Drug Addiction and Related Clinical Problems

234 Pages·1995·11.45 MB·English

by  A. Herz (auth.)

A. Tagliamonte and I. Maremmani (eds.)
Drug Addiction
and Related
Clinical Problems
Springer-Verlag Wien New York
Alessandro Tagliamonte, M.D.
Professor of Pharmacology
University of Siena, Institute of Pharmacology, Siena, Italy
Icro Maremmani, M.D.
Professor of Medicine and Drug Addiction
University of Pisa, Psychiatric Institute, Pisa, Italy
This work is subject to copyright.
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© 1995 Springer-Verlag Wien
Product Liability: The publisher can give no guarantee for information about drug dosage and
application thereof contained in this book. In every individual case the respective user must
check its accuracy by consulting other pharmaceutical literature. The use of registered names,
trademarks, etc. in this publication does not imply, even in the absence of specific statement,
that such names are exempt from the relevant protective laws and regulations and therefore
free for general use.
Typesetting: Camera ready by editors
Printed on acid-free and chlorine-free bleached paper
With 39 Figures
Library of Congress Cataloging-in-Publication Data
Drug addiction and related clinical problems / edited by Alessandro Tagliamonte and
lero Maremmani. p. cm. Includes bibliographical references. ISBN-13:978-3-211-82674-4
(alk. paper) 1. Substance abuse - Chemotherapy. 2. Substance abuse - Molecular aspects.
3. Methadone maintenance. 4. AIDS (Disease) - Prevention. I. Tagliamonte, Alessandro.
II. Maremmani, lero. [DNLM: 1. Substance Dependence - rehabilitation. 2. Methadone
therapeutic use. 3. Health Policy - Europe. WM 270 D79348 1995] RC564.D779 1995
616.86'061 - dc20 DNLM/DLC
ISBN-13:978-3-211-82674-4 e-ISBN-13:978-3-7091-6901-8
DOl: 10.1007/978-3-7091-6901-8
PREFACE
Many of the questions related to the treatment of drug addiction originate from the
confusion that still characterizes this issue, even though biology is irreversibly changing
our outlook on the physiology and psychopathology of the mind. In fact, prejudices
stemming from the archaic concept of mind-body dualism are so difficult to eradicate
that even a skilled psychiatrist may find it hard to distinguish a psychiatric symptom
from a socially transgressive behavior.
The dilemma becomes even more salient for drug addiction, since many of the
substances which induce abuse and dependence are illegal, and their production, trade
and use are forbidden by law. If the use of heroin is connoted as a crime, it may become
controversial to recognize its chronic sequelae as a disease. Hence, withdrawal symptoms
may alternatively be attributed to drug effects, or labelled as immoral attitudes arising
from a vicious personality.
However, the physician's judgement, which has to be merely instrumental at
improving the patient's quality of life, should never be influenced by such complex
setting. In fact, the only concern of the physician must be that of ascertaining the causes
of symptoms and of removing them: if symptoms are induced by the toxic effect of a
drug, he has to use the most effective antidote, and then proceed towards a detoxification;
if they are due to withdrawal, a substitutive substance should be given initially. In the
case of narcotics, substitutive therapy on a maintenance basis may become mandatory.
Treatment must be pragmatic, professional and never contaminated by non medical
motivations.
In the present book the diverse issues related to drug addiction, from basic research
to clinical treatments, are examined with a scientific approach, without ideological
constraints.
In the first part, H.H. Loh discusses some of the most recent studies on opioid
receptors c-DNA isolation and cloning, and the intriguing role played by OBeAM
(opiate binding cell adhesion molecule) in the regulation of opioid receptor function.
The role of dopamine, and the interplay between different dopamine and opioid
receptors in the mediation of rewarding and motivational effects ofd rugs of abuse in the
limbic system are treated in separate chapters by A. Herz and G.L. Gessa. New relevant
data indicating that endogenous morphine is the physiological ligand for J.l-opioid re
ceptors are presented by A. Tagliamonte.
V.P. Dole's chapter is an historical overview of methadone maintenance (M. M.)
VI
therapy, which also points out that basic research plays a key role in understanding the
psychopathology of drug addiction.
The sections concerning the medical aspects of drug addiction deal with:
1) the high prevalence of psychiatric co-morbidity among drug addicts (L. Daini);
2) the issue of polydrug abuse, sustained by the availability of recreational drugs like
tobacco and alcohol, and by the excess of prescribed psychoactive drugs -such as
hypnotics, tranquillizers, and stimulants (S. Rawaf). In particular, the problem of
alcohol abuse, as well as that of cocaine, is especially considered in terms of
complications in the therapy of heroin addicts (G.P. Guelfi, O. Zolesi).
Almost 80% of the clinical data deal with M. M. programs, and the main conclusions
are:
a) the efficacy of M. M. in the treatment of heroin addiction has now been objectively
demonstrated (M. Parrino, M. Rizzi);
b) the dose of methadone has to be tailored to each patient according to herlhis individual
and contingent needs;
c) the correct treatment with methadone reduces heroin use -up to its complete cessation
in most patients, and helps to control the abuse of other psychotropic drugs;
d) from a medical point of view, it is irrational to discharge a patient from a M. M.
program only because she/he abuses heroin or any other drug (R. Newman);
e) the possible complications associated with pregnancy, childbirth and infant develop
ment in drug dependent women can be markedly diminished if adequate care and
pharmacotherapy (in the form ofM. M.) are provided (L.P. Finnegan);
f) the long-term use of methadone in heroin addicts has resulted to be safe in terms of
side effects, being of no harm on the functions of the liver, and of the endocrine,
immune and central nervous systems (M.J. Kreek);
g) M. M. programs facilitate social adjustment, reduce criminality rate (J.J. Deglon, E.
Buning, B. Sommer, H. Joseph), decrease engagement in socially disapproved
working activities, like prostitution (L. Gunne);
h) finally, M. M. diminishes the risk of contracting infectious diseases (C. Kaplan, M.
Reisinger).
Indeed, in a study carried out in New York city from 1983 to 1984, the average
incidence ofHIV infection in patients on M. M. was less than 10%, at a time when over
50-60% of untreated addicts were infected (M.J. Kreek). In Sweden, admissions for new
patients to M. M. programs were closed from 1979 to 1983, due to political controversy.
When they were reopened in 1984, the incidence ofHIV infection was 3% among old
patients, whereas a rapid increase of seropositivity was observed in newly admitted
addicts, with a peak of 59% in 1988 (0. Blix).
Such data are of a particular value in view of the fact that the myth held in the 1970' s
that tuberculosis (TB) could be totally eradicated, vanished with the spreading ofHIV
epidemics which brought about a new upsurge of TB in the industrialized countries,
making this disease the largest cause of death from a single pathogen in the world (J .H.
Lowinson).
In conclusion, we have to admit that the alarm consequent to the spread of AIDS
epidemics has contributed to the rationalization of the approach to drug addiction more
effectively than the most advanced discoveries on the long-term effects of ethanol,
cocaine or opioids on neuronal plasticity. However, the firm acquisition that an effective
VII
and safe pharmacological therapy specific for opiate addiction does exist, should
stimulate the search for medications active on other forms of drug dependence (e.g.,
alcohol and cocaine )(1. Maremmani).
The diffused idiosyncrasy towards methadone has been partially neutralized by the
emotionality induced by the threat of AIDS. However, we should not forget that
prejudices are still thriving (A. Coluccia, C. Vetere). In fact, specialists, public health
agencies, and laymen still dispute endlessly on whether drug addiction is a disease, and
whether only physicians should be responsible for M.M. programs. It must be recog
nized that such a debate, in light of the reported data on the efficacy of M.M. therapy
and of the spreading of HIV epidemics, constitutes. a mere ideological, irrational
constraint to correct medical practice and basic research.
GIOVANNI B. CASSANO
Institute of Psychiatry
University of Pisa
Italy
Pisa, November 1994
CONTENTS
1. Opposing Tonically Active Endogenous Opioid System
Modulating the Mesolimbic Dopamine Reward Pathway. 1
A.HERZ
2. Recent Advances in the Understanding of Membrane
Opioid Receptor. A. P. SMITH, H. H. LOH 13
3. Central Dopaminergic Mechanism of Alcohol and Opiate
Withdrawal Syndromes. M. DIANA, Z. L. ROSSETII,
G. L. GESSA 19
4. Endogenous Morphine and Codeine As Possible Physiologi-
cal Ligands of Il-Opiate Receptors A. TAGLIAMONTE,
M. GUARNA, E. BIANCHI 27
5. Drug of Abuse Craving in Free-Choice Experimental
Conditions. M. SALA, D. BRAIDA, M. COLOMBO,
M. P. LEONE, E. GORI 37
6. Methadone Maintenance. Comes of Age V. P. DOLE 45
7. Pharmacotherapy for craving. I. MAREMMANl,
O. ZOLESI, L. DAINI. M. R. CAPONE, M. AGLIETII,
P. CASTROGIOVA NNl 51
8. The Use of GHB in Anticraving Therapy. Preliminary
Experimental Data of its Use in Alcohol and Heroin
Dependence. O. ZOLESI, L. DAINl, M. R. CAPONE, M.
AGLIETTI, F. RAIMONDI, I. MAREMMANI. 57
x
9. Development of an Italian Version of the "Readiness to
Change Questionnaire" for Alcoholism and Addiction
M. SCAGLIA, E. BAIARDO, I. BALDASSO, E. CRISTINA,
S. DEODATO, W. O. FAUSTMAN, V. SPILLER,
M. STEFANINI, R. TRAMPETTI, G. P. GUELFI 63
10. Mood Disorders in Heroin Dependence and Clinical
Differences Between Heroin Addicts with and without Mood
Disorders. L. DAINI, M. R. CAPONE, T. AGUECI,
M. AGLIETTI, O. ZOLESI, I. MAREMMANI 69
11. Nature and Magnitude of Problems Associated with
Psychoactive Drugs. A. H. GHODSE, S. RAWA F 79
12. The Street Life and Treatment Response of 105 Heroin
Addicted Women L. M. GUNNE, L. GRONBLADH,
L. S. OHLUND 91
13. The Pharmacological Rationale for Methadone Treatment of
Narcotic Addiction R. G. NEWMAN 109
14. Reducing Heroin Consumption During Methadone Treatment
and Limitation of Post-Treatment Relapses:Two Crucial
Public Health Problems. J. J. D:EGLON 119
15. Methadone Against AIDS. The Swedish Experience O. BLIX 129
16. Addiction and Pregnancy: Maternal and Child Issues
L. P. FINNEGAN 137
17. Tuberculosis. The Comeback ofa Killer. J. H. LOWINSON,
M. GOUREVITCH 149
18. Lowering the Threshold: A Comparative Overview of AIDS
Prevention Among Injecting Drug Users Using Outreach
Technology. C. D. KAPLAN 157
19. Pharmacological Treatment of Addiction: Normalization of
Physiology and AIDS Risk Reduction M. J. KREEK 165
20. Methadone Treatm~nt and the Epidemiology of AIDS in the
European Community. M. REISINGER 175
21. Public Health in Face of Drug Addiction and AIDS
C. VETERE 181
XI
22. The Dark and Light Aspects of Italian Legislation on Sub-
stances of Abuse. A. COLUCCIA 187
23. Methadone and Criminality. Euro-methwork Workshop.
E. BUNING, P. LANG, M. TORRENS, C. HERZOG,
L. GRONBLADH, H. JOSEPH, A. TAGLIAMONTE, O. BLIX 193
24. Workshop of the European Collaborating Centres in
Addiction Studies (ECCAS). 199
mv
Methadone Substitution Therapy and its Impact on Risk
Behaviors. A.H. GHODSE, C. CLANCY, M. JONES,
M. BOURQUIN, B. DE LAS HERAS, M. MONTES,
E. KEENAN, I. LOPES, M. RlGLIETTA, L. TlDONE,
C. ROSINGER, K. RUNGE NIELSON, L. SAN, F. SCHIFANO,
P. SCHOEMANN, J. WERENNE, L. CREMMERS,
B. SOMMER,S. WIEVIORKA 200
A Report from Denmark. B. SOMMER 203
A Report from Germany. C. ROSINGER 204
A Report from Ireland. E. KEENAN 205
A Report from Italy:
Methadone Treatment in Opiate Addicts: 12 Years Experience
in Italy. M. RlGLIETTA, R. BAGNATO, M. CAMPANA,
P. COLLEONl, P. DRAGO, M. FUSINI, Z. VYHNA'LKOVA ,
L. TID ONE 206
The Padova Centre Report.F. SCHIFANO 207
A Report from Spain. The Methadone Maintenance Programs
in Barcelona. M. TORRENS, L. SAN 209
A Report from Switzerland. Methadone Treatment in
Switzerland. M. BOURQUIN 211
25. 1st European Methadone Conference. Opening Remarks
M.W. PARRINO 213
26. Incorporating a Methadone Maintenance Program into a
Drug-free Treatment System M. A. RIZZI 219
27. Heroin Dependence. Theory of Different Levels of
Intervention. I. MAREMMANI, O. ZOLESI, L. DAINI,
R. NARDINI, P. CASTROGIOVA NNl 225
CONTRIBUTORS
Aglietti,M. Institute of Psychiatry, University of Pisa , Italy
Agueci,T. Institute of Psychiatry, University of Pisa, Italy
Bagnato,R. SERT, USSL 29, Bergamo, Italy
Baiardo,E. SERT, USL 3 "Genovese", Genova, Italy
Baldasso,1. SERT, USL 3 "Genovese", Genova, Italy
Bianchi,E. Institute of Pharmacology, University of Siena, Italy
Blix,O. Department of Alcohol and Drug Diseases, Malmo General
Hospital, Sweden
Bourquin,M. The Phenix Foundation, Geneva, Suisse
Braida,D. Institute of Pharmacology, Faculty of Mathematical, Physical
and Natural Sciences, University of Milan, Italy
Buning,E. Euro-methwork, GC&GD, 1018 WT Amsterdam, Holland
Carnpana,M. SERT, USSL 29, Bergamo, Italy
Capone,M.R. Institute of Psychiatry, University of Pisa, Italy
Castrogiovanni,P. Institute of Psychiatry, University of Pis a, Italy
Clancy,C. ECCAS, London, U.K.
Colleoni,P. SERT, USSL 29, Bergamo, Italy
Colombo,M. Institute of Pharmacology, Faculty of Mathematical, Physical
and Natural Sciences, University of Milan, Italy
Coluccia,A. Departement of Legal Medicine, University of Siena, Italy
CreIlHIlers,L. ECCAS, Brussels, Belgium
Cristina,E. SERT, USL 3 "Genovese", Genova, Italy
Daini,L. Ph.D. Research Program, Siena,Cagliari & Pisa Universities,
Italy
De las Heras,B. ECCAS, Oviedo, Spain
Deglon,J.J. The Phenix Foundation, Geneva, Suisse
Deodato,S. SERT, USL 3 "Genovese", Genova, Italy