This is how he defended it Néstor Szerman, psychiatrist consultant of the Institute of Psychiatry and Mental Health of Hospital General Universitari Gregorio Marañón de Madrid, during the 24th Dual Pathology Congress, held in Madrid and organized by the Spanish Society of Dual Pathology (SEPD) and the Dual Pathology Foundation and the World Association on Dual Disorders (WADD), and where the topic of opioids and mental disorders have had a leading place.
In Szerman’s opinion, today “there is still a great deal of ignorance among psychiatrists about how opioid drugs work, which could help many people with mental disorders.”
And despite the accumulation of scientific evidence, the fear persists that the modulation of the opioid system through the use of opiate drugs generates an addiction; something that, from the perspective of dual pathology, would only occur if there is a prior vulnerability on the part of the patient”.
He also pointed out that not all opioid drugs are indicated by the regulatory agencies for use in the treatment of mental disorders, but “there are numerous controlled clinical trials that demonstrate their effectiveness”.
The opioid system, explained this doctor, who is also president of the Spanish Foundation of Dual Pathology, is an endogenous brain system, composed of widely dispersed neurons that naturally produce endorphins, that controls pain (sensory and emotional), addictive behaviors, and reward; and that it is also involved in attachment and many other essential functions.
Therefore, “the modulation of the opioid system, of its different receptors and ligands, therefore opens up new opportunities to be able to treat these mental disorders”.
Opioids for dual pathology and other mental disorders
However, he regretted that, “despite the accumulation of scientific evidence, the fear persists that the modulation of the opioid system through the use of opiate drugs will lead to addiction”; something that, from the perspective of dual pathology, would only occur in the event that there is a prior vulnerability on the part of the patient:
In his opinion, using opioids or other substances is not the same as having an addictive disorder and “only 10% of people exposed to addictive substances end up developing an addiction because due to individual, genetic and neurobiological factors they present vulnerability to developing -the” .
Szerman has also defended that it is “fundamental” to adopt the nomenclature based on neurosciences (NbN), an initiative that tries to define drugs by their mechanism of action and not so much by their “indication”, as governs the current model.
“On this basis, opioid drugs could, depending on their design, improve for example the treatment of mental disorders such as psychosis, depression or substance use disorders, i.e. dual pathology,” he said. said
From left to right: Doctor Néstor Szerman, president of the Spanish Foundation of Dual Pathology; Antonio Prieto Fernandez, manager of Madrid Health; Joan R. Villalbí, Government delegate for the National Drug Plan; doctor Carlos Ronceropresident of the Spanish Society of Dual Pathology, and Doctor Pablo Vegamember of the executive committee of the Spanish Society of Dual Pathology. Photo provided.
Addictions and mental disorders
The 24th Congress of Dual Pathology, to which more than 1,500 psychiatrists, psychologists and health professionals linked to the field of mental health attendedwas held under the theme Dual Pathology: Vulnerability from Neuroscience to Mental Health and has again brought to the fore a health and social problem: the convergence of addictions and other mental disorders, with high prevalence rates.
In this sense, the president of the Dual Pathology Foundation has pointed out that despite the enormous work done to demonstrate that both from an epidemiological and neuroscientific point of view, addictions cannot be separated from other mental disorders, there are still resistances to incorporate the concept of dual pathology at all levels.
Also the bidirectional relationship between sleep and mental health have been the subject of debate in this forum, where it has been explained that sleep disturbances deteriorate mental health while sleep problems, especially insomnia, are common in patients with psychiatric disorders.
Thus it has been stated that according to existing scientific evidence, it is estimated that around 80% of patients with mental disorders during the acute phase and approximately 30% during follow-up have insomnia and that other epidemiological studies have It has also been shown that insomnia precedes depression.
“During the depressive phase, 90% of patients have insomnia and 10% have hypersomnia, a characteristic of bipolar depression. The non-restoration of sleep after a depressive episode is also associated with a greater likelihood of relapse”, said the doctor Francesca Cañellaspsychiatrist of the Multidisciplinary Sleep Unit of Son Espasses University Hospital in Palma de Mallorcaduring his intervention.
Sleep disturbances, anxiety and depression
This close relationship between sleep and mental health also extends to Dual Pathology – the coexistence of addictions and other mental disorders – as confirmed during the same symposium by Dr. Carlos Ronceropresident of the Spanish Society of Dual Pathology (SEPD).
“Sleep disturbances sometimes produce other mental disorders such as anxiety or depression; and push to the consumption of legal substances such as hypnotic drugs or alcohol or illegal substances such as cannabis which, on the surface, may seem to improve the ability to fall asleep, but which in the medium and long term have absolutely no effect distorters of sleep architecture and can end up generating a substance use disorder”.
The specialist added that in the opposite direction, in people who have a substance use disorder and who, in turn, have another mental disorder (what is considered dual pathology), one of the frequent symptoms is sleep disorders, mainly insomnia.
“It is a vicious circle that is difficult to break, where mental disorders, substance use, dual pathology and, at the same time, sleep disorders come together, which enhance and multiply addictions and/or other mental disorders”, added the psychiatrist, who according to the data has vindicated the need for training in sleep medicine among professionals in the field of mental health so that the sleep disturbances of patients with dual pathology can be evaluated in depth from consultation.
“Psychoeducation and advice on good rest habits are important to break some of the patients’ inappropriate dynamics, but this will probably not be enough in most cases, in which a pharmacological approach complemented by cognitive-behavioral therapy will be necessary, which have shown effectiveness in regulating the sleep-wake cycle”,
This is what the president of the SEPD has recommended, who wanted to be optimistic about the “promising” pharmacological innovations that could be available in the coming years to address sleep problems in patients with Dual Pathology.
“Preclinical data and experience in the United States seem to indicate that drugs that act as antagonists of orexin receptors do not generate problems of addiction and misuse, unlike what does happen with the drugs currently used, mainly hypnosedants such as benzodiazepines which, although initially can help improve insomnia difficulties, in the medium and long term can end up producing compulsive consumption problems, so they must be used with great caution in patients with dual pathology”, he said.
Attention deficit and hyperactivity
Also, and among other topics, attention deficit hyperactivity disorder (ADHD), which affects millions of children and often continues into adulthood, was present at the symposium, as it was presented as a factor that predisposes to the development of addictive behaviors.
This is what the doctor assured Francisco Ferre Navarretehead of the Adult Psychiatry Service al Gregorio Marañón University General Hospitalduring one of the interventions.
“In behavioral addictions dual pathology is the norm, and these addictions are especially associated with depression, anxiety, obsessive compulsive disorder and ADHD. In the case of ADHD, the association with pathological gambling and video game addiction is particularly important. Up to 39% of video game addicts are diagnosed with ADHD”.
Regarding this, the spokesperson for behavioral addictions of the Spanish Society of Dual Pathology has explained that the research carried out on this relationship shows several psychological and biological traits that would motivate the dual pathology of ADHD and behavioral addictions, among them impulsivity, the need for stimuli and rewards, the dysfunction in the activation and reinforcement system and a low activation of the frontal lobe of the brain.
“However, not all the empirical evidence supports these factors in a decisive way, although there is a prevalence of the impulsivity factor in the literature that connects this comorbidity, so much more research is required in this line” , argued Ferre.
The specialist has pointed out that it is “evident” that the poor impulse control typical of ADHD “favors self-medication, the basis of psychotropic abuse, dependence and other pathologies related to pathological gambling”.
Today, the underdiagnosis of ADHD continues to constitute a problem of great magnitude, which for Dr. Francisco Ferre is because in certain professional areas the importance that many experts in mental health give to the detection of ADHD is still considered exaggerated.
In his opinion, there is a need for wider recognition of ADHD in the health, educational, work, judicial and public spheres, particularly with children with predominantly inattentive symptoms and more generally to raise awareness that ADHD it persists in many cases into adulthood.