The Challenge in Substance Use Disorders Patients: Organic Diseases and Psychiatric Comorbidities

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Background

Over the past few years, many studies focusing on substance use disorders have shown a high level of co-morbidities in these patients, such as psychiatric disorders and organic diseases. Addict patients frequently have complex needs with profound problems in other health-related aspects of their lives, supplementary to their mental health and substance use issues and require several medications. Using psychiatric drugs to treat drug dependence and its comorbidities is very common. Several treatments in these patients may lead to drug interactions, as the pharmacokinetics (modification of the absorption, distribution, metabolism or excretion of the drug) and pharmacodynamics (modification of the effect of the drug without alteration in drug kinetic) are impaired. A large part of drug interactions may be preventable since they can be predicted from the known pharmacological properties of the drugs involved, but also by the change in the drug metabolism induced by the organic disease.

With advances in medicine and increased lifespan of the population, more patients are prescribed therapy for chronic diseases. Among them people with addictive disorders often exhibit arterial hypertension, diabetes mellitus, chronic congestive heart disease, cardiovascular and cerebrovascular pathology, epilepsy, psychiatric disorders, morbid obesity, hepatitis and liver cirrhosis, pancreatitis… which may worsen the course of the substance use disorder.

Depending on specific situation, patients may be required to stop their medications, switch to alternative drugs and continue or add one the prescribed drugs increasing the chances of both adverse drug interactions and misuse leading the physician to prescribe only after careful consideration, with close monitoring for compliance. Information regarding pharmacology and toxicology of these substances in abuse settings is still lacking. These areas include but are not limited to the higher risk of misuse when many drugs are prescribed, especially for opioids, benzodiazepines, and prescription stimulants, e.g., amphetamines, methamphetamines, methylphenidate, some of them being given without approval (off label prescription). Thus, the interest in a holistic approach involving many specialists is required to place the patient in an integrated approach.

Although different approaches have been identified to avoid drug-related problems in people with addictive disorders, there is still insufficient information about their clinical management for physicians involved in substances abuse treatment. This research topic seeks to provide updated studies, reviews, minireviews and case reports concerning care management of these patients on the ground of drugs of abuse as many questions require further clarification. Many articles on drug interactions have been published during recent years, but few give sufficient information about the clinical importance or public health impact of drug interactions in the addiction field. Therefore, it is difficult to assess if and how they alter clinical practice in the real world related to the confounding factors, the non-specificity of symptoms and the lack of systematic identification in routine toxicology screening.

1. Deprescribing strategies for potentially inappropriate medications and management of withdrawal;
2. How can the pharmacokinetic profile of a drug be used as an aid to improve medication adherence in such patients - How should the timeline of dose adjustments be tailored to the responses and needs of the patient?
3. What are the main drugs associations that may be avoided in patients with substance use disorders?
4. How may a collaborative medical discussion between addiction specialists and other physicians help emphasize transverse, global, and integrated approach toward care of patients with substance use disorders to limit drug misuse or adverse drug reaction?
5. Tools or guidelines combining evidence and opinion of experts to address any drug-related problems and/or acts of omission to prescribe drugs when indicated.
6. Should the medication be replaced in case of misuse or acute self-poisoning? What preventive strategies may be done?
7. May anti-epileptic or antipsychotic drugs prescribed off label be able to reduce or eradicate addictive behavior?
8. Should Antidepressant drugs be effective for treating psychopathological symptoms of drug abstinence and meantime to treat depressive symptoms?
9. Are opioid substitution drugs effective for treating depression-like symptoms?
10. What are the main pathophysiologic interactions between “potential” toxicity from a given drug and somatic comorbidity?

Keywords: The Challenge in Substance Use Disorders Patients: Organic Diseases and Psychiatric Comorbidities

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