Research reportThe long-term outcomes of heroin dependent-treatment-resistant patients with bipolar 1 comorbidity after admission to enhanced methadone maintenance
Introduction
Bipolar spectrum disorders and addiction often co-occur and constitute reciprocal risk factors (Bahorik et al., 2013, Hoblyn et al., 2009, Reif et al., 2011, Schneier et al., 2010) that we believe are best considered from a unified perspective (Maremmani et al., 2006). We studied the correlation between bipolar spectrum and heroin addiction at various levels. In our in-patient setting we found that a majority of our heroin addicts were affected by bipolar 1 disorder (Maremmani et al., 2000), whereas in our outpatient setting they obtained a diagnosis of bipolar 2 disorder (Maremmani et al., 1994). We found that depression and hostility as part of the bipolar spectrum – in the context of early-onset drug dependence, work and social-leisure problems – appear to be independently associated with suicidal ideation. (Maremmani et al., 2007a). We also found that subthreshold bipolarity, including hyperthymic and cyclothymic temperaments, seems to predispose patients to heroin addiction (Maremmani et al., 2009), but craving for the suppressed hypomania could, in its turn, lead to cocaine abuse, which eventually unmasks a frankly bipolar disorder – in some cases leading to mixed state, severe mania, or even to psychosis beyond mania (Maremmani et al., 2008). We also studied clinical presentations of substance abuse in bipolar heroin addicts at time of treatment entry. Besides one expected result – the prominent use of CNS stimulants during a depressive phase of bipolar patients – this study supports the hypothesis that mood elation is a pleasurable, rewarding experience that, in bipolar patients, can be started or prolonged by means of CNS stimulant drugs. Stimulant use was, therefore, more prevalent during the ‘up’ rather than the ‘down’ phase of the illness (Maremmani et al., 2012c). In conclusion, we are aware that the use of substances worsens the therapeutic outcome of bipolar patients (Camacho and Akiskal, 2005, Maj et al., 2003, Mazza et al., 2009, van Rossum et al., 2009). Agonist Opioid Treatment improves symptoms of psychopathology present in patients addicted to heroin (Maremmani et al., 2007b, Pani et al., 2000). In this perspective, we can assume that opiates // are an effective treatment in bipolar patients heroin addicts.
The aim of this study was to compare the long-term outcomes of treatment-resistant, heroin-dependent patients (HD) with bipolar 1 (BIP1-HD) ones, and patients without DSM-IV axis 1 psychiatric comorbidity (NDD-HD). We decided to evaluate whether comorbid psychopathology was able to influence methadone treatment outcomes in patients who had previously failed in first-line, low threshold treatment facilities, when those patients were included in a high-threshold, maintenance-oriented, high-dose methadone programme.
The hypothesis of the study was that DSM-IV bipolar 1 psychiatric comorbidity would not affect treatment outcomes if patients with comorbid disorders received higher, individualized doses of methadone and that a favourable outcome would be related to long-term ongoing treatment (retention).
To test this hypothesis, a group of treatment-resistant heroin addicts, with bipolar 1 or without DSM-IV axis I psychiatric comorbidity, were followed in a naturalistic approach for a minimum of 0.5 and a maximum of 8 years in the context of the maintenance high-threshold, high-dose Pisa methadone programme, using retention in treatment and rates of heroin use as the main end-point parameters.
Section snippets
Design of the study
A prospective cohort study was designed in order to evaluate treatment outcome (in terms of retention in treatment, substance use, clinical improvement and general social adjustment) of patients included in a methadone programme, in terms of its relationship to the presence of a bipolar 1 psychiatric comorbidity. Treatment-resistant, heroin-dependent patients (TRHD) were divided into two groups – those with bipolar 1 psychiatric comorbidity (BIP1-TRHD patients) and those without concomitant
Baseline evaluation (at the beginning of the treatment)
On the basis of DAH-RS-collected information, Table 1 reports the demographic, clinical and addiction history data of the sample at the beginning of treatment. BIP1-TRHD patients turned out to be different from NDD-TRHD patients in their educational level. The two groups did not differ significantly in the other demographic variables investigated (age, gender, marital status, work).
Moreover, BIP1-TRHD patients seemed to indicate a lower frequency for “daily or more” heroin intake and to have
Discussion
We examined treatment retention and outcomes for BIP1-TRHD and NDD-TRHD treatment-resistant, methadone-maintained patients. We observed that:
BIP1-TRHD and NDD-TRHD patients differed at baseline in terms of their educational level, duration of their heroin addiction, level of heroin use, and age at first addiction treatment, but these differences did not appear to be related to the better retention or better outcome of the BIP1-TRHD patients.
BIP1-TRHD patients were retained in treatment for
Conclusion
The main conclusions to be drawn from our results are:
- (i)
In the presence of problematic non-compliant patients with a bipolar 1 diagnosis, a flexible dosing regimen that permits the administration of higher doses may lead to higher retention rates. The relevance of the present data becomes clearer when we consider that between a third and a half of all opiate addicts suffer from additional mental disorders (Farrell et al., 1998, Rounsaville et al., 1981, Rounsaville et al., 1982).
- (ii)
Bipolar 1
Role of funding source
Authors states that this study was financed with internal funds.
No sponsor played a role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.
Conflict of interest
None of the authors have a conflict of interest.
References (66)
- et al.
Methadone maintenance. Does dose determine differences in outcome?
Journal of Substance Abuse Treatment
(1999) - et al.
Proposal for a bipolar-stimulant spectrum: temperament, diagnostic validation and therapeutic outcomes with mood stabilizers
Journal of Affective Disorders
(2005) - et al.
Retention in treatment of heroin users in Italy: The role of treatment type and of methadone maintenance dosage
Drug and Alcohol Dependence
(1998) - et al.
Patterns of major depression and drug-related problems amongst heroin users across 36 months
Psychiatry Research
(2009) - et al.
Substance misuse and psychiatric comorbidity: an overview of the OPCS national psychiatric morbidity survey
Addictive Behaviors
(1998) - et al.
Predictors of follow-up health status in the Drug Abuse Treatment Outcome Study (DATOS)
Drug and Alcohol Dependence
(2003) - et al.
Buprenorphine versus methadone for opioid dependence: Predictor variables for treatment outcome
Drug and Alcohol Dependence
(2004) - et al.
Different profile of substance abuse in relation to predominant polarity in bipolar disorder: The Vitoria long-term follow-up study
Journal of Affective Disorders
(2010) - et al.
Cocaine abuse and the bipolar spectrum in 1090 heroin addicts: Clinical observations and a proposed pathophysiologic model
Journal of Affective Disorders
(2008) - et al.
Affective temperaments in heroin addiction
Journal of Affective Disorders
(2009)