En France, la buprenorphine est actuellement le traitement principal de la dependance aux opiaces. Les donnees recentes de l'Observatoire Francais des Dragues et des Toxicomanies [OFOT] montrent qu'en 2003, la moitie au moins des personnes dependantes des opiaces en France etait en traitement, soit entre 83 000 et 95 700 personnes selon les estimations, dont 71 800 a 84 500 traitees par buprenorphine [1]. Les principaux prescripteurs en sont les medecins generalistes (entre 91 et 99 % selon les agglomerations] [2]. En 2002, la buprenorphine se situait au 16eme rang des principes actifs les plus prescrits et rembourses en France et au 3eme rang des psychotropes, derriere la paroxetine [Deroxat®, 9eme rang] et la fluoxetine [Prozac®, 11eme rang] [3]. L'efficacite et la securite du traitement par buprenorphine ont ete demontrees par de nombreuses etudes randomisees: associe a une prise en charge psychologique et sociale adaptee, le traitement par buprenorphine reduit la consommation d'heroine et la delinquance associee, diminue le taux de seroconversion pour le VHC et le VIH, et la mortalite [4-B].

Objective: Animal research has outlined a vulnerability trait to drug dependence like behavior. The behavioral characteristic of this vulnerability is hyperactivity in response to a novel environment of which sensation seeking (SS) has been suggested as a possible equivalent in humans. If this is the case, SS should be more frequent in drug dependent and risky sports practicing subjects then controls. The objective of this study was to determine if opioid dependent subjects (ODS) and regular paragliders (RP) would be more SS then normal controls. Design: Cross sectional study. Participants: Three groups of 34 individuals (total 102) matched for age and sex were selected from ODS seeking treatment, a paragliding club, and a college staff. Main outcome measures: Global and sub-scores of the Zuckerman sensation seeking scale (SSS). Results: Non parametric statistics (Kruskal Wallis and Wilcoxon 2-Sample Tests) were used given the non-normal distribution of SSS scores in the ODS and RP groups. Significant differences were found across the three groups for the Thrill and Adventure Seeking (TAS) (P=0.001), dishinibition (Dis) (P=0.0003) and total score (P=0.001). ODS and RP scored significantly higher than controls on two (Dis and the TAS scales). RP also scored significantly higher on the Boredom Susceptibility (BS) scale (P=0.04). Conclusion: Our results show that RP and ODS differ from controls and have some similarities based on the SSS. In this study, the ODS and the RP could express different forms of a general tendency to seek intense and abrupt sensations through various behaviors. Our results in humans are in favor of the hypothesis that the behavioral trait of vulnerability to drug dependence behavior is expressed through SS.

BACKGROUND:Both the general public and non-sports medicine health professionals have recently been made aware of a large use of performance enhancing drugs among sports practicing subjects. It has been suggested that this behavior is similar to that of substance dependence. Also some have reported that practice of a sport could be in itself an addictive behavior. OBJECTIVE:The main objective was to address the following question: is performance enhancing drug use in sports an addictive behavior? Methodology. We first reviewed the definition of performance enhancing drug use in sports and the diagnostic criteria of substance dependence as they are currently accepted and attempted to determine a possible common factor. Secondly we reviewed epidemiological data from the literature according to three approaches: RESULTS:Use of performance enhancing drugs is an important and increasing phenomenon among adolescents. It is sometimes associated to risk taking behaviors for health (syringe use and sharing). Competition participants are at increased risk (up to 20% according to some authors) and some substances (anabolic steroids) are also used by non-sports practicing individuals. It has not been shown that sports practicing subjects were more at risk of using addictive substances compared to non-sports practicing subjects. It is not established that practice of a sport is by itself a risk factor for substance use. However, it could be that a sub-group of individuals that practice certain types of sports in an intensive way, that use both performance enhancing drugs and addictive substances and that engage in health risk taking behaviors have an increased risk for developing a dependence syndrome to both addictive and performance enhancing drugs. This sub-group is even more at risk because some performance enhancing drugs (anabolic steroids) could increase the risk for occurrence of a substance dependence syndrome through neurobiological actions. Yet, the few available clinical studies show that at most only half of regular users actually meet criteria for dependence. Also, one study has reported an overrepresentation of sports professionals among patients seeking treatment for heroin addiction. CONCLUSION:The large majority of sports practicing subjects have no dependence to either performance enhancing or addictive drugs. However, a subgroup of individuals that practice sports intensely and makes use of both addictive and performance enhancing drugs appear to be at increased risk for developing a substance dependence syndrome.

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La clinique des pratiques addictives des douloureux chroniques est complexe et a longtemps fait l’objet de publications contradictoires. Une mise au point s’avère d’autant plus nécessaire que le rôle étiopathogénique, de l’abus médicamenteux dans l’aggravation et la chronicité de certains types de douleurs est largement reconnu. Différents auteurs soulignent que l’évaluation des comportements addictifs des patients douloureux chroniques pourrait être améliorée, si l’on utilisait les définitions standardisées appliquées classiquement à la toxicomanie, celle de l’Association Américaine de Psychiatrie (dépendance et abus), et celle de l’Organisation Mondiale de la Santé (dépendance et usage nocif pour la santé). Le recours à des définitions standardisées (abus, dépendance) ne peut rendre que plus lisibles les données recueillies. Les comparaisons deviennent possibles et l’examen des études publiées fournit une approximation de la prévalence de l’abus et de la dépendance médicamenteuse des sujets consultant pour une douleur chronique (entre 10 à 20%). Mais, l’inadaptation partielle de ces définitions lorsqu’elles sont appliquées à la population des douloureux chroniques est discutée. Leur inconvénient principal est que les comportements addictifs de la majorité de ces sujets douloureux chroniques n’entrent pas dans la catégorie de la dépendance ni même de l’abus de médicaments. Cette évaluation, bien qu’utile, s’avère être réductrice face à la complexité de la psychopathologie des conduites addictives et de ses intrications multiples avec la pathologie douloureuse.

L'objectif de cette etude etait d'evaluer les pratiques a risque pour la contamination VIH et les facteurs de risques pour ces pratiques chez les usagers de drogues par voie intraveineuse hors traitement. L'objectif de cette publication est de presenter l'instrument principal utilise (RAB) et les premiers resultats concernant les activites de partage de materiels contaminants. Les sujets ont ete recrutes parmi les primo-consultants declarant utiliser la voie intraveineuse dans le cadre d'un centre de soins pour toxicomanes au sein d'un service universitaire de psychiatrie. La toxicomanie, les pratiques d'utilisation du materiel d'injection, les comportements sexuels et l'etat psychologique ont ete evalues par l'intermediaire du Risk for Aids Behaviors (RAB), un auto-questionnaire qui evalue a la fois le partage du materiel d'injection et les comportements sexuels a risque, l'auto-questionnaire de depression de Beck (BDI) et de l'Addiction Severity Index (ASI), qui mesure la severite des problemes dans 7 domaines habituellement affectes par la toxicomanie. Les resultats portent sur 66 sujets consecutifs declarant utiliser la voie intraveineuse parmi 102 primo-consultants de moyenne d'âge de 31 ans, dont 74 % d'hommes. La moyenne du score de severite de l'ASI pour la drogue est 6,53. Trente-huit sujets (58 %) ont partage leur seringue ou leur materiel d'injection au cours des 6 mois precedant l'etude. Malgre les campagnes d'information destinees aux usagers de drogue sur les comportements a risque pour le SIDA et les maladies infectieuses, plus de la moitie de ceux qui font une demande de traitement continuent a partager le materiel d'injection.

Cette etude exploratoire a pour objectifs: 1) d'evaluer l'adaptation des patients candidats a la greffe et des greffes cardiaques, en mesurant les dimensions objectives et subjectives de la qualite de la vie, 2) de determiner les relations existant entre les evaluations subjectives et objectives. Methode: il s'agit d'une etude transversale; 21 candidats (C) evalues apres 10 mois (Sd 21,4) d'attente de la greffe sont apparies a 21 transplantes (T) evalues a 29,2 mois de la greffe en fonction de l'âge, du sexe, du type de cardiopathie. Les mesures subjectives de qualite de la vie sont recueillies par des instruments d'autoevaluation, le Tableau d'evaluation assistee de la qualite de la vie (TEAQV) et le Nottingham Health Profile (NHP). Les mesures objectives sont le score d'insuffisance cardiaque NYHA evalue par le cardiologue et les diagnostics psychiatriques sur l'axe 1 du DSM III-R, evalues par un psychiatre au cours d'un entretien semi-structure. Resultats: les candidats et les transplantes evaluent positivement leur qualite de vie. Aucune difference significative n'est retrouvee entre les groupes aux scores de la NHP et du TEAQV. Les seules differences significatives concernent les mesures objectives heteroevaluees: les diagnostics psychiatriques plus frequents chez les candidats [(C) = 16/21 vs (T) = 9/21Chi2 p < 0,05)] avec une prevalence des troubles de l'adaptation (10/21) dans ce groupe, le score d'insuffisance cardiaque evidemment plus eleve chez les candidats [(C) = 2, 7 Sd 0,56 vs (T) = 0,7 Sd 0,8 p < 0,01)]. Chez les greffes, des correlations significatives sont retrouvees entre les scores de la NYHA et le NHP (r= 0,6, p < 0,01) et les scores dimensions physiques et psychiques du TEAQV (r = - 0,65 et r = - 0,55, p < 0,01) mais pas chez les candidats. Ces donnees suggerent que l'evaluation subjective de la qualite de vie n'est que peu liee aux problemes psychologiques et physiques eprouves par les candidats. Conclusion: les avancees techniques medicales confrontent les individus a des situations extremes face auxquelles ils font preuve de remarquables facultes d'adaptation, comme tendent a le suggerer les resultats de ce travail. Les 21 greffes cardiaques evaluent positivement leur qualite de la vie et les 21 candidats a la greffe en font egalement une appreciation subjective positive malgre des difficultes objectives, physiques et psychiques significativement plus importantes que celles des greffes. Ces donnees sont, dans leur ensemble, conformes a la litterature, cependant partagee sur la qualite de la vie des candidats. La petitesse de l'effectif limite l'interpretation de ces resultats qui doivent etre confirmes dans une etude prospective.

OBJECTIVE:Although evaluation of heart transplant candidates and recipients is usually based on objective clinical variables, self-assessment has been proved to be an important component of treatment evaluation. Quality of life is a multidimensional concept, a mix of objective and subjective measures, that could reflect the adjustment to the illness and its treatment. Few studies have reported on quality of life in heart transplantation candidates. This exploratory study, conducted in Bordeaux (France), was designed to assess both objectively and subjectively the quality of life in heart transplant candidates and recipients and to determine the relationships between subjective and objective variables.METHOD:The assessment was cross-sectional; 21 candidates evaluated at an average of 10 (Sd 21.4) months into the waiting period, were matched with 21 recipients at 29.5 months post operative. Subjective evaluation of the quality of life was self-assessed by the Tableau d'évaluation assistée de la qualité de la vie (TEAQV) and the Nottingham Health Profile (NHP). A semi structured psychiatric interview, and the NYHA (New York Heart Association) cardiac insufficiency score provided objective measurements.RESULTS:The NHP and TEAQV mean scores were not not significantly different between the two groups: candidates (C) and recipients (R) reported similar subjective data regarding positive quality of life experience. The objective data indicated significant disadvantages for the candidate group: the cardiac insufficiency score was worse in the candidates [(NYHA mean score: (C) = 2.7 Sd 0.56 vs (R) = 0.7 Sd 0.8, t de Student p < 0.01)] and the DSM III-R axis 1 diagnoses were more frequent in the candidates [(C) = 16/21 vs (R) = 9/21 Chi2 p < 0.05)]. There was a prevalence of adjustment disorders in the candidates. Significant correlations were found between NYHA and NHP mean scores (r = 0.6, p < 0.01) and NYHA and physical and psychological dimensions of the TEAQV (r = -0.65 and r = -0.55, p < 0.01) in the recipient group. In the candidate group, no correlation was found between these scores.CONCLUSION:In the recipient group, objective and subjective assessment showed greater concordance than in the candidate group. Despite more objective physical and moderate yet frequent psychiatric complications, the candidate group reported as positively as did the recipients upon the quality of their life experience. This could be the result of psychological adaptation to the stressful situation. These data were in accordance to several earlier reports. However, the literature has remained controversial upon the evaluation of the quality of life of the candidates. The results of this study, limited by some methodological bias (the small number of patients assessed), need to be confirmed in a prospective study.

Objective: although evaluation of heart transplant candidates and recipients is usually based on objective clinical variables, self-asesment has been proved to be an important component of treatment evaluation. Quality of life is a multidimensional concept, a mix of objective and subjective measures, that could reflect the adjustment to the illness and its treatment. Few studies have reported on quality of life in heart transplantation candidates. This exploratory study, conducted in Bordeaux (France), was designed to assess both objectively and subjectively the qualify of life in heart transplant candidates and recipients and to determine the relationships between subjective and objective variables. Method : the assessment was cross-sectional; 21 candidates evaluated at an average of 10 (Sd 21,4) months into the waiting period, were matched with 21 recipients at 29,5 months post operative. Subjective evaluation of the quality of life was self-assessed by the Tableau d'evaluation assistee de la qualite de la vie (TEAQV) and the Nottingham Health Profile (NHP). A semistructured psychiatric interview and the NYHA (New York Heart Association) cardiac insufficiency score provided objective measurements. Results: the NHP and TEAQV mean scores were not not significantly different between the two groups : candidates (C) and recipients (R) reported similar subjective data regarding positive quality of life experience. The objective data indicated significant disavantages for the candidate group : the cardiac insufficiency score was worse in the candidates [(NYHA mean score: (C) = 2,7 Sd 0,56 vs (R) = 0,7 Sd 0,8, t de Student p < 0, 01)] and the DSM III-R axis I diagnoses were more frequent in the candidates [(C) = 16/21 vs (R)= 9/21Chi2 p < 0,05)]. There was a prevalence of adjustement disorders in the candidates. Significant correlations were found between NYHA and NHP mean scores (r = 0,6, p < 0,01) and NYHA and physical and psychological dimensions of the TEAQV (r = - 0,65 and r = - 0,55, p < 0,01) in the recipient group. In the candidate group, no correlation was found between these scores. Conclusion : In the recipient group, objective and subjective assessment showed greater concordance than in the candidate group. Despite more objective physical and moderate yet frequent psychiatric complications, the candidate group reported as positively as did the recipients upon the qualify of their life experience. This could be the result of psychological adaptation to the stressful situation. These data were in accordance to several earlier reports. However, the literature has remained contreversial upon the evaluation of the quality of life of the candidates. The results of this study, limited by some methodological bias (the small number of patients assessed), need to be confirmed in a prospective study.

The objective of this study was to quantify the occurrence of AIDS risk related sharing activities in i.v. opiate users seeking treatment using a self administered questionnaire. Subjects were recruited among first time consultants of an outpatient clinic and assessed using the Risk for AIDS Behavior questionnaire (RAB), a self administered questionnaire that assesses both needle-sharing and unprotected sexual activity; the Beck Depression Inventory (BDI) a self administered questionnaire that assesses depressive symptoms; and the Addiction Severity Index (ASI), a 45-min, structured interview that provides assessments of problem severity in seven functional areas commonly impaired among drug abusers. Among the 102 patients who came in for treatment, all 66 subjects reporting i.v. drug abuse agreed to participate. The study was based on the data collected from these 66 subjects of whom 49 were males (74%) and mean age +/- SD was 31 +/- 5. Fifty-eight-percent of theses subjects reported having shared needles or related paraphernalia over the past 6 months. Despite informational campaigns on the risks of sharing and despite the well spread knowledge of such a risk, most i.v. opiate users seeking treatment report having shared at least once over the previous 6 months.

The objective of this study was to quantify the occurrence of AIDS risk related sharing activities in IV opiate users seeking treatment using a self administered questionnaire. Subjects were recruited among first time consultants of an outpatient clinic and assessed using the Risk for AIDS Behavior questionnaire (RAB), a self administered questionnaire that assesses both needle-sharing and unprotected sexual activity; the Beck Depression Inventory (BDI) a self administered questionnaire that assesses depressive symptoms; and the Addiction Severity Index (ASI), a 45-min, structured interview that provides assessments of problem severity in seven functional areas commonly impaired among drug abusers. Among the 102 patients who came in for treatment, all 66 subjects reporting IV drug abuse agreed to participate. The study was based on the data collected from these 66 subjects of whom 49 were males (74 %) and mean age +/- SD was 31 +/- 5. Fifty-eight-percent of theses subjects reported having shared needles or related paraphernalia over the past 6 months. Despite informational campaigns on the risks of sharing and despite the well spread knowledge of such a risk, most IV opiate users seeking treatment report having shared at least once over the previous 6 months.

Within the field of substance abuse, it is now widely admitted that the addictive personality does not exist. No one personality type is predisposed to addiction. The predisposition to drug dependence involves many different factors: psychological, social, familial, biological. None of these factors can be the sole determinant of drug dependence. Keeping that in mind, it is of interest to review the recent data on the relationship between personality traits or disorders and opiate and cocaine dependence. Using DSM and ICD categorical assessment, no single personality disorder emerged, instead a range of personality disorders has been evaluated in opiate and cocaine dependent subjects. Every type of personality disorders (PD) existed but cluster BPD were the most common (especially antisocial personality disorder in opiate addicts). However, it is noteworthy that a large minority to a majority of subjects did not display any king of PD. The implication of these results is that antisocial PD is probably over-diagnosed in drug dependence clinical settings. The studies reviewed failed to demonstrate that personality disorders were strong predictors of outcome in opiate or cocaine dependence. However, opiate dependent PD subjects entering treatment had more severe problems and lower retention rate than non PD subjects. But the amount of improvement was not significantly different between PD subjects and non PD subjects. This demonstrated that substance dependent PD patients could benefit from treatment whose intensity and duration must be adjusted. There is good support for the idea that Sensation Seeking trait is a vulnerability factor to substance abuse. But after dependence develops, sensation seeking is probably irrelevant to continued use of the drugs. This break between the psychopathology of vulnerability of substance abuse and the psychopathology of dependence raises the question of the existence of dramatically different factors involved in both phases of addiction.

OBJECTIVES: Determine how well drug abusers requesting care accept urine sampling and the reliability of this method for evaluating drug use. METHODS: Subjects attending a specialized drug abuse clinic for the first time were requested to provide a urine sample for semiquantitative analysis using an immunological technique to identify the following substances: barbiturates, benzodiazepines, opiates, cocaine, amphetamines, cannabis, and destropropoxyphen. RESULTS: Ali 98 subjects included in the study accepted the urine sample. More than 80% of the samples were positive for 1, 2 or 3 substances. The most frequent were, in decreasing order, opiates, cannabis, benzodiazepines and dextropropoxyphen. Among the opiate-positive subjects (70%), 80% were positive for 2 other substances, usually cannabis and benzodiazepines. Two-thirds of the cocaine-positive cases were observed among the most recently seen subjects. Among the 27 opiate-negative subjects, 16 stated they used buprenorphine. CONCLUSION: Within the setting of this study, urine sampling appeared to be well accepted by drug abusers. Urinalysis gave an objective evaluation of drug use and can be useful on an individual level providing complementary information to the overall examination. Urine sampling can also provide indicators for studying the evolution of drug use practices in different populations, both in a clinical and non-clinical setting.

OBJECTIVES:Determine how well drug abusers requesting care accept urine sampling and the reliability of this method for evaluating drug use.METHODS:Subjects attending a specialized drug abuse clinic for the first time were requested to provide a urine sample for semiquantitative analysis using an immunological technique to identify the following substances: barbiturates, benzodiazepines, opiates, cocaine, amphetamines, cannabis, and dextropropoxyphen.RESULTS:All 98 subjects included in the study accepted the urine sample. More than 80% of the samples were positive for 1, 2 or 3 substances. The most frequent were, in decreasing order, opiates, cannabis, benzodiazepines and dextropropoxyphen. Among the opiate-positive subjects (70%), 80% were positive for 2 other substances, usually cannabis and benzodiazepines. Two-thirds of the cocaine-positive cases were observed among the most recently seen subjects. Among the 27 opiate-negative subjects, 16 stated they used buprenorphine.CONCLUSION:Within the setting of this study, urine sampling appeared to be well accepted by drug abusers. Urinalysis gave an objective evaluation of drug use and can be useful on an individual level providing complementary information to the overall examination. Urine sampling can also provide indicators for studying the evolution of drug use practices in different populations, both in a clinical and non-clinical setting.