Effectiveness of antiretroviral therapy in HIV-1-infected active drug users attended in a drug abuse outpatient treatment facility providing a multidisciplinary care strategy.

OBJECTIVE: HIV-1-infected active drug users (ADU) obtain smaller clinical benefits with antiretroviral therapy (HAART) compared to non-ADU subjects with sexually-transmitted HIV-1 infection. Therefore treatment strategies are required to address the specific issues arising in this challenging scenario. We describe the effectiveness of HAART provided in a drug abuse outpatient treatment facility through a comprehensive integrated care that includes medical, drug dependence, and psychosocial support. METHODS: We included all consecutive HIV-1-infected ADU admitted for drug dependency treatment and who started their first HAART. A comparator arm consisted of a control group of sexually transmitted HIV-1-infected subjects attended in a reference hospital under standard care. The strategy did not include directly observed treatment. RESULTS: A total of 71 ADU and 48 matched subjects infected through sexual transmission were included. ADU had lower baseline CD4+ T-cell counts (196 vs 279 cells/µL, P=.001), and more advanced CDC stages (P=.001). The estimated probabilities of patients with virological response ( < 50 copies/mL) at weeks 48 and 96 were 92.9% (95%-CI: 87.1%-99.1%) and 87.3% (95%-CI: 78.7%-95.2% for ADU, and 93.7%(95%-CI: 84.1%-99.8%) and 87.5% (95%-CI: 77.5%-97.3%) for sexually-infected subjects (P= .1325 and .241). Kaplan-Meier estimates of time to loss of virological response did not show differences between groups (log rank test, P=.965). CONCLUSIONS: An integrated multidisciplinary care of HIV-1-infected antiretroviral naïve ADU provided in a drug abuse treatment center obtains high rates of virological suppression, similar to those observed in a comparison group of sexually-transmitted HIV-1-infected subjects. This strategy should be further evaluated in public health programs and assessed in randomized trials.

Edad de inicio en el consumo de sustancias y gravedad clínica de la drogodependencia / Age of onset of substance use and clinical severity

El objetivo de este estudio es confirmar la hipótesis demayor comorbilidad psiquiátrica, somática (HIV, VHC),gravedad psico-social y pero funcionamiento global enpacientes con inicio antes de los 18 años en el consumode sustancias ilegales en una Unidad Hospitalaria deDesintoxicación (UHD). Se estudian de forma prospectivatodos los pacientes ingresados (n=2883) en una UHDdurante un período de 20 años, comparando aquellospacientes con inicio en el consumo de sustancias ilegalesantes de los 18 años (Inicio precoz) con el resto de pacientesen función de variables: socio-demográficas,toxicológicas, comorbilidad psiquiátrica, complicacionesorgánicas (VHC,VIH), gravedad psico-social, funcionalidadglobal y variables de evolución del ingreso. Los pacientesdel grupo IP presentaron más diagnósticos TUS,siendo más frecuentes los trastornos por uso de opiáceos,cannabis e hipnosedantes, y mayor comorbilidad en ejeII, siendo más frecuentes los diagnósticos de TP Antisocialy TP Límite. También presentaban más infección porel VIH y VHC, mayor número de sobredosis referidas,más detenciones e ingresos penitenciarios, mayor tasade desocupación y menor puntuación en el GAF en relaciónal grupo de inicio tardío en el consumo de sustancias

The aim of this study is to confirm the hypothesis of morepsychiatric and somatic (HIV, HCV) comorbidity, morepsycho-social severity and worst global functioning inpatients with early-onset of illicit substance use (before18 years old), in an inpatient detoxification unit. All casesadmitted to a detoxification unit during a 20 yearsstudy period (n=2883) were studied prospectively,comparing those patients with an onset of substance usebefore 18 years old (early-onset) with the rest of thepatients, considering socio-demographic and substanceuse characteristics, psychiatric comorbidity, somaticcomplications (HCV, HIV), psycho-social severity and globalfunctioning and outcome characteristics. Early-onsetsubstance users (EOSU) had more number of substanceuse disorders, more frequently presented opioids,cannabis and sedatives related disorders and presentedmore Axis II comorbidity, concretely antisocial andborderline PD diagnostics. EOSU had also more HIV andHCV infection, more previous overdoses, more arrestsand imprisonments, a lower score in GAF Scale, andwere more frequently unemployed in comparison to lateonsetsubstance users

Efficacy of antidepressants in substance use disorders with and without comorbid depression. A systematic review and meta-analysis.

Antidepressants are commonly used in substance abusers due to the potential effect on some underlying mechanisms involved in drug use disorders and to treat comorbid depression. A systematic review of the literature of the efficacy of antidepressant drugs in subjects with drug abuse disorders, including alcohol, cocaine, nicotine and opioid, with and without comorbid depression was performed. Only randomised, double-blind, controlled trials have been evaluated. A meta-analysis was done with the included studies that used common evaluation procedures in alcohol, cocaine and opioid dependence. Based on the present review some recommendations may be proposed. The prescription of antidepressants for drug abuse seems only clear for nicotine dependence with or without previous comorbid depression (bupropion and nortryptiline). In alcohol dependence without comorbid depression, the use of any antidepressant seems not justified, while in cocaine dependence has to be clarified. The use of antidepressants in alcohol, cocaine or opioid dependence with comorbid depression needs more studies in well-defined samples, adequate doses and duration of treatment to be really conclusive. Interestingly, SSRIs do not seem to offer significant advantages compared with tricyclic drugs in substance abuse disorders. Differences both related to individual characteristics and specific antidepressant drugs need to be clarified in future studies.

Comorbilidad psiquiátrica y trastorno por dependencia de opiáceos: del diagnóstico al tratamiento / Psychiatric comorbidity and opioid dependence disorder: from diagnosis to treatment

En los últimos años, las graves consecuencias sanitarias y sociales de la coexistencia de otros trastornos psiquiátricos en pacientes dependientes de opiáceos, han incrementado el interés por mejorar el diagnóstico y el tratamiento de estos trastornos. La identificación fiable y válida de otro trastorno psiquiátrico concomitante en los sujetos con drogodependencias ha mejorado sustancialmente con la utilización de los criterios DSM-IV y la utilización de la entrevista diagnóstica “Psychiatric Research Interview for Substance and Mental Disorders”, especialmente diseñada para ello. Tomando como “patrón oro” los diagnósticos realizados con el método LEAD, mediante la entrevista PRISM-IV se obtuvieron diagnósticos válidos de depresión mayor, psicosis inducida, trastornos de ansiedad y trastornos de personalidad antisocial y límite. Así mismo, los diagnósticos obtenidos mediante la PRISM-IV mostraron mejores índices kappa que con la entrevista SCID-IV. La revisión de la literatura muestra que entre los sujetos dependientes de opiáceos que acuden a tratamiento se ha detectado una elevada prevalencia de comorbilidad psiquiátrica (47%-93%), siendo los trastornos depresivos y de ansiedad así como los trastornos de personalidad antisocial y límite los diagnósticos más frecuentes. Si bien se reconoce la necesidad de realizar tratamiento adecuado de los trastornos comórbidos, todavía no hay suficientes estudios controlados que aporten datos concluyentes sobre las pautas terapéuticas más adecuadas. En el caso de la depresión comórbida, la revisión sistemática de los ensayos clínicos controlados disponibles, avala la necesidad de nuevos estudios para clarificar las pautas de tratamiento (AU)

Diagnosing and treating psychiatric comorbidity in substance abusers has become increasingly important in the last 10 years because of important consequences from a health and social point of view. The identification of reliable and valid diagnosis of psychiatric co morbidity in substance abusers has being improved using the “Psychiatric Research Interview for Substance and Mental Disorders” for DSM-IV criteria. This instrument is a structured interview designed “ad hoc” to diagnoses nonsubstance use disorders in substance abuser population. Compared to the Longitudinal, Expert, All Data (LEAD) procedure, as a “gold standard”, the Spanish version of PRISM-IV seemed to be a valid instrument for diagnosing major depression, induced psychosis, anxiety disorders, antisocial and borderline personality disorders. Also the Spanish PRISM-IV resulted in better kappa statistics than the Spanish version of SCID-IV for diagnosing major depression, and borderline personality disorders in substance abusers. Many clinical studies have revealed a high degree of co-occurrence of opioid dependence and other psychiatric disorders, ranging from 44% to 93%. Major depression, anxiety disorders, antisocial and borderline personality disorders are the most prevalent non-substance use disorders in opioid dependent subjects. Most studies are needed to determinate the evidence based treatments for comorbid psychiatric disorders in opioid dependence. In the case of comorbid major depression in opioid abusers, after a systematic review of the randomized and controlled clinical trials available, new studies to clarify the evidence based treatments are required (AU)