Il trattamento farmacologico del poliabuso nell'Addiction da eroina Dr. Angelo G. I. Maremmani Dirigente Medico, Azienda USL Toscana Nord-Ovest (Zona Versilia) Dottorando di Ricerca di Biochimica e Biologia Molecolare, Università degli Studi di Siena Master di II Livello in "Dipendenze Farmaco-Tossicologiche e Comportamentali", Università di Pisa Abilitato alle funzioni di Professore Universitario di Seconda Fascia Congresso Nazionale SITD. Roma, 24/11/2017
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Il trattamento farmacologico del poliabuso nell'Addiction da eroina
Dr. Angelo G. I. MaremmaniDirigente Medico, Azienda USL Toscana Nord-Ovest (Zona Versilia)
Dottorando di Ricerca di Biochimica e Biologia Molecolare, Università degli Studi di SienaMaster di II Livello in "Dipendenze Farmaco-Tossicologiche e Comportamentali", Università di Pisa
Abilitato alle funzioni di Professore Universitario di Seconda Fascia
CongressoNazionaleSITD.Roma,24/11/2017
Outline
• The role of bipolarity in addiction and polyabuse
• Heroin Use Disorder + Sedatives (Alcohol / BZDs)
• Heroin Use Disorder + Cocaine
• Treatment implications
Psychiatric Comorbidity in Addiction
%
Mood Disorders 33-90
Anxiety Disorders 1-36
Personality Disorders 3-91
Violence and Impuls Control Disorder 10-45
Suicide 10-20
Schizophrenia 0.2-19
(Maremmani et al., Heroin Addiction and Related Clinical Problems, 2003)
Substance Use Disorder (Lifetime) in Bipolar Disorder patients
Author (year) N Alcohol Cannabis Amphet Cocaine Sub Ab
Maremmani A. G., Bacciardi S., Gehring N. D., Cambioli L., Schutz C., Jang K., Krausz M. (2017): Substance Use Among HomelessIndividuals With Schizophrenia and Bipolar Disorder. The Journal of nervous and mental disease. 205(3): 173-177.
Maremmani et al., 2000. Heroin Addiction and Related Clinical Problems 2, 35-42.
Maremmani I., Maremmani A. G. I. el al., (2012): Clinical presentations of substance abuse in bipolar heroin addicts at time of treatment entry. Ann Gen Psychiatry. 11(1): 23.
Data collected at the Centre for the Assessment and Treatment of Alcohol- Related Pathology, La Sapienza University, at the Umberto I University Hospital in Rome, Italy
Why looking at former heroin use disorder in alcoholics?
Addiction history, social adjustment and physical complications of Former Heroin Addicts-Alcohol Use Disorder (FHA-AUD) and
Alcohol Use Disorder patients (AUD)
FHA-AUD
N=60
AUD
N=388 p
Age alcohol first use 15.17±4.8 15.70±5.1 nsAge alcohol misuse 24.27±6.4 24.02±7.2 nsDrinking duration 28.22±8.2 28.44±10.6 nsAlcoholism duration 19.15±8.6 20.12±10.7 nsInitial alcohol Units/daily 9.78±9.1 7.02±7.5 0.003Max alcohol Units/daily 25.13±11.6 21.55±10.1 0.016Physical severe complications 16 (26.7) 64 (16.5) 0.056Problematic social adjustment 28 (46.7) 157 (40.5) ns
Heroin Addiction and Treatment History of 60 Former Heroin Addicts-Alcohol Use Disorder patients
Heroin addiction historyAge at heroin continuous use (M±sd) (range) 22.12±8.2 (13-49)
• R-Met: • affinità al recettore Mu 2x S-Met• potenza analgesica 50x S-Met• variazione interindividuale 16-17x (250ng/ml sono raggiunti con 55mg/die oppure con
900mg/die)• S-Met:
• antagonismo non competitivo NMDA che blocca l’iperalgesia NMDA-indotta e la tolleranza alla morfina
Kristensen, K., et al.,1996. Therapeutic drug monitoring 18, 221-227.
Meini, M., et al., 2015. Eur J Pharmacol 760, 1-6.
D,L-Methadone Vs L-Methadone
• Same efficacy after switching from D,L- to L-Methadone (with ratio 2:1)– Sherbaum et al., 1996 Pharmacopsychiatry 29, 212-215– de Vos et al., 1998 Eur Addict Res 4, 134-141– Meini et al., 2015 Eur J Pharmacol 760, 1-6– Verthein et al., 2005 Drug and alcohol dependence 80, 267-271
• Better safety of cardiological ground (QTc)– Ansermot et al., 2010 Archives of internal medicine 170, 529-536
• Reduction in craving • Reduction in concomitant substance use• Better compliance to treatment
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Versilia (Italy), Photo from Tonfano’s Pier, Winter 2016