The role of the physician in addiction prevention and treatment.

With increasing pressure on general physicians by managed care organizations and the public to treat and advocate for drug and alcohol addicted patients, it is more necessary than ever that physicians have the knowledge and skills to appropriately address this segment of the population. Specifically, physicians need a better understanding of the prevalence of alcohol and drug dependence in a variety of populations, along with increased awareness of the economic impact of addictive illnesses on our society. Routine screening questions should be incorporated into patient encounters, and physicians should be able to identify environments that may pose a risk for the development of addiction. Physicians need training and practice in referring patients to treatment teams, monitoring patients in recovery, and providing interventions that will eliminate or reduce substance abuse before it becomes addiction. The treatment outcomes in abstinence-based programs, particularly those combined with referral to AA, have been encouraging, demonstrating that addiction is a treatable illness and not a character defect. In addition, several studies provide evidence that addiction treatment is cost-beneficial, resulting in reduced medical costs, lowered absenteeism, and increased productivity. Despite these encouraging results, there is still room for improvement. Treatment is not always effective, and it is not sufficiently available to everyone who needs it. Addicted individuals are both stigmatized and marginalized, and many are too ill to advocate for themselves. Widespread recognition in the medical community of addiction as a treatable illness will contribute to a greater understanding of addictive disorders and reduce the stigma attached to the diagnosis and treatment of addiction. For this to occur, better training for physicians in the recognition and management of addictive disorders, starting at the medical school level, is necessary. The approval of addiction medicine as a clinical specialty by the American Medical Association also has helped to advance the legitimacy of addiction as a treatable illness, and provides a focal point for the synthesis and integration of clinical, teaching, and research activities central to addiction medicine. The combination of knowledge, skills, and attitudes outlined in the article will go a long way toward increasing physicians' abilities to assist their patients with recovery from addiction.     

Analgesic nitrous oxide in neuropsychiatry: past, present and future

We highlight the distinction between analgesic and anesthetic concentrations of nitrous oxide, with special reference to the safety of analgesic nitrous oxide. We present evidence that the gas at analgesic concentrations is an opioid agonist. Its extremely low abuse potential, despite its opioid properties, is discussed with regard to its evanescent action and possible partial agonistic effects, making it the least addictive of all mind-altering addictive substances. The activities of analgesic nitrous oxide make it an almost ideal agent with which to investigate the functions of the opioid system in man. We also discuss its use as a diagnostic and therapeutic agent in neuropsychiatry.     

The System of Medical Treatment for Addiction in France

ABSTRACT

The French Addictions Treatment system was recently reformed. The ministerial memo was clearly inspired by professionals and from the clinical reality of patients. The main purpose of this reform was to reorganize the treatments (fighting against the historical split of the different structures) but also to fight against the substances approach in favor of a global approach. Thus, this new plan allows addiction treatment professionals to be concerned with the prevention and the detection of addictive behaviors (abuse and risk use), which was relatively new in the French medical profession. We present a brief history of the evolution of the system of treatment for addiction, and we describe the new system of treatment for addiction as it is now defined in France.     

Historical and cultural aspects of man's relationship with addictive drugs

Our taste for addictive psychoactive substances is attested to in the earliest human records. Historically, psychoactive substances have been used by (i) priests in religious ceremonies (eg, amanita muscaria); (ii) healers for medicinal purposes (eg, opium); or (iii) the general population in a socially approved way (eg, alcohol, nicotine, and caffeine). Our forebears refined more potent compounds and devised faster routes of administration, which contributed to abuse. Pathological use was described as early as classical Antiquity. The issue of loss of control of the substance, heralding today's concept of addiction, was already being discussed in the 17th century. The complex etiology of addiction is reflected in the frequent pendulum swings between opposing attitudes on issues that are still currently being debated, such as: is addiction a sin or a disease; should treatment be moral or medical; is addiction caused by the substance; the individual's vulnerability and psychology, or social factors; should substances be regulated or freely available.     

Prégabaline et risque d’addiction : une nouvelle demande de soin ?

PurposePregabalin (PRG) is a gamma-aminobutyric acid (GABA) analogue used for treatment of epilepsy, neuropathic pain, generalised anxiety disorder and currently being studied for other indications. Supported by the results of case studies and a limited number of studies, there is an ongoing debate about the addictive potential of PRG. However, evidence is scarce and no definitive assessment on the potential for abuse and dependence to PRG is available. The objective of our study was to identify the number of cases of abuse or dependence to PRG published and to study potential risk factors of addiction to PRG.MethodsWe have identified on PubMed and ScienceDirect published case studies of PRG abuse or dependence and analysed these cases on the basis of several clinical parameters.ResultsA total of 118 cases of PRG abuse or dependence were identified, including 21 isolated cases (mean age 33 years, 67 % men). The mean daily dose of PRG was 2,9 g. Current or past polydrug abuse was present in the majority of cases. Psychiatric diagnoses, other than substance-related disorders, were reported in as many patients, and almost all patients experienced withdrawal symptoms when PRG was discontinued.ConclusionCurrent literature suggests an important and growing concern for the abuse of PRG. Male sex, psychiatric and/or addiction history, including opioid addiction, may be potential risk factors for the development of addictive behaviours associated with PRG.     

The neurobiology of addiction

Drug addiction includes complex neurobiological and behavioural processes. Acute reinforcing effects of drugs of abuse are responsible for the initiation of drug addiction, whereas the negative consequences of drug abstinence have a crucial motivational significance for relapse and maintenance of the addictive process. The mesocorticolimbic system represents a common neuronal substrate for the reinforcing properties of drugs of abuse. Both dopamine and opioid transmission play a crucial role in this reward pathway. Common neuronal changes have also been reported during the abstinence to different drugs of abuse that could underlie the negative motivational effects of withdrawal. These changes include decreased dopaminergic activity in the mesolimbic system and a recruitment of the brain stress pathways. All drugs of abuse interact with these brain circuits by acting on different molecular and neurochemical mechanisms. The existence of bidirectional interactions between different drugs of abuse, such as opioids and cannabinoids, provides further findings to support this common neurobiological substrate for drug addictive processes.     

Emerging treatment guidelines for mentally ill chemical abusers

Dr. Miller's Introduction: We are becoming more and more aware that many alcoholics and chemically dependent individuals also suffer from a psychiatric disorder. This reality emerges now after a period in which the possibility of coexisting mental and addictive disorders was often denied by the alcoholism and drug fields. Psychiatrists and other mental health professionals need to be alert to patients with these dual disorders so that relapses of both the dependency and the psychiatric disorder can be averted. This month's column presents useful guidelines to help professionals deal effectively with this difficult problem.     

Opiates, psychostimulants, and adult hippocampal neurogenesis: Insights for addiction and stem cell biology

Once thought to produce global, nonspecific brain injury, drugs of abuse are now known to produce selective neuro-adaptations in particular brain regions. These neuro-adaptations are being closely examined for clues to the development, maintenance, and treatment of addiction. The hippocampus is an area of particular interest, as it is central to many aspects of the addictive process, including relapse to drug taking. A recently appreciated hippocampal neuro-adaptation produced by drugs as diverse as opiates and psychostimulants is decreased neurogenesis in the sub-granular zone (SGZ). While the role of adult-generated neurons is not clear, their functional integration into hippocampal circuitry raises the possibility that decreased adult SGZ neurogenesis may alter hippocampal function in such a way as to maintain addictive behavior or contribute to relapse. Here, we review the impact of opiates and psychostimulants on the different stages of cell development in the adult brain, as well as the different stages of the addictive process. We discuss how examination of drug-induced alterations of adult neurogenesis advances our understanding of the complex mechanisms by which opiates and psychostimulants affect brain function while also opening avenues for novel ways of assessing the functional role of adult-generated neurons. In addition, we highlight key discrepancies in the field and underscore the necessity to move "beyond BrdU"--beyond merely counting new hippocampal cells labeled with the S phase marker bromodeoxyuridine--so as to probe mechanistic questions about how drug-induced alterations in adult hippocampal neurogenesis occur and what the functional ramifications of alterations in neurogenesis are for addiction.     

Usage de Jeux de hasard et d’argent et d’Internet dans une population de patients en demande de soins en addictologie–Étude multicentrique

BackgroundTransversal grouping of addictions under the heading “Substance related and addictive disorders” in the DSM-5 has led to a common policy on addictions and the promotion of addiction services covering all types of addictions, including behavioral addictions.Material and methodsThe main objective of this study was to describe the prevalence of problem gambling in a population of patients seeking treatment in addictive disorders center. Secondary objectives were: to describe the use of Internet and the prevalence of gaming disorder, sexual addiction and compulsive buying online ; to describe a population of patients consulting in addictive disorders center; to explore associated factors related to problem gambling. A self-questionnaire was built, evaluating the socio-demographic elements, the addiction pathway, problem gambling and Internet use with a focus on video game disorder, sexual addiction and compulsive buying. It was offered to consultants from five addictology centers in Brittany.Results252 patients seeking treatment for addictive disorders were included. Problem gambling was present in 9.9 % of patients. Problem gamblers were more likely to have been asked about their gambling by the addictology team than other patients. The rate of identification of gambling habits, whether in addiction or outside, was generally low. Internet use was 83 %. The prevalence of other online behavioral addictions was low.Discussion and conclusionThe prevalence of problem gambling is almost 4 times higher among addictology consultants, compared to the general population, probably related to addictive comorbidities. The identification of gambling habits concerned a small proportion of the patients included, whether in specialized care or outside. There is significant room for improvement in the identification of problem gambling, in addictology and beyond. It is important to question gambling habits for any reason for addiction consultation and to repeat this identification over time. As the Internet is widely used by addictology consultants, it can represent a key element in care, both in the identification of behavioral addictions and in follow-up.     

Drug abuse among residents of Beijing: an epidemiologic survey of 1,822 households

An epidemiological survey was conducted in the residential areas of 6 neighbourhood committees of Chao Yang District of Beijing in search of the prevalent status and related factors of drug abuse among 1,822 households out of 6,114 population. The result of present study reveals that the prevalence rate of limit daily-used drug abuse is 3.09% among a sample of 5,509 people over the age of fifteen. However, the extent of drug abuse seems neither great nor epidemic and all 17 dependents living in scattered geographical sites. In exploring the causation of drug abuse, the authors found that family structure, economic status, individual social function or stressful life events are not correlated and the use of drug is not a coping method to environmental maladaptation. On the contrary, most of the drug dependent are attributable to some iatrogenic reasons lacking of certain drug monitoring measures in their long-term medication. In a word, the misuse of drug facilitated addictive behaviors. No social problem emerged among all cases of study as measured with SDSS, but it is still a potential hazard to the psychosomatic health condition in the long run.     

Current concepts in pharmacotherapy of substance abuse

The cost to society of alcohol, tobacco, and illicit drug dependence is enormous. Although the importance of treatment for substance abuse to public health is increasingly acknowledged, pharmacotherapy is generally underutilized. However, the selection of medications for clinical testing is increasingly guided by the rapidly evolving science of addictive drugs and behavior. The benefit of medication for smoking cessation is firmly established, particularly for nicotine replacement and antidepressant therapy. Naltrexone is an important addition to the pharmacopoeia, and acamprosate may soon be approved as well. Although no new medications are approved for cocaine and amphetamine abuse, a variety of candidate treatments have shown promise in ongoing studies. Opiate substitution therapy is highly effective for rehabilitation of heroin addiction, and several alternative forms will soon be available; alternative forms of opiate detoxification have also received attention. Overall, there is increasing recognition that physicians have an obligation to identify and treat all forms of substance dependence, although knowledge of the efficacy of the available treatments is steadily increasing.     

Sentencing Problem Gamblers in New Zealand

Any recognition of the societal impact of problem gambling necessarily implies that there is an effect on the incidence of crime. However current New Zealand Department of Corrections statistics, which extensively chart drug and alcohol abuse in prisoners, lack any reference to the incidence of gambling addiction. The invisibility of gambling addition, as a mitigating factor in criminal sentencing, arises from a misunderstanding of agency in addiction which leads to drug and alcohol abuse being factored into sentence programmes while problem gambling is often viewed as a matter of choice. There is no principle of sentencing which distinguishes between these various addictions and the failure to factor gambling addiction in sentencing decreases the likelihood of rehabilitation and so increases the likelihood of re-offending.     

Addiction and schizophrenia.

Epidemiologic studies in the general population and those based on the clinical assessment of schizophrenic populations have revealed a high degree of overlap between schizophrenia and addictive disorders. The abuse of psychoactive substances (including alcohol) throughout life is so frequent (50%) that the possibility of a specific link inevitably arises. Various hypotheses have been suggested to explain the high co-morbidity between schizophrenia and addiction: 1) The social-environmental hypothesis has been developed but studies have provided poor evidence to validate it. 2) The possible shared biological vulnerability between schizophrenia and addictions led researchers to explore common genetic determinants and study the involvement of the dopaminergic and opioid systems in the aetiology of both schizophrenia and the abuse of and dependence on psychoactive drugs. 3) Finally, the theory of self-medication suggests that schizophrenics may be attempting to counter the deficit linked to their disorders by using the substances they take or their dependency-type behaviour to cope with their emotional problems. The clinical profile of schizophrenic addicts does seem to display some distinctive features, such as the high level of depressive co-morbidity, very high nicotine and alcohol dependence, with a very poor prognosis. These patients are difficult to manage; the possibility of pharmacologic interactions between the substances they are taking and neuroleptic medication calls for prudence, and their compliance is also poor. Addictive disorders in schizophrenics are currently a topic of active research intended to lead to identifying specific treatments. The early identification of addictive disorders in schizophrenics should make it possible to limit their development and improve the prognosis.     

Have we been ignoring the elephant in the room? Seven arguments for considering the cerebellum as part of addiction circuitry

Addiction involves alterations in multiple brain regions that are associated with functions such as memory, motivation and executive control. Indeed, it is now well accepted that addictive drugs produce long-lasting molecular and structural plasticity changes in corticostriatal-limbic loops. However, there are brain regions that might be relevant to addiction other than the prefrontal cortex, amygdala, hippocampus and basal ganglia. In addition to these circuits, a growing amount of data suggests the involvement of the cerebellum in many of the brain functions affected in addicts, though this region has been overlooked, traditionally, in the addiction field. Therefore, in the present review we provide seven arguments as to why we should consider the cerebellum in drug addiction. We present and discuss compelling evidence about the effects of drugs of abuse on cerebellar plasticity, the involvement of the cerebellum in drug-induced cue-related memories, and several findings showing that the instrumental memory and executive functions also recruit the cerebellar circuitry. In addition, a hypothetical model of the cerebellum's role relative to other areas within corticostriatal-limbic networks is also provided. Our goal is not to review animal and human studies exhaustively but to support the inclusion of cerebellar alterations as a part of the physiopathology of addiction disorder.     

Neuroimmune mechanisms of psychostimulant and opioid use disorders

Substance use disorders are global health problems with few effective treatment options. Unfortunately, most potential pharmacological treatments are hindered by abuse potential of their own, limited efficacy, or adverse side effects. As a consequence, there is a pressing need for the development of addiction treatments with limited abuse potential and fewer off target effects. Given the difficulties in developing new pharmacotherapies for substance use disorders, there has been growing interest in medications that act on non‐traditional targets. Recent evidence suggests a role for dysregulated immune signaling in the pathophysiology of multiple psychiatric diseases. While there is evidence that immune responses in the periphery and the central nervous system are altered by exposure to drugs of abuse, the contributions of neuroimmune interactions to addictive behaviors are just beginning to be appreciated. In this review, we discuss the data on immunological changes seen in clinical populations with substance use disorders, as well as in translational animal models of addiction. Importantly, we highlight those mechanistic findings showing causal roles for central or peripheral immune mediators in substance use disorder and appropriate animal models. Based on the literature reviewed here, it is clear that brain‐immune system interactions in substance use disorders are much more complex and important than previously understood. While much work remains to be done, there are tremendous potential therapeutic implications for immunomodulatory treatments in substance use disorders.     

Addiction and personality

Within the field of substance abuse, it is now widely admitted that the addictive personality does not exist. No one personality type is predisposed to addiction. The predisposition to drug dependence involves many different factors: psychological, social, familial, biological. None of these factors can be the sole determinant of drug dependence. Keeping that in mind, it is of interest to review the recent data on the relationship between personality traits or disorders and opiate and cocaine dependence. Using DSM and ICD categorical assessment, no single personality disorder emerged, instead a range of personality disorders has been evaluated in opiate and cocaine dependent subjects. Every type of personality disorders (PD) existed but cluster BPD were the most common (especially antisocial personality disorder in opiate addicts). However, it is noteworthy that a large minority to a majority of subjects did not display any king of PD. The implication of these results is that antisocial PD is probably over-diagnosed in drug dependence clinical settings. The studies reviewed failed to demonstrate that personality disorders were strong predictors of outcome in opiate or cocaine dependence. However, opiate dependent PD subjects entering treatment had more severe problems and lower retention rate than non PD subjects. But the amount of improvement was not significantly different between PD subjects and non PD subjects. This demonstrated that substance dependent PD patients could benefit from treatment whose intensity and duration must be adjusted. There is good support for the idea that Sensation Seeking trait is a vulnerability factor to substance abuse. But after dependence develops, sensation seeking is probably irrelevant to continued use of the drugs. This break between the psychopathology of vulnerability of substance abuse and the psychopathology of dependence raises the question of the existence of dramatically different factors involved in both phases of addiction.     

Anticraving medications for relapse prevention: a possible new class of psychoactive medications

Psychiatrists have gradually developed a list of medications that are effective in the treatment of addictive disorders. Although alcoholism has received the most attention, nicotine, heroin, and cocaine have all been shown to be influenced by heredity. Of course, the immediate goal is the reduction of drug craving and the prevention of relapse to compulsive drug taking. A medication that can aid in the maintenance of the opiate-free state is naltrexone, a specific opiate antagonist. Naltrexone is also a good example of an anticraving medication used in the treatment of alcoholism. Clinicians currently have two types of medication to aid in the treatment of tobacco use disorder, arguably the most important addiction. Bupropion and nicotine replacement can be given in a coordinated fashion to provide the best available results. At present, no medication is approved by the Food and Drug Administration for the indication of cocaine addiction. Recently, however, five different medications, already approved for other purposes, have been found to be effective among cocaine addicts. Despite clinical trials that show benefit, anticraving medications are not well known and are underused by clinicians. Addiction is a heterogeneous condition, with variability in reactivity to the drug of abuse and to the medications available to treat it. Recent developments in pharmacogenetics may result in improved selection of medications based on genotype.