Background: Heroin addiction is a chronic relapsing disorder associated with substantial psychological, social, and economic consequences. Although pharmacological treatments, particularly methadone maintenance therapy, remain essential for the management of physiological dependence, psychological counselling is required to address the cognitive, emotional, and social dimensions of addiction. This narrative review examines the evidence supporting counselling interventions for heroin addiction and evaluates their applicability within the Sri Lankan treatment context. Methods: A narrative review of international literature was conducted, focusing on established counselling approaches including cognitive-behavioural therapy (CBT), motivational interviewing (MI), contingency management (CM), and supportive psychotherapy, with particular attention to their integration with pharmacological treatment and relevance to local service structures. Results: International evidence indicates that counselling interventions, when combined with opioid agonist treatment, improve treatment retention, reduce heroin use, and enhance psychosocial functioning. CBT supports identification and management of maladaptive cognitions and triggers, MI improves motivation and engagement, CM reinforces abstinence through structured incentives, and supportive psychotherapy strengthens therapeutic alliance and social functioning. In Sri Lanka, increasing heroin use contrasts with limited and unevenly distributed treatment resources, insufficient availability of trained counsellors, and limited systematic evaluation, although preliminary evidence suggests improved adherence when counselling is integrated with pharmacotherapy. Conclusions: Integrated and culturally sensitive counselling approaches, incorporating family involvement, community support, and socioeconomic considerations, are required to optimise treatment outcomes. Expansion of training, improved access to services, and the generation of local evidence represent essential priorities for strengthening counselling interventions in heroin addiction.
Background: Alcohol Use Disorder (AUD) remains a highly prevalent chronic condition for which no pharmacological treatment has achieved widespread acceptance in routine clinical practice. Despite formal approval of several medications, long-term clinical outcomes are often disappointing, leaving many patients without effective medical management. This situation has fuelled an ongoing debate between abstinence-oriented strategies, particularly Disulfiram, and agonist approaches derived from clinical experience with opioids. Methods: This article presents a narrative analysis that integrates long-term clinical experience, observational data, and the existing literature to examine the relative merits and limitations of Disulfiram-based abstinence strategies versus opioid agonist approaches in AUD. Particular attention is paid to mechanisms of action, adherence, patient experience, safety considerations, and long-term clinical trajectories. Results: Clinical experience suggests that Disulfiram can be effective in selected patients, particularly under supervised conditions, but its punitive mechanism and adherence issues limit long-term applicability. In contrast, opioid-based agonist strategies, mainly using dihydrocodeine or buprenorphine, have shown clinically meaningful reductions in alcohol craving and consumption in a subset of treatment-resistant patients, with approximately one quarter achieving long-term symptom remission and many others substantial stabilisation. Conclusions: AUD requires flexible, individualised treatment pathways. For patients unresponsive to abstinence-based approaches or other pharmacological interventions, carefully structured opioid agonist treatment may represent a clinically meaningful harm-reduction strategy, complementing rather than replacing established treatments
Background: Severe substance use disorders (SUDs) may generate complex psychopathology extending beyond craving, withdrawal, and relapse. In advanced addiction, neurobiological dysregulation can give rise to affective and psychotic-like symptoms that closely resemble bipolar disorder, complicating the distinction between primary mood pathology and substance-induced or addiction-driven bipolar-like presentations. This diagnostic uncertainty lies at the core of dual disorder. Methods: A clinical case is presented involving a 38-year-old man with severe opioid and alcohol use disorders, chronic emotional dysregulation, and recurrent manic-, hypomanic-, and mixed-like episodes temporally associated with fluctuations in substance use. His course was characterised by early-onset intravenous heroin use, polysubstance involvement, repeated hospitalisations, homelessness, and chronic hepatitis C with cirrhosis and hepatic encephalopathy. Despite extensive psychopharmacological interventions, affective instability and behavioural dyscontrol persisted while opioid agonist therapy remained suboptimally dosed. Results: The psychiatric symptom burden appeared partly attributable to the phenotypic expression of advanced addiction rather than to a distinct comorbid bipolar disorder. A turning point occurred after adopting an integrated dual-disorder framework with hierarchical prioritisation of SUD treatment. Gradual optimisation of methadone to 120 mg/day, within coordinated psychiatric-addiction care, was followed by marked reductions in heroin use, decreased alcohol consumption, improved affective stability, and cessation of emergency department visits and psychiatric admissions. Conclusions: This case underscores the importance of hierarchical SUD stabilisation and integrated, longitudinal care in the assessment and management of complex dual disorder, particularly when addiction mimics bipolarity.
Background: Bipolar disorder (BD) and eating disorders (EDs) often coexist, creating complex symptoms with emotional dysregulation, reward hypersensitivity, and impaired control. Up to one-third of BD individuals show binge eating, but evidence for pharmacological treatment of BD-bulimia nervosa (BN) is limited. The naltrexone/bupropion combo, approved for obesity, targets hypothalamic pathways and reward circuits, potentially helping with binge eating. Methods: We reviewed seven adult women with BD and BN treated with naltrexone/bupropion in routine care. All were euthymic, on stable lithium, BMI < 25 at start. Data at baseline, 1, and 3 months included binge episodes, compensatory behaviors, food craving (FCQ-S), affective lability (ALS), emotion dysregulation (DERS), and trait craving (FCQ-T). Changes were tested with Friedman tests, effect sizes with Kendall's W and Cohen's d. Results: Binge episodes decreased significantly (p = 0.029; W = 0.508), shifting to lower categories by 3 months. FCQ-S scores dropped notably (d = 1.82), especially in "intense desire to eat" (p = 0.008; d = 2.05) and "anticipation of relief" (p = 0.027; d = 1.77). Compensatory behaviors trended downward but were not significant. Craving was linked to emotional dysregulation, especially DERS Clarity, Non-Acceptance, Impulsivity, and between affective lability (ALS Anger, Depression/Elation) and trait craving. Conclusions: Early findings indicate naltrexone/bupropion may lessen binge-eating severity and cravings in women with BD-BN, possibly via modulation of satiety, reward, and prefrontal control. These results support an integrated neurobiological approach and need confirmation in larger, longer-term studies.
Background: Alcohol Use Disorder (AUD) remains one of the few chronic illnesses for which no widely accepted pharmacological treatment exists. Most patients receive no long-term medication and are referred only to psychological counselling, which is often insufficient, while therapeutic success rates remain unsatisfactory. Methods: To address this unmet need, INTAUD was founded at the EUROPAD 2024 conference as an international network of addiction specialists. It aims to collect and share clinical experiences in treating AUD, including innovative pharmacological strategies such as the use of opioids, combinations of acamprosate and baclofen, or naltrexone with aripiprazole, as well as renewed attention to disulfiram. Although these approaches, except for disulfiram, lack large-scale randomised clinical trials, they arise from daily practice with treatment-resistant patients. Results: Preliminary case-based evidence suggests that such strategies can reduce alcohol consumption or achieve abstinence in otherwise refractory patients, provided that rigorous standards are respected. For opioid treatment in particular, safety depends on three principles: structured introduction, binding dosage schedules, and continuous dialogue. Within INTAUD, physicians report that these conditions can be assured, minimising risks of unsafe prescribing. Experiences presented at regional meetings (e.g. Coimbra 2025) indicate that knowledge exchange helps identify promising combinations and encourages systematic documentation. Conclusions: The absence of an established pharmacological standard for AUD must be regarded as a therapeutic failure. While awaiting formal clinical trials-which remain difficult due to low commercial interest-networks such as INTAUD can bridge the gap by sharing experiences, promoting cautious innovation, and expanding the range of options available to desperate patients. Increased collaboration and openness to neglected treatments, including disulfiram, may reduce suffering, improve prognosis, and help overcome the longstanding therapeutic stagnation in AUD care.
Background: Psychotic symptoms in substance users are often dismissed as transient effects of intoxication or attributed to comorbid primary psychosis. However, research on Heroin Use Disorder (HUD) suggests the existence of stable psychopathological dimensions, including the sensitivity/psychoticism (S/P) domain, characterised by paranoid ideation, interpersonal mistrust, and mild cognitive-perceptual disturbances. This study examined whether S/P symptoms define a clinically distinct subgroup of heroin-dependent individuals. Methods: We conducted a retrospective comparative analysis of three matched groups: HUD patients with predominant S/P features (HUD-S/P), HUD patients without S/P predominance (HUD), and non-addicted individuals with primary psychotic disorders (PSY-NSUD). Psychopathology was assessed using the SCL-90; data were analysed dimensionally and at the item level. Group comparisons were performed using multinomial logistic regression and linear discriminant analysis, following matching by sex and age. Results: Compulsive checking behaviour strongly predicted membership in the HUD group (OR = 4.66), while older age and feelings of being disliked were associated with PSY-NSUD (OR = 1.08 and 4.79, respectively). The belief of being watched or talked about was more characteristic of HUD-S/P than PSY-NSUD. Discriminant analysis identified two significant functions: the first distinguished PSY-NSUD patients based on paranoid and hostile ideation; the second differentiated HUD-S/P from HUD (compulsivity and control). Conclusions: Psychotic sensitivity in HUD appears to reflect a stable and specific psychopathological dimension, distinct from both transient intoxication effects and primary psychosis. Recognition of this profile may improve diagnostic precision and inform targeted treatment strategies.
Background: Opioid Use Disorder (OUD) represents a chronic condition characterised by significant clinical complexity and is particularly prevalent within custodial settings. Methods: This observational report presents the experience of using weekly long-acting buprenorphine depot at the "S. Donato" prison in Pescara, involving a sample of 13 incarcerated individuals with OUD. Results: The findings indicate high treatment tolerability, complete absence of drug craving, and consistently negative toxicological screenings over a 24-week follow-up period. The treatment was well received by the patients, who reported improvements in psychological well-being, emotional stability, and a perceived sense of greater autonomy, attributed to the reduced frequency of drug administration and minimal disruption to the prison routine. Furthermore, the introduction of the long-acting formulation yielded notable organisational benefits, including a significant reduction in the time required for administration and enhanced safety for healthcare personnel. Conclusions: While further studies with larger cohorts are warranted, the data from this preliminary experience are consistent with international findings on the use of long-acting buprenorphine in correctional environments. These results support the feasibility and sustainability of buprenorphine depot as a viable and effective treatment strategy in Italian prisons.
Background: Substance use disorders (SUDs) are increasingly recognised as heterogeneous conditions, often shaped by underlying temperamental traits. Among these, affective temperaments-especially cyclothymic temperament-may serve as potential endophenotypic markers for vulnerability to substance misuse. Methods: This cross-sectional observational study assessed affective temperaments in a sample of 178 individuals undergoing treatment for substance use, comprising patients diagnosed with alcohol use disorder (AUD, n=77), heroin use disorder (HUD, n=43), and cocaine use disorder (CUD, n=58). All participants completed the short version of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-Autoquestionnaire version (TEMPS-A[P]) to assess five affective temperaments: depressive, hyperthymic, cyclothymic, irritable, and anxious. Statistical analysis included non-parametric tests and logistic regression models to examine differences across groups and identify predictors of primary substance choice. Results: Cyclothymic temperament scores were significantly elevated across all three groups, with the highest values observed in the HUD and CUD subgroups. Hyperthymic temperament was more frequently associated with CUD, while depressive and anxious traits were more prevalent in AUD. Logistic regression models confirmed cyclothymic temperament as the strongest common predictor across substance categories. Conclusions: These findings suggest that cyclothymic temperament may represent a transdiagnostic vulnerability factor for substance use disorders, with distinctive temperamental profiles influencing the type of substance preferentially used. The study underscores the importance of integrating temperament-based assessments into the clinical evaluation and treatment planning of individuals with SUDs. Further longitudinal research is warranted to clarify the causal role of affective temperaments in the onset and course of addictive behaviours.
Background: Heroin use induces biochemical alterations in the body by affecting oxidative stress, thiol-disulfide homeostasis, and ischemia-modified albumin (IMA) levels, with these parameters potentially serving as biomarkers for the early diagnosis and treatment of heroin use disorder. Methods: This study aims to investigate the changes in thiol-disulfide homeostasis and IMA levels, as well as their interrelationships, between patients with heroin use disorder and a control group. This study was conducted with patients aged 18-65 who were diagnosed with 'heroin use disorder' according to DSM-5 diagnostic criteria and received outpatient follow-up and treatment. A total of 171 people were included in our study, 86 of whom were diagnosed with opioid (heroin) use disorder, and 85 were healthy controls. Results: The study's results demonstrated statistically significant differences between the groups regarding age, marital status, education level, employment status, co-residing persons and stay in prison. Additionally, it was determined that there was a significant difference in depression, anxiety, disulfide, Disulfide/Native thiol, Disulfide/Total thiol, Native thiol/Total thiol and IMA between the case and control groups. Regression analysis indicated that duration of heroin use and maximum duration without substance were associated with total thiol and IMA in patients with HUD. Conclusions: These findings may contribute to the adoption of new perspectives targeting oxidative stress and inflammatory mechanisms in the early diagnosis and treatment of heroin use disorder.
Background: Dissociative symptoms coexist in patients with other trauma-based disorders, such as complex post-traumatic stress disorder, borderline personality disorder and substance use disorders (SUD). Given the emerging data suggesting a relationship between opioid use disorder (OUD) and dissociation, we aimed to determine the prevalence of patients who had elevated Dissociative Experiences Scale (DES) scores among inpatients with OUD, its clinical correlates and cognitive impairments related to dissociation. Methods: A total of 167 inpatients with OUD or poly-substance use disorder that included opioid use as the main substance were included in the study. All patients underwent detoxification with oral buprenorphine/naloxone (2-32 mg/day flexible doses). Patients were followed up during the inpatient detoxification program. All participants were separated into two groups: patients with high dissociative experiences and low dissociative experiences by DES. Two groups were interviewed in terms of addiction, childhood trauma, depression, anxiety, withdrawal and personality traits. The Tower of London and the Go/No-go Test examined response inhibition and planning ability differences. Results: 40.7% of the sample was in the low-DES group, and 59.3% were in the high-DES group. Addiction severity (p=0.004), withdrawal (p< 0.001), depression (p<0.001), anxiety (p<0.001), craving (p = 0.008), all CATI subscales (p<0.05), impulsivity (p<0.001), ASRS (p<0.001) and CTQ scores (p<0.001) were higher in the high-DES group. Go/No-Go Test Commission Error total numbers were higher in the high-DES group (p=0.007). Conclusions: The high rates of comorbid psychiatric symptoms and impulsivity highlight the need for clinicians to conduct detailed examinations of patients. Even if the optimum treatment for OUD patients is employed, it would be challenging to utilise treatment retention without screening, predicting and implementing effective strategies for dissociative symptoms. Interventions that enhance response inhibition with OUD patients can effectively improve the treatment outcomes.
Background: The Deltito-Maremmani Subjective Wellness Scale (DM-SWS) was developed to assess subjective wellbeing among individuals recovering from heroin addiction. Building on prior work that established its reliability and structural validity, the present study investigates the sensitivity to clinical change and temporal responsiveness of the DM-SWS in patients undergoing opioid agonist treatment (OAT). Methods: A total of 63 individuals diagnosed with Heroin Use Disorder (HUD) were recruited from outpatient addiction treatment centres in Tuscany, Italy. Participants completed the DM-SWS in relation to three distinct time points: the current week, the worst week during treatment, and the best week outside of treatment. The scale comprises ten items assessing emotional, social, and existential wellness dimensions. Non-parametric tests (Friedman and Wilcoxon signed-rank) were used to analyse changes in wellness scores across time points, with Bonferroni correction applied. Results: Significant improvements were observed between the current and worst treatment weeks in multiple domains, including the ability to manage daily responsibilities (p < 0.001), tolerate everyday irritations (p < 0.001), and maintain hope for the future (p = 0.001). These changes were also reflected in the global severity index (p = 0.033) and two DM-SWS factors: Resilient Stability (p < 0.001) and Proactive Social Engagement (p = 0.002). However, Existential/Intimate Fulfilment scores declined in the current week compared to the worst (p = 0.020). Comparisons with the best week outside treatment revealed fewer significant differences, with Resilient Stability scoring higher in the current week (p = 0.030), while other domains remained stable or declined modestly. Conclusions: The DM-SWS demonstrates strong sensitivity to change and captures meaningful fluctuations in subjective wellness over time. Its multidimensional structure allows for a nuanced assessment of recovery, supporting its utility as a patient-centred outcome measure in addiction treatment settings. These findings underscore the need to incorporate broader wellness indicators into treatment evaluation and highlight specific domains, such as existential fulfilment, that may require targeted clinical attention.
Background: Opioid medications are extensively employed in clinical practice for managing moderate to severe pain and for treating drug addiction through agonist therapy. However, their long-term use can lead to a range of adverse effects that may diminish patients' quality of life. Among these, constipation is one of the most common manifestations of opioid-induced bowel dysfunction. This condition poses significant challenges for patients, necessitating effective management strategies to improve gastrointestinal health. Methods: This study evaluated the effect of naldemedine on a group of patients undergoing opioid agonist therapy primarily with methadone and levomethadone. Naldemedine, the most recently introduced PAMORA, has demonstrated efficacy in improving both small and large bowel movements in patients with chronic OIC. The effect on alleviating OIC symptoms was assessed starting 5 months after the initiation of therapy. Results: Naldemedine demonstrated efficacy in alleviating OIC in the majority of patients undergoing therapy, with significant improvements observed during the clinical assessment conducted at 5 months following treatment initiation. The therapeutic effects were sustained for the subsequent 36 months, and no significant adverse effects were reported throughout the treatment period. Conclusions: Naldemedine has proven effective and is associated with minimal side effects in the treatment of opioid-induced constipation (OIC) among patients undergoing drug addiction therapy through agonist treatment. This is the first study to demonstrate its long-term efficacy in patients receiving opioid agonist therapy, highlighting its potential as a sustained therapeutic option in this population.
