earthquake survivors. Conclusion: A female-tailored AOT treatment programme is already necessary and achievable in the approach to heroin addiction.

Published: Volume 21 • Issue N6 • December 2019 (pages: 17 - 19)

Title: Intravenous Abuse of Naphazoline and Heroin Mixture, a Case Report

Authors: Kordrostami R., Akhgari M., and Ameri M.

Summary: Nasal and oral preparations are widely used by patients, as they are considered relatively safe drugs with few significant adverse drug reactions. They may, however, be misused and abused, causing euphoria and other pharmacological effects. We report the case of a 50-year-old man who started using nasal or ophthalmic naphazoline in combination with heroin via intravenous injection three years ago. During hospitalization for the treatment of ulna body fracture, he showed withdrawal symptoms. He had uncontrolled hypertension and anaemia. Nasal and ophthalmic preparations may be abused due to their CNS stimulant and vasoconstrictor properties to get a stronger euphoric effect from the substance that was abused. This raises the further concern of the abuse potential of over the counter drugs.

Published: Volume 21 • Issue N6 • December 2019 (pages: 21 - 29)

Title: Adherence, Abstinence and Quality of Life in Patients with Heroin Dependence Receiving Methadone or Buprenorphine-Naloxone Replacement Therapy

Authors: Pérez V., Hidalgo M.J., Martínez M., Orozco D., and Girón M.

Summary: Introduction: Buprenorphine-naloxone is an alternative to methadone in patients with heroin dependence. Our study aimed to find differences in abstinence from use, adherence to therapy and quality of life between both treatments. Methods: An observational prospective cohort study was conducted during 12 weeks in 72 patients in one health area. Results: No differences in abstinence rates were found. Methadone patients had greater adherence and, at baseline, worse quality of life levels. There were no differences between treatment groups in the percentage of relative change in health-related quality of life. Conclusion: It is concluded that while adherence was higher in methadone patients, both therapies were equivalent in the degree of abstinence and in their impact on quality of life.

Published: Volume 21 • Issue N6 • December 2019 (pages: 31 - 36)

Title: A Clinical Case Control Study to Evaluate Oxidative Stress in Heroin Addicts

Authors: Ullah A., Khan A., Iqbal Z., Khan I., Ahmad L., Kaleem W.A., Alam M., Ullah N., and Ahmad M.

Summary: Background: Heroin is a widely abused drug worldwide. Prolonged use has been associated with oxidative stress through the mechanism of increasing the production of reactive species. Aim: This study aims to evaluate the oxidative stress status of heroin addicts. Methods: A total of 108 participants (60 heroin addicts and 48 controls), all of them age- and area-matched, were selected for this study. After taking the blood samples, serum and erythrocytes were separated, processed and stored for further analysis. The overall antioxidant status of heroin addicts was evaluated by measuring antioxidant vitamins (alpha-tocopherol and all-trans-retinol), uric acid, bilirubin, and antioxidant enzymes (such as superoxide dismutase and catalase) using HPLC-UV, spectrophotometric and manual colorimetric methods. Results: The levels of alpha-tocopherol (P = 0.039), all-trans-retinol (P = 0.007), bilirubin (P = 0.003), SOD (P = 0.033) and catalase (P = 0.021) in the blood samples of heroin addicts were found to be significantly lower than those of healthy volunteers with no significant change in the uric acid level (P = 0.143). Conclusion: Our study concluded that one of the results of heroin addiction is to compromise the anti-oxidant status of the body by decreasing the levels of antioxidants, so disturbing the balance between oxidants and antioxidants and resulting in oxidative stress.

Published: Volume 21 • Issue N6 • December 2019 (pages: 37 - 44)

Title: Identification of Humoral Immune Indicators in Some Clinical Manifestations in Patients with Heroin Use Disorder without Hepatitis C Infection

Authors: Simonovska N., and Zafirova-Ivanovska B.

Summary: Background The effect of opioids on the immune system is a complex phenomenon dependent on such variables as the type of opioid, the character of the response (humoral versus cellular) and the types of cells involved. Aim To characterize humoral immune indicators and determine their predictive impact on the onset of common clinical manifestations observed in heroin users without hepatitis C infection. Methods A total of 140 outpatients were enrolled in this cross-sectional study, which lasted over a 3.5-year period at the University Clinic of Toxicology in Skopje from January 2009 to June 2012. Multivariate logistic regression analysis was used to determine the impact of several humoral immune indicators at the onset of the common clinical manifestations. The following instruments were used for analysis of patient samples: immunoturbidimetric assay, indirect immunofluorescence, spectrophotometer, fluorescence polarization immunoassay. Results: Most of the patients were male n=108, with an average age of 28.34 ± 5.34 years. Arthralgia was observed in 42.14%, skin changes in 12.14%, respiratory difficulties in 15.0%, neurological disorders in 12.86%, Raynaud's disease in 19.28%, and proteinuria in 42.86% of patients. Multivariate logistic regression analysis showed that significant factors having a potential correlation with intravenous heroin usage included: immunoglobulin G (0.027), immunoglobulin M (0.026), and cryoglobulins (<0.001). Conclusions Heroin users with cryoglobulinemia have a greater chance of developing arthralgia, skin changes, respiratory difficulties, neurological disorders, and Raynaud's disease. Some of these conditions were more common among participants who were taking heroin intravenously. These manifestations require treatment that is delivered on time.

Published: Volume 21 • Issue N6 • December 2019 (pages: 45 - 47)

Title: Avoiding the “Wrong Door Syndrome”. The Experience of Dual Disorder Unit in Catanzaro, Italy, Eu

Authors: Insardà A.

Summary: Not available

Published: Volume 22 • Issue N1 • February 2020 (pages: 5 - 6)

Title: Writer's Block Due to Pharmacokinetic Interaction

Authors: Zullino D., and Penzenstadler L.

Summary: Not available

Published: Volume 22 • Issue N1 • February 2020 (pages: 7 - 8)

Title: Mood Stabilizing Effects of Methadone in Opioid Use Disorder Patient

Authors: Gohari J., and Riaz U.

Summary: Lower doses of mood stabilizers may be necessary in patients receiving Methadone, especially when considering the metabolic syndrome and prolongation of QT interval which both Methadone and some psychoactive medications can cause. Research has shown that Methadone is a µ-opioid receptor agonist, as well as a serotonin and noradrenaline uptake inhibitor and NMDA receptor antagonist. Moreover, Methadone has the most evidence of efficacy in comorbid BD and opioid use disorder. We present here a case of a pregnant individual with a history of substance use disorder, BD-II and ADHD.

Published: Volume 22 • Issue N1 • February 2020 (pages: 9 - 16)

Title: The impact of affective temperaments on opioid dependence and addiction severity

Authors: Inanli I., Ozturk H.I., Caliskan A.M., Ozbek S., Demirel B., Er M., and Eren I.

Summary: Background: Previous studies have reported that affective temperaments may predispose to opioid dependence. Both affective temperaments and severe, recurrent substance use have an impact on clinical features. Aim: We have aimed to evaluate the relationship linking oipoid dependence with affective temperaments, and the effects of different temperaments on the severity of opioid dependence. Methods: A total of 82 male patients with some form of opioid dependence and 71 healthy male volunteers participated in the study. All of the patients in the study were hospitalized, and were assessed during the stabilization phase of buprenorphine–naloxone treatment. Participating patients and controls were evaluated with the Temperament Evaluation of Memphis, Pisa, Paris and San Diego self-report questionnaire (TEMPS-A), while only patients were evaluated by applying the Addiction Severity Index (ASI). Results: The cyclothymic, irritable and anxious temperament scores for opioid-dependent patients were higher than those of the control group, besides being higher than the scores of patients with cyclothymic and irritable temperaments. Additionally, a diagnosis of substance dependence in the patient's family and the factor of not being married proved to be predictors of opioid dependence. Only the depressive temperament had a negative effect on addiction severity in life domains, whether those of family domains, or psychiatric ones. Conclusions: Both cyclothymic and irrtitable temperaments predispose individuals to the development of opioid dependence, while depressive temperament aggravates the severity of that dependence.

Published: Volume 22 • Issue N1 • February 2020 (pages: 17 - 22)

Title: Stigma against pregnant women addicted to opioids with a case report

Authors: Mehić-Basara N., Marjanović-Lisac S., and Grabovica M.

Summary: Background: Opiate addicts are often stigmatized; this applies especially to pregnant women addicted to opiates, due both to stigma expressed by the general population and also by health professionals working in other fields of medicine. Methods: The study is epidemiological and retrospective. The sample included 45 pregnant addicted women on agonist opioid therapy (AOT). The study used medical records: the Pompidou form, medical histories, discharge letters, treatment protocols, and therapy follow-up lists. Results: Of the total sample, 42 pregnant women were on methadone and 3 on buprenorphine treatment, 69% were in AOT before pregnancy, and 31% started AOT after they found out that they were pregnant. A majority (77.8%) had a partner who was also an addict, and as many as 20% had some other mental disorder in addition to diagnosis F11.2. From baseline, 57.8% of respondents remained stably in the AOT programme during pregnancy. All pregnancies ended in childbirth, mostly with premature delivery. E.K. gave birth prematurely after bleeding and pain, but was discharged by the Gynaecological Clinic staff only two hours after delivery. The patient walked 1.5 km and, in an extremely exhausted condition, reached the addiction centre. In the period before birth, due to various subjective problems, the gynaecologist sought the opinion of an internist, pulmonologist, haematologist, cardiologist, infectologist and nephrologist. Conclusions: The use of agonist opioid therapy during pregnancy allows for continuous professional monitoring of the pregnant woman and a better pregnancy outcome, but not the reduction of stigma, which lives on in the minds both of the general population and many healthcare professionals.

Published: Volume 22 • Issue N1 • February 2020 (pages: 23 - 30)

Title: High prevalence and risks factors for non-communicable diseases in older people with opioid use disorder.

Authors: Vallecillo G., Robles M.J., Duran X., Castillo C., Fonseca F., and Torrens M.

Summary: Background: Opioid use disorders populations are aging, and aging is associated to non-communicable diseases (NCDs) in the general population, however, data in opioid use disorders populations are scare. The aim of the study was to analyze the prevalence of NCDs and related factors in individuals with opioid use disorder. Methods: Cross-sectional study including patients with heroin use disorder on opioid agonist therapy receiving primary care at a drug addiction outpatient center. Socio-demographic factors associated with the cumulative number of NCDs (according to O'Halloran criteria) were evaluated with Poisson Regression models. Results: Two hundred and eighty-two participants were included in the study. Mean age was 44.9 years and 30.5% were >50 years. Smoking was observed in 79.5% participants, alcohol use in 25.9% and 82.9% were poly-substance users. Chronic viral infections were present in 58.9% of the participants and 24.4% had metabolic syndrome. Overall, 164 (58.2%) participants had >1 NCDs (95% confidence interval: 52.4-63.9). One NCD was present in 95(33.7%) patients, two in 43(15.3%), and more than three in 26(9.2%). Participants were taking a median of 2 (IQR:1-3) chronic medications for the treatment of NCDs, other than opioid substitution therapy. Factors associated with NCDs were: age >50 years (incidence rate ratio (IRR): 1.96), women (IRR: 1.45), foreigners (IRR: 0.39), and employment (IRR: 0.47). Conclusions: NCDs represent a primary health concern in individuals with opioid use disorder, especially among older and women. Given the high prevalence of risk factors for NCDs, interventions to prevent and treat NCDs are necessary in this population.

Published: Volume 22 • Issue N1 • February 2020 (pages: 31 - 40)

Title: Is the Treatment Long Enough? Associations Between Quality of Life and Treatment Duration in Methadone Maintenance Treatment

Authors: Chen Y.-A., Yen T.-T., Hsu W.-Y., Chang T.-G., Chang Y.-J., Chiu N.-Y., and Chang C.-C.

Summary: Background: Methadone maintenance treatment is currently the mainstream opioid addiction treatment, with proven benefits to quality of life. Aim: Our study aims to determine the right treatment duration to achieve the best quality of life. Methods: This cross-sectional study explored the associations of treatment duration with sociodemographic characteristics, substance-related characteristics, severity of dependence, depression and anxiety, and quality of life among patients with opioid use disorder. We created 5 periods of treatment duration and examined trends using chi-squared tests. Power regression, locally weighted scatterplot smoothing regression analysis, and multivariate regression analysis measured the minimum treatment duration required to achieve the best quality of life. Results: The 200 participants were divided into 5 treatment duration groups (<6 months, 6 months–1 year, 1–2 years, 2–5 years, >5 years). Significant power regressions were found in all domains. Results of the LOESS regression show that scores for all domains of quality of life were lower in participants with a treatment duration shorter than 1-2 years. The curve peaked for participants with a treatment duration in the 1-2-year range. Multivariate regression analysis showed that participants with a treatment period of <1 year have the lowest quality of life; there were no significant differences between the other treatment periods. Conclusions: Participants may need methadone maintenance treatment for at least 1-2 years in order to significantly improve their quality of life and bring it to a stable level.

Published: Volume 22 • Issue N1 • February 2020 (pages: 41 - 48)

Title: Nearly thirty years of experience of real-world long-term treatment with Opioid Agonists

Authors: Lamanna F., Maremmani A.G.I., and Maremmani I.

Summary: Background: The most significant contradiction in the treatment of Heroin Use Disorder (HUD) is that the disease is considered by the WHO to be a chronic brain disease necessarily involving proneness to relapse over many years, whereas, in most countries, Agonist Opioid Treatment (AOT) has a limited time-span. Methods: The authors describe the demographic, anamnestic, behavioural, psychopathological features, and the loss and traumatic event reactions of 7 patients treated with AO medications continuously for nearly thirty years. Results: At treatment entry, we treated all patients with methadone, but five patients are currently being treated with a low daily dose of buprenorphine. The achieved stabilization dosage was over-standard, between 100 and 250 mg/die, and the stabilization time varied between 2 and 45 months. Drastic changes, all pointing in a positive direction, were observed in the demographic, anamnestic, behavioural and psychopathological features of these patients. The patients' addictive behaviours practically disappeared. The Worthlessness-Being Trapped (W/BT) psychopathological dimension was reduced to a frequency of zero, while all the other dimensions showed much lower scores (less than 50 standardized scores). Regrettably, a Heroin Post-Traumatic Stress Disorder Spectrum (H/PTSD-S) persisted in 5 out of 7 patients even after nearly 30 years of continuous Agonist Opioid Treatment. Conclusions: If addictive behaviours have not disappeared, opioid agonist treatment must not be terminated. Unless and until that condition is met, the W/BT psychopathological dimension continues to be predominant; the same is true if the H/PTSD-S is over 32.

Published: Volume 22 • Issue N2 • April 2020 (pages: 5 - 14)

Title: Mapping service user needs to inform a supervised Injecting room location in Cork, Ireland, EU

Authors: Horan J.A., and Van Hout M.C.

Summary: Background: Supervised injecting facilities (SIF) are intended to reduce the harm related to illicit intravenous drug use. Aim: The aim of the study was to map the location of current injecting practices of people who inject drugs (PWID) in Cork, Ireland, and to document the related high risk behaviours, ahead of a planned supervised injecting facility. Methods: A cross sectional survey, utilizing geo- mapping software (GMS) mapping, was offered to PWID, at sites within the homeless services, needle exchange, and addiction services. Data was analysed using GPS mapping, and descriptive and inferential statistics. Results: 51 PWID completed the survey (98% response), 66.67% were male. The age range was 20-55 years (mean age 30.78 years). 56.9% were in stable accommodation, with 43.1% currently homeless. 92.16% had been tested for HIV/Hepatitis C. 31.5% reported injecting into “high risk” areas (groin and neck), 72.55% injected alone. 58.82% reported injecting at least three times/day, 35.29% reported injecting at least four times/day. 54.9% reported sharing equipment/ needles. 58.82% had previously overdosed. 89.3% of recalled overdoses involved an emergency services response. Correlation between history of accidental overdose, and injecting alone was statistically significant (p = 0.039), as was previous history of overdose and injecting at least three times per day (p = 0.012). 86.27% indicated they would use a SIF. A mapping exercise presented visual information around injecting sites, locations of overdoses, fatal overdoses, and preferred location of the SIF. Conclusions: The study provides an understanding of PWID profile and risk behaviours, alongside a geospatial analysis of injecting, overdose and potential location of a SIF in Cork, Ireland. The findings are intended to inform SIF location, and would allow dynamic comparison of both geographic and behavioural changes injecting drug use over time, post SIF provision.

Published: Volume 22 • Issue N2 • April 2020 (pages: 15 - 22)

Title: Is there a correlation between vitamin D deficiency and low serum level of GDNF in substance use disorder cases?

Authors: Alipour M., Jafarian M., Mokri A., Gorji A., Zarindast M.R., Kargar Kheirabad A., and Razaghi E.M.

Summary: Background: GDNF is a neurotrophic factor that is crucial in survival and development of dopaminergic neurons. It is produced in the adult brain in Nucleus Accombens (NA) and subsequently transported as retrograde to Ventral Tegmental Area (VTA). The VTA, NA pathway is an important component of the mesolimbic dopamine system, which is the main target of substances of abuse in the brain. Interestingly, wide distribution of vitamin D receptors throughout the brain and particularly the concentration of those receptors in dopaminergic neurons raises the assumption of potential interaction between GDNF and vitamin D. Vitamin D is effective in GDNF expression and the administration of vitamin D, increases GDNF, mRNA, and protein levels in the striatum of adult rats. Our study investigated the association between serum Vitamin D and GDNF levels in subjects who were using substances compared to controls. Aim: Evaluation for serum levels of Vitamin D and GDNF in people who use substances. For this purpose GDNF and vitamin D serum level between three groups of subjects who use opioids and methamphetamine concomitantly, subjects who use methamphetamine without opioids, and a control who use no substances were compared. Methods: According to inclusion and exclusion criteria of the study, 54 cases who used substances and 23 healthy subjects as control group were evaluated for serum levels of Vitamin D and GDNF. Results: Serum levels of GDNF and Vitamin D were significantly lower in subjects who used substances compared to the control group. There was a significant correlation between the serum levels of vitamin D and GDNF in both groups of subjects who used substances. Conclusions: We would like to suggest the hypothesis that treatment of vitamin D deficiency in people who use substances might improve the outcome of treatment for substance use disorder by increasing the level of serum GDNF.

Published: Volume 22 • Issue N2 • April 2020 (pages: 23 - 28)

Title: Buprenorphine for the treatment of alcohol dependence: 14 attempts, 3 successful cases

Authors: Ulmer A., and Meinhold C.

Summary: Background: Alcohol dependent patients can be treated very well with the opioid Dihydrocodeine (DHC). We published this in 2012. But in some cases, a DHC treatment fails because of the side effects, especially itching and constipation. Buprenorphine is better in this regard. It is also less dangerous to life in case of an overdose. Methods: We have prescribed it in 14 patients because of alcohol dependence. Results: We treated 3 female and 11 male patients. Their age was 28 – 64 years. The dependence had lasted for 4 – 30 years (mean 12 ± 8.3). Patients had undergone 165 medically supported withdrawals (mean 11.8 ± 18.2), 99 of them in a hospital. They also had initiated 22 “therapies” in addiction clinics (mean 1.6 ± 1.5). 4 of the 14 had a history with opioid dependence, years ago. We didn't reach sustained success in 11 patients. Buprenorphine prescription was finished after mean 11.1 months. In three patients, the treatment is experienced as very successful and still ongoing. Conclusions: Buprenorphine can serve as a very effective medication for the treatment of alcohol dependence in singular cases.

Published: Volume 22 • Issue N2 • April 2020 (pages: 29 - 34)

Title: Assessing the Medical and Psychological Problems Faced by ‘Majun-e-falak Sair' Addicts

Authors: Jan S.U.K., Ali A., and Asad A.Z.

Summary: Background: Pakistan has traditionally been one of the cannabis and opium producing countries. Both cannabis and opiates have been used and abused in raw form and through derivatives. One of the opium- and cannabis-based derivatives is known as ‘Majun-e-falak Sair'; it has highly addictive characteristics and makes addicts physically and psychologically dependent on it. Aim: The aim of the current study has been to analyse the medical and psychological problems faced by a highly addictive opium- and cannabis-based narcotic drug mixture that is prepared locally and known as ‘Majun-e-falak Sair'. Methods: An exploratory study was conducted by selecting 384 respondents; the addicts chosen were traced through the snowball sampling technique. To test the association between dependent and independent variables a Chi-squared test was applied. Results: Our results showed that a majority (n=245, 63.80%) of the respondents were married, (n=102, 26.54%), with an age range of 31-40 years. At bivariate level, a highly significant (p=00.5) relationship was found between medical and psychological problems and ‘Majun-e-falak Sair' use, comprising: dry mouth, mood disorder, muscle cramps and spasms, kidney problems, high blood pressure, effects on teeth, irregular heartbeat, memory problems, constipation, even loss of consciousness. In addition, a highly significant (p=0.05) relationship was discovered between various medical and psychological problems and ‘Majun-e-falak Sair' withdrawal i.e. hallucinations, muscle and joint pain, insomnia, mood disorders, aggressiveness, sexual dysfunctions, dysentery, bodily weakness, headaches, runny nose, haematuria and rectal bleeding. Conclusions: The study found that ‘Majun-e-falak Sair' is a strong narcotic drug which can lead to many medical and psychological problems.

Published: Volume 22 • Issue N2 • April 2020 (pages: 35 - 43)

Title: A prospective study of psychopathology stability and changes after 3-month residential treatment in Italian Substance Use Disorder patients

Authors: Maremmani I., Iantomasi C., Pani P.P., Maremmani A.G.I., and Mathis F. for the VOECT Group

Summary: Background: Using the SCL-90 checklist, we previously showed that a cluster of five psychopathological symptoms could be found in Heroin Use Disorder patients. This aggregation demonstrated a high specificity for Substance Use Disorder (SUD) patients. In this prospective study, we have explored the consistency across time of these dimensions by considering psychopathological stability and changes after 3-month residential treatment (TC: therapeutic community) in Italian SUD patients. Methods: 636 subjects with SUD according to DSM-IV diagnostic criteria, 558 (87.7%) male and 78 (12.3%) females, mean age 36.23 ± 8.8 years, were evaluated at treatment entry and after three months during their stay in a TC. All patients recruited for this study had been detoxified elsewhere. Results: After a 3-month period in a TC, the severity of all psychopathological dimensions decreased significantly over time. This development was especially frequent in subjects characterized by predominant Worthlessness-Being Trapped (W/BT), Somatic Symptoms (SS) and Sensitivity-Psychoticism (S/P) symptomatology, whereas a majority of Panic Anxiety (PA) and Violence-Suicide (V/S) subjects remained unchanged or showed a worsening of their symptoms. The baseline PA subjects appeared to be the most stable over time, followed by S/P, then by V/S, then by SS, and, lastly, by W-BT subjects. Stable W-BT patients showed greater severity in their baseline symptomatology, while stable PA patients showed lower severity. The only prediction of psychopathological stability arose from the 3-month PA score for severity. By contrast, V/S baseline severity, W-BT and S/P baseline typology all indicated psychopathological instability. Conclusions: After continuing for three months in a TC, a general reduction of SCL-90 severity is accompanied by a reduction in the frequency of the dimensions most closely linked with the intoxication/withdrawal state and with active substance abuse-related behaviour (SS and W/BT). The less frequent change regards patients allocated to the dimensions most involved in addiction processes (PA and V/S).

Published: Volume 22 • Issue N3 • June 2020 (pages: 5 - 11)

Title: Hepatitis C Related Mortality in a Cohort of Drug Users in Flanders

Authors: De Ryck H., and Matheï C.

Summary: Background. Illegal drug use has increased in Europe over the past decades, alongside the overall drug-related mortality. In Flanders, both overall and HCV-related mortality are relatively understudied. Aim. The present study has aimed to estimate the mortality rate in a group of people who use drugs (PWUD) while currently in treatment, and to compare that with the rate for the general population. More importantly, it focused specifically on the impact of chronic hepatitis C infection on mortality in PWUD. Methods. This retrospective study is based on data concerning 2,834 drug users in follow-up at the Free Clinic in Antwerp. Mortality rates were calculated and compared with a Flemish reference population. Afterwards, mortality was analysed in function of hepatitis C status, by applying bivariate and survival analyses. Results. The mortality rates obtained for PWUD were consistently higher than the average for the Flemish reference population. Higher age and Belgian nationality were associated with a higher mortality rate. In terms of the impact of HCV status, the analyses could only prove a lower mortality rate for cured patients, suggesting a positive effect on mortality by treating PWUD with chronic HCV infection. While not statistically significant, the data also seemed to indicate a higher mortality rate in chronically infected patients. Conclusions. This study provides the first available data in Belgium on mortality in a population of drug users. In order to obtain more meaningful conclusions about the effects of HCV on mortality, more studies with larger numbers of patients and a longer follow-up are needed. Furthermore, more research confirming the long-term positive effects of antiviral treatment is necessary.

Published: Volume 22 • Issue N3 • June 2020 (pages: 13 - 19)

Title: Extent and Trend of Prescription Opioids in Assisted Treatment Programmes for Opioid Addiction and Pain Medications in Slovenia from 2007 until 2018

Authors: Kostnapfel T., Korosec A., and Kastelic A.

Summary: Background. There is a wide accessibility of prescription pain medications and medications for treating opioid-dependent individuals in medication-assisted treatment programmes for opioid addiction in the Republic of Slovenia. Aim: The aim of the present study was to analyse the overall trends in prescriptions for opioid analgesics (N02A) and for the medications used in medication-assisted treatment (N07B) of opioid addictions in Slovenia in the period from 2007 until 2018. Methods. Anonymised data from the Slovenian "Outpatient Prescription Database" were used based on the WHO Anatomical-Therapeutic-Chemical methodology. Compiled data were processed by means of descriptive statistics and tested for the presence of linear trends. Results. In Slovenia, DDD/TID of opioid analgesics rose between 2009 (9.07 DDD/TID) and 2017 (12.57 DDD/TID), with a decrease observed in 2018 (11.76). The percentage of the population treated with prescription opioids rose from 6.7% in 2009 to 7.6% in 2013, and fell between 2013 and 2018. In the Centres for the Prevention and Treatment of Drug Addiction in Slovenia, an upward trend was seen in buprenorphine use between 2013 and 2018, and a downward trend in methadone use after 2015. Conclusions. Clinical guidelines for pain management and medication-assisted treatment programmes have been developed in the Republic of Slovenia, but treatment should only be initiated and performed by competent and well-trained clinicians to reduce the abuse, misuse and diversion of opioid medications, which often lead to fatal overdoses and higher public costs.

Published: Volume 22 • Issue N3 • June 2020 (pages: 21 - 30)

Title: Children's Psychological Well-Being, Anxiety, Depression, and Stress: The Role of Addicted and Non-Addicted Parents

Authors: Moeenizadeh M., Anbarani B., and Asghari Ebrahimabad M.J.

Summary: Background: Today, substance abuse, drug addiction and alcohol are among the most common psychiatric disorders in the general population. Therefore, consideration of what is affecting the general health of addicts and their families, especially their children, is inevitable. Aim: The objective of this study is to compare the influence of parents' addiction on the psychological well-being, stress, depression, and anxiety of their offspring by selecting group samples of people whose parents are with or without substance abuse. Methods: To achieve this goal, descriptive, correlation and causal-comparative methods were used. The statistical population of this study included 250 people; 120 of these individuals had at least one parent with drug addiction, while the remaining 130 had non-addicted parents. They were selected using the available sampling method. Results: The outcomes showed that there was a significant difference in psychological well-being between children with and without addicted parents (mean for addicted parents: 8.30, for non-addicted parents: 4.75, P=.000). Conclusion: The depression, anxiety and stress scores of children who have addicted parents were significantly higher than those of the children with non-addicted parents, which is consistent with the results of other studies in this area. Therefore, by recognizing and exploring the role of parents' addiction and other factors, such as addicted friends, proactive programmes can be implemented for those parents' children.

Published: Volume 22 • Issue N3 • June 2020 (pages: 31 - 36)

Title: Association of Serum Leptin Level with Body Mass Index and Lipid Profile in Diacetylmorphine (Heroine) Addicts Versus Healthy Controls.

Authors: Habib S.H., Khizar S.H., Malik M.O., Tariq M., Ramzan M.H., and Khan M.K.

Summary: Background: Diacetylmorphine (DAM) addiction is a common socioeconomic problem that markedly affects the nutritional and metabolic status of those taking it. Leptin is an important marker in regulating the body weight and lipid metabolism of each patient. Previous reports have suggested that leptin leads to the derangement of the metabolism in DAM addicts. Our study has had the aim of comparing circulating serum leptin with body mass index and lipid profile in DAM addicts, when set side by side against healthy individuals. Methods: This was a cross-sectional study including 82 male subjects (41/group) between 25 and 46 years of age. Participants were excluded if there were any comorbid conditions. Anthropometric measures were recorded and diet history was noted using 24 hour dietary recall. Dietary data were analysed using Windiet® software. Blood samples were collected for lipid profile, complete blood picture and leptin levels. Serum leptin levels were calculated using the enzyme-linked immunosorbent assay (ELISA) technique. Results: Basal serum leptin levels in addicts were significantly lower compared with controls (3.08 ± 0.13 pg/ml vs 3.24 ± 0.24 pg/ml; p<0.001). In addition, LDL and haemoglobin proved to have been significantly reduced in these addicts (71.8 ± 25.99 vs 105.39 ± 39.09; p<0.001 and 13.44 ± 0.78 vs 14.73 ± 0.91; p<0.001). The differences found between other parameters were not significant. Univariate and multivariate regression did not reveal any significant association of leptin with BMI or lipid profile in addicts (p=0.198). A significant association of leptin with BMI was, conversely, observed in normal subjects (p=0.027). Conclusions: Circulating concentrations of leptin fall in heroin addiction. The association of serum leptin levels with body mass index and lipid profile disappears in heroin addicts.

Published: Volume 22 • Issue N3 • June 2020 (pages: 37 - 48)

Title: Prominent Psychopathological and Clinical Characteristics of Heroin Post-Traumatic Stress Disorder Spectrum Patients During Treatment

Authors: Maremmani I., Cecchini L., Avella M.T., Novi M., Ciapparelli A., and Maremmani A.G.I.

Summary: Introduction: The overlap between stress and reward system has been documented with growing evidence. Alterations in stress system may increase the vulnerability to drug addiction but harmful drug use may impact on stress reactivity. Methods: The main purpose of this study was to estimate the extent of differences between Heroin Use Disorder (HUD) patients who presented, during the treatment, a Post Traumatic Stress Disorder spectrum (H/PTSD-S) and those who did not. These two groups were compared, using standardized instruments, at univariate and multivariate levels, regarding the natural history of the disorder, the psychopathology and the craving-related behaviors during a treatment with opioid agonist medications (AOT). Results: H/PTSD-S patients were more frequently women without partners and with blue-collar or unemployed jobs. They showed problematic social adjustment and in their natural course of heroin addiction showed increased harmful substance use, especially with regard to benzodiazepines. If they maintained addictive behaviors during treatment, risky-, exchange- and time-behaviors were prominent and were characterized by the inappropriate use of no-rewarding substances when rewarding or substitute drugs came to lack. In addition, they maintained a boost to the use of opioids when stimulated by heroin presence or being in contact with people who intake heroin. Finally, these patients maintained a greater severity of psychopathology during treatment. Conclusion: Detecting of an abnormal stress reaction in HUD patients (H/PTSD-S) may be proposed as a suitable means of monitoring treatment outcomes and effectiveness.

Published: Volume 22 • Issue N4 • August 2020 (pages: 5 - 14)

Title: Dermatological and Psychiatric Manifestations in Heroin and Bonsai Use Disorder

Authors: Can Y., Kıvanç Altunay İ., Mercan S., Evren C., Poşpoş Ö.H., and Özkur E.

Summary: Background: In in cases of substance use disorder (SUD), dermatological findings may provide significant information about the mental state of the patients involved. Awareness of cutaneous signs together with psychiatric manifestations may be an effective way to address the issue of treating substance use. Aims: This study aims to detect cutaneous signs and mental state of patients with heroin and bonsai use disorder through dermatological and psychiatric examinations. Methods: 156 male inpatients with SUD (heroin, n=104 and bonsai, n=52) were included. A standart personal information form, the Symptom Checklist-90-Revised (SCL- 90-R) and the Drug Use Disorders Identification Test (DUDIT) were filled out by each patient. Assessment of patients' psychiatric condition and their dermatological examinations were performed by the same psychiatrists and the same dermatoalogist. Tattoos and self-inflicted scars (SIS), which were the result of self-harm behavior (SHB) were rated separately. Results: The most frequent and dramatic findings in all SUD cases were tattoos (n=70), SIS (n=64), traumatic scars (n=59), cutaneous infections (n=49), acne (n=42), and vascular lesions (n=18). Injection scars, and vascular lesions were detected at higher rates in heroin users, while acne lesions were significantly more frequent in bonsai users (p =0.022). The rates recorderd for having tattoos were 32.7% (n=17) in bonsai users and 51% (n=53) in heroin users. The age of onset for first substance use, and regular substance use, besides the patients' age at first treatment were both lower in tattoo patients than in those without tattoos. From subscale scores of SCL 90-R, the somatization, depression, interpersonal sensitivity, anxiety scores were all higher in heroin users than in bonsai users. Conclusions: Physicians should be aware of dermatological clues in SUD patients. Evaluation of dermatological findings including tattoos is important in detecting SUD and obtaining information on the mental state of the patients.

Published: Volume 22 • Issue N4 • August 2020 (pages: 15 - 22)

Title: Medical Adjustment of Alcohol Dependence – a Comparison of Treatment Results with Dihydrocodeine and Acamprosate

Authors: Ulmer A., Frietsch B., and Mueller M.

Summary: Acamprosate is admitted for reducing craving and hence for relapse prevention in alcohol dependents for up to 12 months. Publications in 2009 and 2012 indicate that the effect of Dihydrocodeine (DHC) could be superior for this indication, connected with the advantage of realizing a prolonged medical adjustment. Data from treatment in this office, which published the two papers, was analyzed as preparation for a potential comparative clinical trial. 116 patients were treated with DHC, 138 with Acamprosate. The evaluation shows a significantly better retention rate in the DHC patients: 52.6 vs. 29.7% after 24 weeks, and 46.6 vs. 18.1% after 48 weeks. DHC was also significantly superior in days without alcohol, the percentage of completely alcohol-abstinent patients and a number of additional parameters. Source of this data is not a comparative study. But the results can serve as a suitable basis for a clinical trial.

Published: Volume 22 • Issue N4 • August 2020 (pages: 23 - 27)

Title: Frequency Rate of Violence and Contributing Factors in Methadone Maintenance Treatment Centers in Tehran, Iran

Authors: Kheradmand A., Iliaiee S., Ghafari Nejad A., and Mashayekhi M.M.

Summary: Background: High rates of verbal violence and physical violence have been reported in the field of addiction. The purpose of this study is to investigate the frequency and distinctive features of violence and its determinants in drug abuse treatment centres. Methods: This study was carried out among 200 staff members of drug treatment clinics in 2017. To investigate the population, a researcher-compiled questionnaire was used to calculate the number of cases, the location and the consequences of violence and its impact on the therapist. Results: 56 (26%) of nurses and physicians were subjected to violent verbal or behavioural violence in their work environment. The most violent insults and most types of psychological violence were conveyed through telephone harassment. The most common location of behavioural violence was in the place where drugs were distributed to patients. In 67% of the cases of violence, the stress was so severe that an intervention was performed, and 6.5% of those attacked needed treatment. Also, the results of this study showed that the psychological and physical violence against male personnel was greater than that against women; in addition, violence against doctors was more severe than that against nurses; a frequent location was the place where drugs were distributed to patients. Conclusion: The results of this study indicate the importance of training and supporting employees who work at these centres, with the aim of improving their efficiency and preventing an outcome in which employees become prone to psychiatric disorders and job fatigue.

Published: Volume 22 • Issue N4 • August 2020 (pages: 29 - 38)

Title: Harm Reduction 24/7: Evaluation of the Vending Machine Program for Drug Users in North Rhine-Westphalia, Germany.

Authors: Deimel D., Felix O., Bock C., and Stöver H.

Summary: Background: Needle and syringe programmes (NSP) are considered effective and efficient methods of reducing high-risk injecting practices and blood-borne virus transmission. The distribution of sterile needles, syringes and other equipment via syringe vending machines in public areas and prisons is done in Germany in about 120 cities. This service guarantees an anonymous 24/7 access to sterile equipment. North Rhine-Westphalia (NRW) is the most populous federal state of Germany. Of the 160 vending machines currently in operation throughout Germany, 113 are in NRW, operating since 30 years. Aim: This analysis presents the results of an evaluation of the work of vending machine operators in NRW. The central concern was to illustrate the current supply situation with harm reduction materials in the local structures. Another aim was to generate practice-based evidence for operating the vending machines, making it possible to further development the project. Methods: The vending machine operators were surveyed using an online questionnaire with 69 questions about their experiences and assessments as experts. All operators were contacted via e-mail to participate in the survey. 36 operators participate at the survey (59% response rate). Results: In the absence of a 24/7 supply of harm reduction materials covering the whole of NRW the supply of sterile equipment via vending machines represents an additional offer to existing institutions and syringe distribution points for drug users in NRW. In 2016, 138,765 syringes were dispensed to PWID in NRW via the 113 vending machines. Of all syringes distributed to PWID in NRW, the proportion dispensed via vending machines ranged from 6.0% to 7.2% between 2014 and 2016. In cities, between 1.2% and 8.3% of dispensed syringes were via vending machine, while in regional and rural areas the proportion of syringes dispensed via vending machines was between 90.3% and 100%. The installation and operation of a new syringe vending machine can be accompanied by conflicts in the community (e.g. with local residents and businesspeople). Conclusion: Syringe vending machines represent a very good supplement to the existing supply system of harm reduction materials for PWID. However, they are not a replacement for existing and established addiction help services.

Published: Volume 22 • Issue N4 • August 2020 (pages: 39 - 47)

Title: The Psychopathology Specific to Substance Use Disorder Is Able to Discriminate between Young People with and without Problematic Internet Use

Authors: Maremmani A.G.I., Cerniglia L., Cimino S., Maiello M., Della Rocca F., and Maremmani I.

Summary: Background: Problematic Internet use (PIU), which may otherwise be called excessive Internet use, is distinguished by excessive or poorly controlled preoccupations, urges, or behaviours regarding computer use and internet access; and shows high comorbidity associated with psychiatric disorders. In previous studies, our Research Group highlighted five psychopathological dimensions that appear to be specific to SUD (1-Worthlessness-Being Trapped; 2-Somatic Symptoms; 3-Sensitivity-Psychoticism; 4-Panic Anxiety and 5-Violence-Suicide). Methods: We have investigated the association between PIU and the specific psychopathology of SUD, as assessed by SCL-90, in 493 young people 16.35±0.9 years old (min 15, max 21). Of these, 244 (49.5%) were males and 249 (50.5%) females. We divided the sample according to the cut-off (15 scores) of the Problematic Internet Use Questionnaire Short Form (PIUQ-SF-6) in 411 (83.4%) without and 82 (16.6%) with problematic use. We used the discriminant analysis with the SCL-90 five dimensions we found in SUD patients to differentiate these two groups. Results: The groups were homogenous regarding age (F=0.14; p=0.989) and gender (chi=0.01 p=0.920). We found no difference between males and females according to the subject's age, the SCL-90 total score and the severity of PIU. The psychopathology specific to SUD discriminated (p<0.001) between subjects with and without problematic use of the Internet at 98.2%. The subjects with PIU were marked out by the high severity of the Panic Anxiety and Somatic Symptoms dimensions. They more frequently showed Panic Anxiety and, less frequently, Sensitivity-Psychoticism as their predominant psychopathological typology. Conclusions: Our five psychopathological dimensions made it possible to differentiate between young people with and without PIU, so allowing these dimensions to be considered a newly available tool in monitoring Internet use in youngsters.

Published: Volume 22 • Issue N5 • October 2020 (pages: 5 - 11)

Title: Can the Psychopathology Specific to Substance Use Disorder Distinguish between Reward and Relief Craving?

Authors: Maremmani A.G.I., Pallucchini A., Manni C., Cipollone G., Della Rocca F., Salarpi G., Perugi G., and Maremmani I.

Summary: Introduction: Substance Use Disorder is, probably, the most common comorbid psychiatric condition in adult patients with Attention Deficit Hyperactive Disorder. As reported by many A-ADHD patients, the use of stimulants can be viewed as a response to ADHD symptoms, by at least temporarily alleviating or suppressing them, in line with the Self-Medication Hypothesis theorized by Khantzian. This theory is supported by the fact that Cocaine Use Disorder (CUD) patients with Adult ADHD (CUD/A-ADHD) can show a reduction in the use of cocaine, a decrease in craving symptoms, and an improvement in social functioning, reaching higher levels of executive functionality, if treated with stimulants for ADHD. The V.P. Dole Research Group at the Santa Chiara University Hospital of the University of Pisa, Italy, has shed light on the possible definition of a specific psychopathy dimension in SUD, suggesting the trait- rather than the state-dependent nature of the five psychopathological dimensions introduced to supersede SUD. Methods: In the present study we compared, at treatment entry, the psychopathological typology and the severity of symptoms affecting 24 CUD patients without a Dual Disorder and 120 CUD/A-ADHD patients, while assuming that CUD patients are motivated prevalently by a craving for reward and CUD/A-ADHD patients by a craving for relief. Results: The general indexes of psychopathology were more severe in CUD/A-ADHD than in CUD patients, and the same trend was observed regarding the five psychopathological dimensions. In CUD patients the Worthlessness/Being Trapped (W/BT) dimension, which should be a proxy for reward craving, acquired greater importance, especially when its severity was inversely correlated with that of the Violence/Suicide (V/S) dimension. In CUD/A-ADHD patients, on the other hand, their psychopathology was distinguished by the highest level of V/S severity and the lowest level of W/BT severity. Conclusions: The five SCL-90 psychopathological dimensions can differentiate reward from relief craving, while recognizing that both types of motivation mark out addictive disorders, though these do differ in severity and treatment outcome. Making this distinction allows further proof of the five dimensions' specificity in separating types of addiction psychopathology.

Published: Volume 22 • Issue N5 • October 2020 (pages: 13 - 18)

Title: Tramadol as the Most Prescribed Opioid Analgetic Medication in Slovenia in Recent Years

Authors: Kostnapfel T., Korošec A., and Kastelic A.

Summary: Background: There is a variety of options available for the treatment of chronic pain. Tramadol is an opioid analgesic licensed for use in moderate to severe pain. A single dose of a weak opioid, possibly combined with paracetamol, has greater analgesic efficacy than paracetamol alone. Aim: The aim of the present study was to analyse the trends in prescriptions of tramadol as a monocomponent drug (ATC group N02AX02) and in combination with paracetamol (ATC group N02AJ13) in Slovenia between 2006 and 2018. Methods: Anonymised data from the Slovenian "Outpatient Prescription Database" were used based on the WHO Anatomical-Therapeutic-Chemical methodology. Compiled data were processed by means of descriptive statistics and tested for linear trend. Results: In Slovenia, the number of tramadol (N02AX02) prescriptions significantly decreased, and the number of tramadol/paracetamol (N02AJ13) prescriptions increased between 2006 and 2017, with a decrease in 2018. The percentage of people who received at least one tramadol (N02AX02) and tramadol/paracetamol (N02AJ13) prescription per year differed according to gender. Conclusions: While tramadol is recognised as having lower abuse and respiratory depression potential compared to opioid agonists, it is not without risks. Increasing public awareness, not only doctors' but patients' as well, would be necessary to reduce the possibilities for potential misuse, abuse, addiction and opioid-related overdoses, through stricter implementation of national and international guidelines and recommendations.

Published: Volume 22 • Issue N5 • October 2020 (pages: 19 - 27)

Title: Sleep Quality in Heroin-Dependent Patients Undergoing Three Types of Maintenance Therapy: The Benefits Promised by Opium Tincture Maintenance Therapy

Authors: Hojjat S.K., Kaviyani F., Akbari H., and Norozi Khalili M.