[Addiction psychiatry in specialized care--towards more precise differential diagnosis]. / Erikoissairaanhoidon päihdepsykiatria etenee kohti tarkempaa erotusdiagnostiikkaa.

A mental disorder and a substance abuse problem are often present simultaneously. Possible underlying substance abuse is surveyed in examining psychic symptoms. Screening of the substance abuse problem facilitates revealing the presence of previously unrecognized substance abuse problems. Screening of alcohol abuse with the AUDIT questionnaire is necessary for all patients in psychiatric specialized care. The DAST-20 questionnaire is utilized in the screening of drug abuse. The DSM-IV diagnosis system and the PRISM interview define more closely the differential diagnosis associated with dual diagnoses. Treatment of a substance abuse problem related to severe mental disorders should be conducted in an integrated manner by the same treatment unit.

Participation in opioid substitution treatment reduces the rate of criminal convictions: evidence from a community study.

OBJECTIVE: Positive outcomes associated with opioid substitution treatment include reduced illicit opioid use and lower risk of HIV and other blood-borne infections. The effect on the reduction of criminal activity remains unclear. Our aim was to investigate the impact of treatment on criminal activity using conviction register data. METHOD: This observational retrospective study included all new patients (N=169) enrolled in an opioid substitution treatment program in the Helsinki University Central Hospital Clinic for Addiction Psychiatry between 2000 and 2005. Psychiatric and psychosocial services were provided as part of the program. Patient treatments were followed up for 18 months. Data on criminal convictions were collected for approximately 3 years before and after the start of treatment. RESULTS: Mean rates of convictions decreased significantly during treatment. The effects were similar for total convictions, drug convictions, and property crime convictions. Although the numbers of violence and drunk driving convictions were too small to be analysed separately, on a bivariate level there was no indication of reduction in these crime types. Patients with amphetamine co-dependence fared best. Sex, age, other co-dependences or psychiatric diagnoses, negative urine analyses during the treatment, and dropping out from treatment had little impact on the outcomes. CONCLUSIONS: Opioid substitution treatment seems to reduce criminal activity effectively. However, more information is needed to determine how treatment influences different types of criminality and which types of patients benefit most.

Substance-induced psychoses converting into schizophrenia: a register-based study of 18,478 Finnish inpatient cases.

BACKGROUND: Despite the clinical importance of substance-induced psychosis (SIP), few studies have examined the course of this condition after its acute manifestation. OBJECTIVE: To investigate the rate of SIP conversion to a schizophrenia spectrum disorder and the length of follow-up needed to catch the majority of these patients whose diagnoses change. In addition to the conversion rate and pattern, we wanted to look for possible related factors. METHOD: Using the nationwide Finnish Hospital Discharge Register, we followed all patients (N = 18,478) since their first inpatient hospital admission with a diagnosis of SIP (codes 2921 and 2928 in DSM-III-R and codes F10-F19 in ICD-10 with a third digit of 4, 5, or 7) between January 1987 and December 2003 in Finland. Patients (mean age = 43.7 years, standard deviation = 13.5 years) were followed until first occurrence of schizophrenia spectrum disorder, death, or the end of December 2003, whichever took place first. Conversions of discharge diagnoses into schizophrenia spectrum disorders (codes 2951-2959 and 2971 in DSM-III-R and codes F20, F22, and F23 in ICD-10) were recorded at follow-up. RESULTS: Eight-year cumulative risk to receive a schizophrenia spectrum diagnosis was 46% (95% CI, 35%-57%) for persons with a diagnosis of cannabis-induced psychosis and 30% (95% CI, 14%-46%) for those with an amphetamine-induced psychosis. Although alcohol-induced psychosis was the most common type of SIP, 8-year cumulative risk for subsequent schizophrenia spectrum diagnosis was only 5.0% (95% CI, 4.6%-5.5%). No differences were detected with regard to gender, except for amphetamine-induced psychosis, which converted into a schizophrenia spectrum disorder significantly more often in men (P = .04). The majority of conversions to a schizophrenia spectrum diagnosis occurred during the first 3 years following the index treatment period, especially for cannabis-induced psychosis. CONCLUSION: Substance-induced psychotic disorders predict schizophrenia spectrum disorders to a greater extent than previously thought. The intensity of clinical attention focused on substance-induced psychotic disorders should be increased.

Extended-release methylphenidate for treatment of amphetamine/methamphetamine dependence: a randomized, double-blind, placebo-controlled trial.

AIMS: To assess the efficacy of methylphenidate as a substitution therapy for amphetamine/methamphetamine dependence in Finland and New Zealand. DESIGN: Parallel-group, double-blind, randomized placebo-controlled trial. SETTING: Out-patient care. PARTICIPANTS: Amphetamine-/methamphetamine-dependent, aged 16-65 years. MEASUREMENTS: The primary outcome measure was presence/absence of amphetamine/methamphetamine in urine samples collected twice weekly. Secondary measures included treatment adherence, alterations in craving scores and self-reported use. Primary analysis was by intention-to-treat (ITT). The study drug, methylphenidate (as Concerta(®) ), was up-titrated over 2 weeks to a maximum dose of 54 mg daily and continued for a further 20 weeks. Doses were given under daily supervision at the clinics. FINDINGS: Seventy-nine participants were randomized (40 methylphenidate; 39 placebo); 76 received allocated treatment and 27 completed the trial. ITT analysis (n = 78) showed no statistically significant difference in the percentage of positive urines between the methylphenidate and placebo arms (odds ratio: 0.95, 95% confidence interval: 0.83-1.08). However, there was a significant difference (P < 0.05) between the active and placebo arms in retention, the placebo arm displaying a significantly lower retention from 6 weeks that persisted until the end of the trial. CONCLUSIONS: The trial failed to replicate earlier findings suggesting that methylphenidate was superior to placebo. The low retention rate confounded the ability to draw firm conclusions about efficacy. The higher retention rate was observed in the methylphenidate arm. Any replication of this work would need to consider alternatives to the rigid clinic attendance criteria, and consider an increased dose.

A retrospective evaluation of patients switched from buprenorphine (Subutex) to the buprenorphine/naloxone combination (Suboxone).

BACKGROUND: In Finland, buprenorphine (Subutex) is the most abused opioid. In order to curb this problem, many treatment centres transferred ("forced transfer") their buprenorphine patients to the buprenorphine plus naloxone (Suboxone) combination product in late 2003. METHODS: Data from a retrospective study involving five different treatment centers, examining the effects of switching patients to Suboxone, were gathered from 64 opioid-dependent patients who had undergone the medication transfer. RESULTS: Most patients (90.6%) switched to Suboxone at the same dose of buprenorphine that they had been receiving as Subutex (average 22 mg). The majority of these patients (71.9%) were maintained at the same dose of Suboxone throughout the 4-week study period. During the first 4 weeks, 50% of the patients reported adverse events and at the four month time point, 26.6% reported adverse events. However, due to adverse events one patient only discontinued treatment with Suboxone during the 4-week study period, and five during the four month follow-up period. Of the 26 patients in the follow-up period, Suboxone was misused intravenously once each by 4 patients and twice by 1 patient. These 5 patients all reported that injecting Suboxone was like injecting "nothing" with any euphoria, or that it was a bad experience. CONCLUSION: We conclude that when patients are transferred from high doses (> 22 mg) of buprenorphine to the combination product, dose adjustments may be necessary especially in the later phase of the treatment. We recommend that a transfer from Subutex to Suboxone should be carefully discussed and planned in advance with the patients and after the transfer adverse events should be regularly monitored. With regard of buprenorphine IV abuse, the combination product seems to have a less abuse potential than buprenorphine alone.

A comparison of aripiprazole, methylphenidate, and placebo for amphetamine dependence.

OBJECTIVE: Problems related to illegal amphetamine use have become a major public health issue in many developed countries. To date, evidence on the effectiveness of psychosocial treatments has remained modest, and no pharmacotherapy has proven effective for amphetamine dependence. METHOD: Individuals meeting DSM-IV criteria for intravenous amphetamine dependence (N=53) were randomly assigned to receive aripiprazole (15 mg/day), slow-release methylphenidate (54 mg/day), or placebo for 20 weeks. The study was terminated prematurely due to unexpected results of interim analysis. An intention-to-treat analysis was used. The primary outcome measure was the proportion of amphetamine-positive urine samples. RESULTS: Patients allocated to aripiprazole had significantly more amphetamine-positive urine samples than patients in the placebo group (odds ratio=3.77, 95% CI=1.55-9.18), whereas patients who received methylphenidate had significantly fewer amphetamine-positive urine samples than patients who had received placebo (odds ratio=0.46, 95% CI=0.26-0.81). CONCLUSIONS: Methylphenidate is an effective treatment for reducing intravenous drug use in patients with severe amphetamine dependence.

Predictors of benzodiazepine discontinuation in subjects manifesting complicated dependence.

We described characteristics of subjects with benzodiazepine dependence that was typically complicated by harmful and hazardous alcohol use or high benzodiazepine doses, and assessed predictors of successful discontinuation of benzodiazepines for this group. Seventy-six patients who participated in a randomized clinical trial of two different gradual withdrawal treatment approaches were assessed. The trial was conducted between February 1995 and July 1999. The mean age +/- SD of subjects was 40.0 +/- 9.6 years, 55% were male, 38% were married or cohabiting, and 70% had received more than nine years of education. The median benzodiazepine dose was 35 mg/day (range 2.5-180) in diazepam equivalents. The median duration of benzodiazepine use was 84 (range 8-360) months. Subjects with lower benzodiazepine doses and no previous withdrawal attempts were more successful at benzodiazepine discontinuation. Cluster B personality/borderline personality disorder was associated with an inability to stop benzodiazepine use and with "dropping out" of treatment. Alcohol use-related disorders or other psychiatric diagnoses were not associated with outcome. Further studies on predictors of successful benzodiazepine discontinuation in different populations are required. Patients manifesting cluster B personality/borderline personality disorder and benzodiazepine dependence may need concomitant treatment for their personality disorders to benefit from benzodiazepine discontinuation treatment.

Symptom severity and quality of life after benzodiazepine withdrawal treatment in participants with complicated dependence.

The aims of the present study were to assess changes in psychopathology and quality of life after withdrawal treatment in participants with benzodiazepine dependence that was in most cases complicated by harmful and hazardous alcohol use or high benzodiazepine doses. Seventy-six participants with benzodiazepine dependence (DSM-III-R) who participated in a randomized clinical trial of two different gradual withdrawal treatment approaches were initially assessed by Symptom Checklist-90 (SCL-90), visual analogue scales (VASs), and the Health-Related Quality of Life battery (HRQOL). The assessments were repeated after treatment ended and again after a follow-up averaging 11 months. During the study, all measurements for the participants with clinically significant (over 50%) benzodiazepine-dose decreases improved more than those for the participants with smaller decreases, and differences in the HRQOL energy/vitality, home management, and life satisfaction scores were significant. Our data indicate that in participants with complicated benzodiazepine dependence, clinically significant dose decreases are associated with improvements in their self-rated quality of life.

Long-term outcome after benzodiazepine withdrawal treatment in subjects with complicated dependence.

BACKGROUND: The study aimed to monitor subjects with benzodiazepine (BZ) dependence after withdrawal treatment in order to evaluate long-term outcome and predictors of remaining BZ-free. Subjects with high-dose dependence or co-occurring alcohol problems were not excluded. METHOD: Seventy-six participants in an earlier, randomized, controlled trial of outpatient BZ discontinuation were interviewed, and documents from their treatment settings obtained, along with urine and serum samples for BZ use. Long-term outcomes for a cognitive-behavioral treatment group and a treatment-as-usual group were measured. RESULTS: BZ discontinuation treatment outcomes were maintained in both treatment groups. No between-group differences were found. At the end of the study 25% of the subjects were BZ-free, and the median dose decrease from pre-treatment levels was 16.1 mg in diazepam equivalents. Subjects with pre-treatment doses exceeding 40 mg were able to maintain their doses at therapeutic levels through the follow-up. Pre-treatment low BZ dose, no previous withdrawal attempts, and high life satisfaction predicted success in staying BZ-free. CONCLUSIONS: In subjects with complicated BZ dependence, the benefits of BZ discontinuation treatment may persist, but more studies are needed.

Treatment of out-patients with complicated benzodiazepine dependence: comparison of two approaches.

AIMS: To evaluate whether gradual benzodiazepine taper combined with cognitive-behavioural treatment is more effective than standard treatment for patients with dependence in out-patient clinics. DESIGN: A randomized, controlled clinical trial, using standard questionnaires and serum and urine tests. SETTINGS: Four public-sector out-patient clinics for alcohol and drug abusers in Helsinki. PARTICIPANTS: Seventy-six patients with benzodiazepine dependence (DSM-III-R). Patients taking high doses of the drug or with alcohol use disorders were included to obtain a subject group representative of usual clinical practice. INTERVENTION: Subjects received gradual benzodiazepine taper combined with cognitive-behavioural therapy (experimental group) or standard withdrawal treatment not scheduled by the researchers (control group). MEASUREMENTS: The outcome was measured in terms of attaining a state of abstinence or by a decrease in the dosage during the study period of up to 12 months' duration. FINDINGS: No statistically significant differences in the outcomes were observed between the groups. A total of 13% of the experimental group and 27% of the control group were able to discontinue drug use. In addition 67% of the experimental group and 57% of the control group were able to decrease the dose. CONCLUSIONS: The search continues for improved methods of helping patients with complicated benzodiazepine dependence.