Use of Street Methadone in Italian Heroin Addicts Presenting for Opioid Agonist Treatment

ABSTRACT

It is commonly assumed that people who are addicted to certain substances would abuse any substance. This position has never been supported by validly collected and analyzed research data. In this study, the authors examine the use of street methadone by heroin addicts seeking their first agonist opioid treatment in a clinical setting. Fifty-four heroin addicts who resorted to street methadone use were compared by socio-demographic, current clinical, and disease-related variables to 251 peers who do not use street methadone. Heroin addicts who resort to street methadone use are more likely to be females and to have a higher degree of education, are less likely to engage in polyabuse (use of more than three substances), are less severely ill, have been addicted for a shorter period of time, and have been seeking treatment sooner in the course of their disease. Also, they suffer from a wider range of psychopathological distress symptoms. In Italy, resorting to street methadone does not seem to be a surrogate form of heroin addiction, but rather represents means of harm reduction, with treatment seeking occurring shortly after its initiation. This should be accounted for when deciding on take-home policies and issues of potential methadone diversion.     

The Financial Impact on Reimbursement of Moderately Hypofractionated Postoperative Radiation Therapy for Breast Cancer: An International Consortium Report

AimsModerately hypofractionated breast irradiation has been evaluated in several prospective studies, resulting in wide acceptance of shorter treatment protocols for postoperative breast irradiation. Reimbursement for radiation therapy varies between private and public systems and between countries, impacting variably financial considerations in the use of hypofractionation. The aim of this study was to evaluate the financial impact of moderately hypofractionated breast irradiation by reimbursement system in different countries.Materials and methodsThe study was designed by an international group of radiation oncologists. A web-questionnaire was distributed to representatives from each country. The participants were asked to involve the financial consultant at their institution.ResultsData from 13 countries from all populated continents were collected (Europe: Denmark, France, Italy, the Netherlands, Spain, UK; North America: Canada, USA; South America: Brazil; Africa: South Africa; Oceania: Australia; Asia: Israel, Taiwan). Clinicians and/or departments in most of the countries surveyed (77%) receive remuneration based on the number of fractions delivered to the patient. The financial loss per patient estimated resulting from applying moderately hypofractionated breast irradiation instead of conventional fractionation ranged from 5–10% to 30–40%, depending on the healthcare provider.ConclusionAlthough a generalised adoption of moderately hypofractionated breast irradiation would allow for a considerable reduction in social and economic burden, the financial loss for the healthcare providers induced by fee-for-service remuneration may be a factor in the slow uptake of these regimens. Therefore, fee-for-service reimbursement may not be preferable for radiation oncology. We propose that an alternative system of remuneration, such as bundled payments based on stage and diagnosis, may provide more value for all stakeholders.     

Diagnostic and symptomatological features in chronic psychotic patients according to cannabis use status

The prevalence and the clinical meaning of cannabis use in patients with chronic psychosis has not been systematically explored. The authors have compared the diagnostic and symptomatological characteristics of 111 male patients affected by chronic psychosis with and without past or current use of cannabis. Sixty-six patients were still using or had used cannabis; in all cases the use preceded the onset of psychotic symptoms. Forty-three patients were cannabis-positive on urinary screening at the moment of hospitalization and 23 were currently cannabis-free but reported the use of cannabis in the past. Forty-five patients were negative on urinary screening and reported no past history of cannabis use. In evaluating the psychopathological features, the Brief Psychiatric Rating Scale (BPRS) and the Overt Aggression Rating Scale (AORS) were used. The three groups showed similar demographic data, except for age, which was lower in current cannabis users than in nonusers; no differences were found between current and past users. As regards diagnostic features, "mood cluster" was significantly better represented in cannabis users and "schizophrenic cluster" in nonusers; bipolar spectrum disorders were more frequently reported than unipolar ones. When past and current users were grouped together, only blunted affect score was significantly higher in nonusers than in users, while clastic violence showed higher scores in users. These data indicate that chronic, psychosis, whether associated with past or with current use of cannabis, is frequently associated with bipolar spectrum disorders and tends to display less blunted affect and more clastic behavior.     

Alcohol abuse in social phobic patients: is there a bipolar connection?

BACKGROUND: Epidemiological and clinical studies have reported the frequent co-occurrence of social phobia (SP) and alcohol use disorders. Patients with SP often use alcohol to cope with the social situations they fear, and to lessen anticipatory anxiety, behavioral inhibition, and phobic avoidance. We investigated whether the presence of lifetime comorbidity with alcohol abuse was associated with significant differences as regards demographic and clinical features, family history and pattern of comorbidity in a large clinical sample of SP outpatients. METHOD: The sample comprised 153 outpatients who met DSM-III-R diagnostic criteria for SP. Demographic, family history and course characteristics were investigated by a semi-structured interview. Social phobic symptoms and the severity of the illness have been assessed by the Liebowitz Social Anxiety Scale (LSAS) and the Liebowitz Social Phobic Disorders Rating Scale, Severity (LSPDRS). Patients completed the Hopkins Symptom Checklist (HSCL 90). RESULTS: Thirty-four patients (22.2%) had a past or current history of alcohol abuse for at least 1 year. There were no significant differences between these patients and those without a history of alcohol abuse, as regards demographic features and lifetime comorbidity with major depression and other anxiety disorders. Bipolar disorder type II was found almost exclusively among patients with alcohol abuse, as well as family history for bipolar disorders. LIMITATIONS: Retrospective study. CONCLUSIONS: Our data indicate a strong relationship between bipolar II disorder and alcohol abuse comorbidity in patients with SP. The socializing and disinhibiting effect that many social phobics report might be mediated by mood elation induced by alcohol. The presence of bipolar diathesis in patients presenting with social anxiety might explain their increased susceptibility to alcohol, as they might undertake alcohol abuse as an attempt to overcome social difficulties.     

Is mood-incongruent manic psychosis a distinct subtype?

Background Despite several research reports on incongruent psychotic features in mania, whether such features define a distinct disorder is unsettled. Method One hundred and fifty-five inpatients with mania according to DSM-III-R were systematically evaluated in order to collect demographic and clinical information. The symptomatological evaluation was conducted by means of the Comprehensive Psychopathological Rating Scale (CPRS) and the Scale for the Assessment of Positive Symptoms (SAPS). The presence/absence of incongruent psychotic symptoms at the index episode defined two subgroups of patients, whose familial, symptomatological, clinical and course characteristics were compared. Results Eighty-six (55.5%) patients presented mood-incongruent psychotic features (MIP+). When this group was compared with the remainder of manic patients without such features (MIP−), we found substantial similarities in most demographic, familial and clinical characteristics. Despite these fundamental similarities, 4% of MIP+ vs 0% of MIP− had family history for schizophrenia (p < 0.05). We also observed a longer duration of the current episode, a higher percentage of chronic course, more suicide attempts and hospitalisations in MIP+. Moreover, other than psychotic symptoms, MIP+ showed more frequently depressive features and hostility. They also reported higher scores in social disability, especially in family and social settings. Conclusion Although our findings suggest that incongruent psychotic features in the main do not distinguish two separate entities – and can be considered as hallmarks of overall severity of mania – in a small minority of cases such features appear linked to familial schizophrenia. The numerous overlapping clinical characteristics in MIP+ and MIP− raise questions about the general nosographic utility of this categorisation. Received: 31 May 2000 / Accepted: 18 October 2000     

A benchmark study on 883 nasopharyngeal cancer patients treated in two Italian Centres from 1977 to 2000. Part II: evolving technical choices and toxicity patterns

Purpose

The authors sought to define toxicity patterns according to the different accrual periods and clinical-therapeutic features in a large series of nasopharyngeal cancer (NPC) patients treated in two Italian centres over more than two decades.

Materials and methods

A total of 883 patients consecutively treated with radiotherapy from 1977 to 2000 at the Florence (FLO) and Brescia (IRA) radiation oncology centres were studied. The crude incidence of late treatment toxicity in the different subgroups of patients was calculated and compared.

Results

Higher total and fractional doses and the ??older?? treatment techniques were related with an increased incidence of the main late effects of treatment. More recently treated patients experienced less treatment-related complications.

Conclusions

Results of this benchmark study may have implications for understanding and developing new radiotherapy techniques, such as three-dimensional conformal radiotherapy (3D-CRT) and, in particular, intensity-modulated radiotherapy (IMRT) for NPC patients.     

Episodic course in obsessive-compulsive disorder

The course of obsessive–compulsive disorder (OCD) is variable, ranging from episodic to chronic. We hypothesised that the former course is more likely to be related to bipolar mood disorders. With the use of a specially constructed OCD questionnaire, we studied 135 patients fulfilling DSM-III-R criteria for OCD with an illness duration of at least 10 years and divided by course: 27.4% were episodic and 72.6% chronic. We compared clinical and familial characteristics and comorbidity. Univariate analyses showed that episodic OCD had a significantly lower rate of checking rituals and a significantly higher rate of a positive family history for mood disorder. Multivariate stepwise discriminant analysis revealed a positive and significant relationship between episodic course, family history for mood disorders, lifetime comorbidity for panic and bipolar-II disorders, late age at onset and negative correlation with generalized anxiety disorder. These data suggest that the episodic course of OCD has important clinical correlates which are related to cyclic mood disorders. This correlation has implications for treatment and research strategies on the aetiology within a subpopulation of OCD. Received: 30 October 1997 / Accepted: 13 July 1998     

Controlled use of heroin in patients on methadone maintenance treatment

The efficacy of methadone maintenance treatment was evaluated on 93 patients after 10 years of therapy. On the basis of therapeutic compliance, patients were divided into three groups: (a) 40 Total-Agreement subjects on weekly take-home methadone; (b) 28 Partial-Agreement subjects, who regularly attended the clinic daily but presented episodic positive urinalysis; (c) 25 No- Agreement patients, who were absent from the clinic more than twice a monthand had a high rate of urinalysis positive for morphine. Statistical analysis, based on social adjustment improvement and criminality rate decrease, divided the 93 patients into 2 distinct categories. The first category, characterized by high social adjustment and low criminality score, included the Total- and Partial- agreement groups. The second, characterized by significantly lower social adjustment and higher criminality score, included all No-Agreement patients. This suggests that methadone treatment was able to dissociate heroin use from low social functioning. It was concluded that, in a condition of adequate compliance the episodic use of heroin is of no harm to patients on methadone maintenance therapy, that is, methadone maintenance treatment permits a controlled use of heroin.     

Organ-confined prostate cancer: treatment with high doses of radioterapy (intensity modulated radiotherapy)

PurposeTo report toxicity and local control in patients with localized prostate cancer, treated with high dose radiotherapy.Materials and methodsThe records of 100 consecutive patients with clinically localized prostate cancer treated between june 2003 and may 2006 were reviewed. They received 80 Gy to the target volume with a biphasic technique (3DCRT + IMRT). The median pretreatment PSA was 9. The median follow-up time was 12 months.ResultsEighteen (18%) developed acute Grade 2 rectal toxicity, and no patient experienced acute grade 3 or higher rectal symptoms. Forty-four (44%) developed acute Grade 2 urinary symptoms while 34% of the patients experienced no GU symptoms (Grade 0) during treatment. Three patients (3%) developed late rectal toxicity grade 2 and eight patients (8%) experienced late urinary toxicity grade 2; any patients experienced more severe symptoms.We recorded biochemical relapse in two patients, both had poor prognostic factors at initial diagnosis of prostate cancer.ConclusionsThe data demonstrate the feasibility and safety of high dose radiotherapy for patients with localized prostate cancer and provide a proof that this method allow safe dose escalation with low severe toxicities to the normal tissues.     

Dual Diagnosis and Chronology of Illness in Treatment-Seeking Italian Patients Dependent on Heroin

ABSTRACT

Although there are studies describing the prevalence of patients with drug addiction and dual diagnosis, there is a paucity of data regarding the progression from psychiatric disorders to drug addiction or vice versa. A total of 1,090 patients dependent on heroin were interviewed to examine the presence of dual diagnosis and the progression from psychiatric disorders to drug dependence or vice versa. A total of 574 patients met the criteria for a dual diagnosis. A total of 362 patients progressed from substance abuse disorders to psychiatric disorders (SUD-PR) and 144 patients progressed from psychiatric disorders to drug addiction (PSY-PR). SUD-PR patients are more frequently affected by mood disorders. PSY-PR patients were more frequently diagnosed as psychotic or affected by anxiety disorders. The authors’ findings suggest that the self-medication theory of dual diagnosis was relevant only for those with existing diagnoses of schizophrenia or anxiety disorders. When treating patients with a dual diagnosis, clinicians should ensure that the same attention is given to the treatment of drug dependence as it is to the treatment of comorbid psychiatric conditions.