The acute effects of a rapid medical detoxification upon dysphoria and other psychopathology experienced by heroin abusers.

Self-reported dysphoria, personality disorder traits, and subjective opioid withdrawal symptoms were assessed in 30 opioid abusers before and after a rapid medical detoxification from heroin. Subject exclusion criteria reflected an effort to control for potential sources of affective change that were extraneous to the effect of detoxification. Subjects received few rehabilitative services during their 12-day inpatient hospitalization, and were not permitted visitors or off-ward privileges. At the preadmission assessment, they reported elevated levels of dysphoria and personality disorder traits, as well as opioid withdrawal symptoms. The results indicate that clinically significant declines in symptoms of dysphoria, opioid withdrawal symptoms, and personality disorder traits occur during the course of a rapid medical detoxification. Dysphoric and opioid withdrawal symptom abatement was most pronounced between the preadmission and admission assessments. These factors should be considered in the clinical diagnosis and treatment, as well as in research about psychiatric comorbidity of these substance abusers.

Organic mood syndrome associated with detoxification from methadone maintenance.

OBJECTIVE: The authors delineate the clinical characteristics of mood state changes that occur in stable opioid-dependent patients undergoing therapeutic detoxification from methadone maintenance treatment. METHOD: Twenty-four patients participated in a blinded protocol for gradual methadone dose reduction that included weekly assessments of affective state using the Profile of Mood States (POMS) as well as weekly assessments of signs and symptoms of opioid withdrawal. Data obtained before methadone dose reduction and during the 2-week period of maximal dysphoric symptoms were compared. Changes in affective and opioid withdrawal measures were compared in patients who differed in their success in completing the detoxification regimen. RESULTS: Sustained increases in POMS scores of greater than 20 points were observed in 12 of the 24 patients during the course of detoxification. The emergence of symptoms of dysphoria was accompanied by insomnia, loss of appetite, and somatic complaints consistent with symptoms of opioid withdrawal but only minimal levels of objective signs of withdrawal. Greater changes from baseline in mood state and opioid withdrawal measures occurred in patients who were unable to complete the detoxification regimen. CONCLUSIONS: The development of an organic mood syndrome is a common occurrence in patients undergoing slow detoxification from methadone maintenance treatment and is associated with a poor outcome.

The dysphoria of heroin addiction.

Levels of dysphoria and opioid dependence were assessed in 54 male patients with heroin addiction applying for drug treatment. During a period of naturalistic heroin use, symptom measures of dysphoria and of spontaneous opioid withdrawal reported by these patients were highly correlated. Upon admission to treatment, levels of dysphoria and opioid withdrawal were assessed before and after a pharmacological challenge with either 0.4 mg naloxone or placebo. Signs and symptoms of opioid withdrawal and symptoms of dysphoria increased in patients following naloxone, but not placebo administration. Naloxone-induced changes in symptoms of dysphoria were correlated with changes in opioid withdrawal as assessed by both subjective and objective measures. These findings suggest that dysphoric mood states in heroin addicts may be, in part, pharmacological sequelae of their drug dependence. Dysphoria due to opioid withdrawal may contribute to the initiation and maintenance of heroin use, and to the high rates of syndromal affective disorders reported in this population.

Clinical characteristics of naloxone-precipitated withdrawal in human opioid-dependent subjects.

Studies were conducted to investigate the clinical characteristics of naloxone-precipitated withdrawal in human opioid-dependent subjects. Each of 20 male patients stabilized on 24 mg of methadone daily received two i.v. pharmacological challenges: one with naloxone (0.05, 0.10, 0.15 and 0.20 mg; five patients each dose), and one with saline placebo. Measures of opioid withdrawal, affective state, cognitive performance and changes in autonomic parameters were assessed after each pharmacological challenge. Naloxone produced dose-dependent increases in opiate withdrawal scale scores and in symptoms of dysphoria as measured by the Profile of Mood States. Differences within subjects between naloxone and placebo infusions in Profile of Mood States scores were highly correlated with differences in opioid withdrawal as assessed by both subjective and objective rating scales. Naloxone also produced substantial increases in pulse, systolic and diastolic blood pressure and respiratory rate, as well as a small decrease in temperature. However, naloxone-induced changes from base-line values in these autonomic parameters correlated only modestly with other measures of opioid withdrawal. No differences between infusions were observed in two measures of cognitive performance (Stroop Color and Word Test, Digit Span Test). The results indicate that dysphoric mood states reflecting a broad range of affective experience must be considered as integral components of the naloxone-precipitated opioid withdrawal syndrome.

Levels of opioid physical dependence in heroin addicts.

The levels of opioid physical dependence in a group of long-term heroin addicts were ascertained by measuring the severity of the opioid withdrawal syndrome before and after pharmacological challenge with either 0.4 mg naloxone or placebo. Prior to challenge, patients manifested some subjective symptoms but few objective signs of opioid withdrawal. Patients who received placebo (n = 18) showed a significant increase in the mean score on one of three rating scales used to assess opioid withdrawal. Patients who received naloxone (n = 58) showed significant increases in mean scores on all three rating scales, but this was due primarily to increases observed in a minority of patients. Sixty-one percent of patients failed to manifest clinically significant changes in subjective symptoms, and 74% of patients failed to manifest clinically significant changes in objective signs of opioid withdrawal following naloxone administration. The results suggest that a substantial subgroup of heroin addicts are able to use opioids regularly while maintaining relatively low levels of physical dependence.

Two new rating scales for opiate withdrawal.

Two new rating scales for measuring the signs and symptoms of opiate withdrawal are presented. The Subjective Opiate Withdrawal Scale (SOWS) contains 16 symptoms whose intensity the patient rates on a scale of 0 (not at all) to 4 (extremely). The Objective Opiate Withdrawal Scale (OOWS) contains 13 physically observable signs, rated present or absent, based on a timed period of observation of the patient by a rater. Opiate abusers admitted to a detoxification ward had significantly higher scores on the SOWS and OOWS before receiving methadone as compared to after receiving methadone for 2 days. Opiate abusers seeking treatment were challenged either with placebo or with 0.4 mg naloxone. Postchallenge SOWS and OOWS scores were significantly higher than prechallenge scores in the naloxone but not the placebo group. We have demonstrated good interrater reliability for the OOWS and good intrasubject reliability over time for both scales in controls and in patients on a methadone maintenance program. These scales are demonstrated to be valid and reliable indicators of the severity of the opiate withdrawal syndrome over a wide range of common signs and symptoms.