Use Disorder pa7ents Icro Maremmani, MD Qualified Full Professor of - PowerPoint PPT Presentation

! ! Psychopharmacology of Dual Disorder Heroin Use Disorder pa7ents Icro Maremmani, MD Qualified Full Professor of Psychiatry Professor of Addic7on Medicine, University of Pisa, Italy VP Dole DD-Unit, Santa Chiara University Hospital, Pisa, Italy President World Federa7on for the Treatment of Opioid Dependence NGO with Special Consulta7ve Status with United Na7ons Economic and Social Council (ECOSOC) New York, NY, USA

WELCOME THE NEW PARADIGM IN NEUROSCIENCE TO UNDERSTAND MENTAL HEALTH !

Presidente : Giampaolo Spinnato (Palermo) ! DireNore Scien7fico: Icro Maremmani (Pisa) Segretario: Vinico C. Romano (Piazza Armerina, Enna) Rappresentan7 degli associa7 Francesco Lamanna (Pisa) Riccardo Gionfriddo (Siracusa) Sedi: Via Generale Gaeta, 14 Piazza Armerina, Enna Via XX Settembre, 83, Pietrasanta, Lucca

! J OINT S TATEMENT ON D UAL D ISORDERS : ADDICTION AND OTHER MENTAL DISORDERS Addiction is a Mental Disorder, not a voluntary, self-indulgent act

! • The above menConed naConal and internaConal scienCfic associaCons have drawn up a statement supporCng the noCon that addicCons are mental disorders in response to unfounded claims to this asserCon. • PaCents with mental disorders, including addicCons, should have access to a mulCdisciplinary care model that integrates and/or coordinates the mental health network and the addicCon network, thereby avoiding the so-called “wrong door syndrome”. Joint Statement on Dual Disorders: AddicCon and other Mental Disorders

Main contradicCons in the addicCons ! Blocking opioid receptors by antagonist opioid medica7ons is encouraged Blocking opioid receptors by agonist opioid medica7ons is not encouraged

Main contradicCons in the addicCons ! The disease is The treatment is chronic limited in 7me

Main contradicCons in the addicCons ! Only CRAVING STOP GO and RELAPSE? Psychopathology ?

! Psychopharmacology PSYCHOPATHOLOGY SPECIFIC TO SUD PATIENTS AND ITS TREATMENT

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Psychic structure of SCL-90 ! Psychiatric paCents Addicted paCents • W orthlessness and B eing • SomaCzaCon T rapped • Obsessive-compulsive • S omaCc- S ymptoms • Interpersonal sensiCvity • S ensiCvity – P sychoCcism • Depression • P anic – A nxiety • Anxiety • V iolence – S uicide • HosClity • Phobic anxiety • Paranoid ideaCon • PsychoCc ideaCon

Psychopathological typology ! 70 Worthlessness 65 65 and being trapped 60 SomaCzaCon 14% 20% 55 52 50 50 48 SensiCvity- 47 24% 45 psychoCcism 22% 40 Panic-anxiety 20% 35 30 Violence-suicide 25 W-BT SS S-P PA V-S Maremmani, I., P. P. Pani, et al. (2010). Annals of General Psychiatry 9 (1): 15

! Old HUDs are generally typified as Worthlessness-Being Trapped pa7ents Young HUDs are generally typified as Sensi7vity-Psycho7cism and Violence-Suicide pa7ents

! The five-dimension SCL-90 solu7on is independent of the treatment choice

! The five-dimension SCL-90 solu7on is independent of the intoxica7on status

! The five-dimension SCL-90 solu7on is independent of the life7me psychiatric problems

! The five-dimension SCL-90 solu7on is independent of the involved drug • Alcohol, Cocaine, or Heroin as principal substance of abuse • Heroin, Heroin+Alcohol or Heroin+Cocaine

Specific psychopathology of Addic7on is independent of the primary substance of abuse in pa7ents without a secondary substance of abuse ! Worthlessness-Being trapped Somatic symptoms Sensitivity-Psychoticism Panic-Anxiety Violence-Suicide COC 8.8 22.8 19.3 29.8 19.3 (N=57) HERO 14.1 21.2 23.5 29.4 11.8 (N=85) ALC 14.9 22.8 26.3 28.1 7.9 (N=114) Chi-square 6.27; df 8; p=0.617 Unpublished

! The high-level correla7on between five-dimension SCL-90 solu7on and addic7ve behaviour stands as further evidence, at least in Heroin Use Disorder pa7ents, of the existence of a psychopathology that is specific to addic7on

! The five-dimension SCL-90 solu7on can discriminate psychopathology between Major Depression and Heroin Use Disorder Pa7ents qualita7vely (77% correctly classified) and quan7ta7vely

! The five-dimension SCL-90 solu7on can par7ally discriminate psychopathology between Obese (non psychiatric) and Heroin Use Disorder Pa7ents qualita7vely (47.2 of obese individuals were reclassified as HUD pa7ents) and quan7ta7vely

Psychopathology of addic7on: May the SCL90-based five dimensions structure be applied in a no-substance-related addic7ve disorder such as Gambling Disorder? ! STEP OR 95% CI p HUD paCents 1.00 1 Age 0.78 0.75-0.82 <0.001 2 EducaCon, low 12.19 5.66-26.2 <0.001 3 Total SCL-90 1.02 1.01-1.03 <0.001 4 Worthlessness-Being trapped 1.00 SomaCc Symptoms 5.43 1.48-19.8 0.010 5 Unemployed 3.07 1.39-6.78 0.005 chi square 444.18 df(8) p<0.001 95.7% of original grouped cases correctly classified Unpublished

! Mood dysregula7on: Worthlessness and being trapped Anxiety dysregula7on: Panic anxiety Impulse-control dysregula7on: Violence and suicide Soma7c symptoms, Sensi7vity and Psycho7cism Stress sensi7vity?

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Research line ! Gerra G., Somaini L., Zaimovic A., Gerra M. L., Maremmani I., Amore M., Ciccocioppo R. (2010): • Developmental TraumaCc Experiences, PTSD and Substance Abuse Vulnerability: The Neurobiological Link. In: Sher L., Vilens A. (Eds.): Neurobiology of Post-Trauma7c Stress Disorder . Nova Science Publishers, Inc, Hauppauge NY. pp. Rugani F., Maremmani A. G. I., Rovai L., Mautone S., Perugi P., Pani P. P., Dell’osso L., Maremmani I. (2011): • Life events (loss and traumaCc) and emoConal responses to them in heroin-dependent paCents before and aier the dependence age of onset. Heroin Addict Relat Clin Probl . 13(3): 17-26. Dell’Osso L., Carmassi C., Straja P., Massimek G., Akiskal K. K., Akiskal H. S., Maremmani I., Rossi A. (2013): • Gender differences in the relaConship between maladapCve behaviours (drug abuse included) and PTSD. A study on 900 L’Aquila 2009 earthquake survivors. . Front Psychiatry . 3(111): 10.3389/fpsyt.2012.00111. Dell’Osso L., Rugani F., Maremmani A. G. I., Bertoni S., Pani P. P., Maremmani I. (2014): Towards a unitary • perspecCve between Post-TraumaCc Stress Disorder and Substance Use Disorder. Heroin use disorder as case study. Compr Psychiatry . 55: 1244-1251. Dell'osso L., Massimek E., Rugani F., Carmassi C., Fareed A., Straja P., Rossi A., Massimek G., Maremmani I. • (2015): Life events (loss and traumaCc) and emoConal responses to them in acute catastrophe survivors and long-lasCng heroin use disorder paCents never exposed to catastrophic events. Heroin Addict Relat Clin Probl . 17(6): 49-58. Maremmani A. G. I., Maiello M., Carbone M. G., Pallucchini A., Brizi F., Belcari I., Conversano C., Perugi G., • Maremmani I. (2017): Towards a psychopathology specific to Substance Use Disorder: Should emoConal responses to life events be included? Compr Psychiat .

! • Before and aler heroin dependence age of onset, Life Events are very common • Aler heroin dependence age of onset, pa7ents who report more life events are the majority • Aler heroin dependence age of onset, reac7ons to life events tend to increase

! QuesCon Marks • Are correlaCons between PTSD spectrum and severity of heroin addicCon significant? • Are opioid medicaCons able to reduce reacCons to life events in Heroin Addicts during treatment?

Are correlaCons between PTSD spectrum and severity of heroin addicCon significant? ! Dell'Osso, L., F. Rugani, et al. (2014). Compr Psychiatry. Stages 1 and 2 Stage 3 Daily or less More than daily Life Events Life Events 20 15 Personality Grief ReacCon Personality Traits Grief ReacCon Traits 10 10 5 Arousal Trauma Arousal Trauma 0 0 MaladapCve EmoConal, MaladapCve EmoConal, Phisical coping Phisical and coping and CogniCve Re- Re- Re-experiencing, Re-experiencing, experiencing, experiencing, Numbing Avoidance p=ns p<0.01 Previous Treatments Polyabuse NO NO Life Events Life Events 15 Personality Grief 15 YES YES Personality Traits ReacCon Grief ReacCon 10 Traits 10 5 5 Arousal Trauma Arousal Trauma 0 0 MaladapCve EmoConal, MaladapCve EmoConal, coping Phisical and coping Phisical and Re- Re- Re- Re- experiencing experiencing experiencing, experiencing, p<0.01 p<0.01

Correla7ons between opioid medica7on dosage and severity of reac7ons to life events in Heroin Addicts during treatment ! Opioid Medica7on Dosage Are opioid medicaCons able to reduce reacCons to life events in Heroin Addicts during treatment? N=82 Severity of r=-0.225 reacCons to life events p=0.042

! Does psychopathology of addicCon exist? CAN HEROIN ADDICTION GENERATE A PTSD SPECTRUM?

ROC analysis on PTSD spectrum database of survivors of the 2009 L’Aquila earthquake. ! Dell'Osso, L., E. Massimek, et al. (2015). Heroin Addict Relat Clin Probl 17 (6): 49-58. Subjects 32 developing PTSD aier L’Aquila earthquake 32 Subjects No- developing PTSD aier L’Aquila earthquake