The term addiction comes from addictus Latin meaning “slave to debt.” There is talk of addiction when a substance becomes the center of existence for a subject.
We differentiate opioids, stimulants and cannabis that cause different effects.
In any case, it must evoke consumer practices to determine if there was or not taking risks with respect to communicable blood borne infections (HIV, hepatitis, etc.).
The patient may also reflect the psychotherapist motivations to stop its consumption.
RISK FACTORS AND PROTECTION:
Risk factors:
Related to the environment:
Environment-related risk factors are: Social: early exposure to products, marginality, etc. ;
– Sociocultural: immigration, acculturation, etc. ;
– Family: violent, confrontational relations, family psychiatric comorbidity, traumatic life events (bereavement, separation, sexual abuse, unwanted pregnancies, etc.); entourage: peers who consume regularly, initiation rites, marginalization, etc.
Related psychiatric disorders:
Unfortunately, we know that behind drug use is hiding great suffering and sometimes psychiatric disorders. In some cases the taking of substances can have a “autotherapy” value. A study (ECA) showed that patients with schizophrenia frequency of abuse or addiction to toxic is 47% against 17% in the general population. Another study (Frages, 1998) found that 70 to 90% of care seekers addicts have a psychiatric comorbidity associated. It is therefore essential that a specialist can detect it so that the treatment is optimal.
Protective factors:
The protection factors are:
– High level of intelligence;
– Ability to solve problems;
– social abilities ;
– self esteem ;
– Suitable family support;
– Academic skills.
ADDICTION:
Dependence criteria:
We will not return here on different stages of addiction to a substance, found in Chapter “alcohol”. As a reminder, there are experimental, occasional, recreational, regular, harmful or abusive and dependence (Box 1).
Box 1. Substance Dependence according to DSM-IV
A dependency exists if 3 or more of the following criteria are present
1. tolerance manifested by the need to increase the doses consumed to achieve intoxication or desired effect, or a decrease in dose consumed constant effects.
2. Withdrawal symptoms after a period of abstinence, prevented or improved by a new intake of the substance.
3. Taking the substance in larger amounts or for longer than expected.
4. A persistent desire or unsuccessful efforts to cut down or control consumption.
5. A lot of time spent using or obtaining the substance.
6. Give up or reduce social, occupational or leisure due to the use of the substance.
7. Continue to use the substance despite the knowledge of the health risks.
Neurobiological factors:
Today dependence is explained by the influence of several factors, not only by old psychic and physical dependence notions. Indeed, recent studies lead us to believe that the neurobiology involved at several levels trivariate scheme addiction Doctor Olivenstein.
For example, a recent study by the NIDA has highlighted that some dopamine receptors, D2 receptors have a role to play in our vulnerability to addiction. Indeed, the number of D2 receptors is inversely proportional to our appetite for all types of drugs and therefore it tends to show a link between neurobiology and addiction.
Opiates:
This is opium and its derivatives such as morphine or heroin. From a neurobiological point of view, these substances have an analgesic effect which slows the flow of information.
They stop the action of GABA and thus allow a large release of dopamine in the nucleus accumbens, which provides a flash of pleasure to the user. These drugs cause all a very addictive phenomenon.
Diagnostic:
For diagnosis, the signs listed by the DSM-IV are behavioral or psychological changes unsuitable euphoria followed by apathy, dysphoria, agitation or motor retardation, impaired judgment, social functioning and / or professional, etc.
Treatment:
Craving:
craving in patient management is a delicate problem to consider case by case.
It is important to get to be able to discuss outside a context of pressure or violence so that dialogue can be part of a nursing process.
Currently the given emergency treatment for craving without substitution treatment project is mostly buprenorphine is more effective than combination therapy benzodiazepine, antispasmodic and Paracetamol.
It is also important to offer the patient an appointment the next day to discuss a care plan secondarily.
Replacement therapy:
The management of addiction begins with the establishment of a relationship of trust between patient and doctor.Treatment is usually based on a multidisciplinary care physicians, psychotherapists, social workers, educators, lawyers, etc. Pharmacological level, there are two main alternative treatments: methadone and buprenorphine (Subutex).
Methadone:
* Indications:
The main indications of a methadone treatment are long-term use of opioid substitution treatment and sometimes use as part of a withdrawal syndrome.
Methadone is preferentially indicated for patients with a former dependency (several years), rather injectors (the syrup form is not for injection), especially when a significant anxiolytic and sedative effect is desired (buprenorphine [Subutex ®] is less anxiolytic).
This long-term treatment has several advantages, it allows:
– Stop the illicit opioid use;
– Reduce the infectious risks associated with the consumption of injectable opiates;
– Start a medical treatment for other somatic problems;
– Promote reintegration and reduce crime;
– Release the patient constraints to consumption, and thus enable it to create a new psychic space.
* Pharmacology:
Methadone is a synthetic opiate that is distinguished primarily morphine (natural opiate) and heroin (semi-synthetic opiate) by its prolonged action. It has an agonistic effect on mu receptors of the nervous system, providing both properties similar to those of morphine. Its analgesic potency is comparable to that of morphine.
Its peak serum concentration is achieved in 2-4 hours post-ingestion.
The half-life of methadone is 24 to 36 hours, enabling once daily. The saturation of opioid receptors causes the heroin effect is reduced or canceled if the patient consumes. This is a phenomenon of cross tolerance to other opioids such as methadone partially blocks the euphoric effect of heroin. The stability of serum is reached after five days of continuous administration of the substance. A period of three to five days is required to ensure the effectiveness of the prescribed dose.
* Short-term effects:
Unlike heroin that gives intense sensations, methadone provides a sense of mild euphoria, early in treatment and emotional stability of sensation brings patients say they feel “normal.” It is also an antitussive.
As with other opioids, the main side effects are constipation, weight gain, peripheral edema, pruritus, somnolence (overdose), sweating, gynecomastia, decreased libido, sexual dysfunction, etc.
* Overdose:
A methadone overdose can cause respiratory arrest. Of its incompatibility with alcohol, tranquilizers, sleeping pills and painkillers, the simultaneous consumption of methadone with one of these products may have harmful effects, and enhance, potentiate, the sedative effects, up to coma.
* Long-term effects:
The appropriate dosage, methadone does not cause chronic organ toxicity. The literature reports of prolonged and continuous use for over 15 years without significant adverse effects in adults. This treatment prolongs the psychological addiction, which can take years to be processed, but reduces the risks associated with consumption (infectious risks, social risks, etc.).
* Drug Interactions and concomitant consumption:
Drug interactions and concomitant consumption.
* Pregnancy:
The effects of methadone on the pregnant woman and the fetus have been studied extensively. The establishment of a treatment during pregnancy helps reduce the risk of repeated sub heroin withdrawal syndromes, promote medical and obstetrical care for pregnancy and reduce illicit substance consumption.Unfortunately, this drug substitution exposes the newborn withdrawal syndrome inconstant whatever the dosage of replacement therapy prescribed to the mother (in 50% of cases the use of an opioid treatment of the child is required). Current knowledge does not allow us to say the long-term effect of methadone on the newborn and child.
Buprenorphine:
Buprenorphine (Subutex®) is also a synthetic opiate.
* Indications:
Its effects are similar to those caused by methadone. It is also used in patients with a former dependency, but not injectors, and with the least need for an anxiolytic effect.
Buprenorphine can be misused, solubilized and injected, which is much more difficult with methadone, which is a syrup.
* Pharmacology:
Used alone, buprenorphine is a partial agonist at mu receptors in the nervous system opiates. Associated with opioids such as heroin, morphine, codeine, it antagonizes causing the opposite effect, a withdrawal syndrome. This is a replacement therapy in the form of triangular pill sublingual.
* Overdose:
Buprenorphine has a ceiling effect, which puts away a coma in overdose unless the latter is combined with other sedative drugs (benzodiazepines, alcohol, etc.), which is in principle counter indicated.
Legal framework of methadone and buprenorphine:
Since 1995, the marketing of methadone and buprenorphine (BHD), opiate dependent users have the ability to track substitution treatment in one of two forms.
While methadone can be prescribed for the first time in a CSST (specialized care center for drug addicts) or a care facility (public hospitals), HDB can be by any doctor.
Terms of prescription of methadone and buprenorphine:
Substitution treatment is prescribed after a preliminary interview, before an arrest desire any use of other opiates, and before a real motivation. Indeed, it is usually a treatment that is established over a long period (several months or years), with catches in multidisciplinary loads (psychological, social, legal, etc.).
Methadone and Subutex® must be prescribed on a secure prescription with the name of treatment and dosage in full, as well as the name and address of the pharmacy delivery.
* Methadone:
Methadone is prescribed in an institution (public or CSST Hospitals) after dosing urinary checking for opiates. The usual starting dose rarely exceeds 40 mg / day, and the dosage is revalued daily (increase of 10 mg daily) in early treatment.
The following urinary assays are useful to check for use of other opiates, or to speak as appropriate.
When the treatment is well balanced, the patient feels no physical shortage or drowsiness evocative of overdose, the doctor may prescribe treatment for several days. Methadone can be prescribed for up to 14 days, usually with a delivery every seven days unless you specify a delivery at once.
The institutional physician can refer the patient to follow a general practitioner chosen in consultation. It then delivers to the patient the primoprescription with the name of the town doctor, methadone dosage, and the words “primoprescription”.
This primoprescription is legally required in the town doctor to prescribe methadone. It registered its orders the name and address of the pharmacy of treatment delivery. The patient can with primoprescription and with the order of his city have doctor issuing its treatment in the pharmacy named.
* Buprenorphine:
Subutex® buprenorphine can be prescribed by any doctor. This treatment is usually started at less than 8 mg / day, and increased if necessary. It can be prescribed for 28 days with a delivery every 7 days unless it is mentioned in a grant once. The name and delivery address of the pharmacy are specified on the order.
Withdrawal:
A withdrawal is not organized in an emergency. Indeed, the patient needs to develop a project to organize a week of hospitalization in a medical facility, consider starting after hospitalization aftercare.
The main indications are:
– Need to be temporarily away from the entourage;
– Reduction difficulties of substitution treatment at low doses (less than methadone or equal to 40 mg Subutex and less than or equal to 4 mg);
– The need for a pause or rewind in case of physical exhaustion and / or psychical.
COCAINE AND PSYCHOSTIMULANT:
Psychostimulants appear to act mainly on the dopaminergic system. Cocaine is derived from coca leaves, while some are purely chemical.
When consumption is chronic tolerance is created and higher amounts are required to achieve the same effect. Then reduce the pleasurable effects (well-being and physical, confidence, euphoria, indifference to problems, loss of feeling tired, etc.) to give way to more negative effects. Cocaine has the distinction of causing a phenomenon of “craving”.This is the irrepressible desire to experience once again the effects of a psychoactive substance previously experienced, desire underpinned by strong impulsiveness.
Symptoms:
When cocaine is chronic encountered the following problems among users:
– A somatic point of view: dehydration problems, lung, nutrition, cardiovascular, neurological, sex, sleep.
Moreover, it seems that this leads to a decreased immune protection;
– A psychological point of view: paranoid episodes, dysphories, delusional and depressive episodes.
When the patient wants to stop its consumption, drug aid can be useful to support the patient’s decision.
Treatment:
Cocaine stop causes psychic asthenia
and major physical, it is difficult to counter by drugs and / or hospitalization.
Weaning is the more difficult it is accompanied by the “craving” this compelling sensation that causes patients to consume again. Often, physical exhaustion or financial impossibility are the only non-voluntary factors that force patients to stop their consumption.
When medical assistance is possible hospitalization in isolation is therapeutic in itself and allows the mental and physical rest. Without hospitalization, the daily passage in a care facility is recommended, with medical care and a daily delivery of treatment to assess daily psychological and medical needs.
Sedative treatment with benzodiazepines, neuroleptics more or less progressively decreasing doses attenuates the major anxiety which is present from cocaine judgment.
A high dose antidepressant treatment is necessary, so that gradually the previous depressive syndrome decision, and secondary to cocaine arrest, can be mitigated.
Psychotherapeutic work is often inevitable to help the patient understand why it is in this situation and what could be his motivation to stop.
CANNABIS:
Cannabis can be in various forms (grass, resin, etc.) having a greater or lesser concentration of tetrahydrocannabinol (THC), the active ingredient. THC acts by increasing the levels of endogenous cannabinoids, secreted into the synapse.
Symptoms:
At the cognitive level cannabis has negative effects on:
– Fluency;
– Psychomotor;
– memory ;
– Summary analysis;
– Logical analysis; temporospatial capacity.
Psychologically, cannabis can cause:
– Anxiety;
– Dysphoria;
– State of panic;
– Paranoia.
Cannabis use is more particularly that another drug, context-dependent and usually used for its anxiolytic effects.
Treatment:
Cannabis stop has a better success rate with smoking cessation, requiring the therapeutic management of coconsommation.
However, stopping only cannabis without smoking cessation, is still possible, if that from the perspective of an experience of a partial withdrawal, with the information of greatest difficulty. Just like quitting smoking, stopping cannabis is dotted with numerous attempts, which can be used positively to the path of long-term cessation.
When stopping cannabis, it is very common to see patients postpone their addictive behavior on tobacco or alcohol.We must be especially vigilant.
Medication:
In the case of concomitant stop cannabis / tobacco, nicotine replacement therapy (patch or gum) based smoking improves the possibilities of success. The addition of an antidepressant treatment if necessary, also significantly improves the possibility of stopping. An anxiolytic treatment in small doses over a short period, and to rapidly decreasing doses is an important adjunct.
Psychological:
Behavioral psychotherapy (brief therapy) allow working strategies to manage cravings reuptake and motivation. The patient may also consider a more in depth on the context that was able to push to consume. He then heads to other types of psychotherapy (family, psychoanalytic, etc.).