Substance Abuse and Psychopathology - Athens Psychiatric Conference - Dec.2 2012

Substance Abuse and Psychopathology - a chicken and egg dilemna Organized by the Hellenic Section of Itaca Dec. 2, 2012 Chairs: I. Liappas (Greece) Z.. Daifti (Greece)

( I woke at 2 am last night, my older biological clocks arthritic arms refusing to digitally adjust. This morning I slept in, but would not forego the breakfast treats offered by Hotel Ilisia’s kitchen. Consequently having indulged myself I arrived late to this series of lectures I’d ear marked earlier in the program. Addiction Psychiatry is my subspeciality but this morning the fair in other lecture series included the definitive update on insomnia as well as post traumatic stress disorder. Sneaking in I didn’t even notice that while the slides were in English the speaker was speaking Greek. The chair came down and shared that the next presentation would be in English.)  

As it was I missed the Neurobiological Approach of Drug Abuse Psychopathology presented by Z. Daifti but did appreciate his later comments. I also missed Neuropsychiatric Sequelae of alcohol abuse by T. Paparrigopoulos but expect with my clinical experience there’s little that would surprise me, alcohol and drug abuse being called the ‘great chameleon’ of psychiatric diagnosis.

Alcohol related disorders and psychiatric co morbidities, an overview was the one I caught. The slides were excllent going into detail with the latest in topics like alcoholic dementia. Drug Abuse and psychopathology

The role of the family by Dr. Dr. Pomini presented a study done by their unit . Study comparing 41 families with heroin addicted male child, 17 families with schizophrenia and a matched sample of 27 non clinical families. Stressful life events in nuclear family - psyvhiatric and chronic physical illness were higher in two clinical samples as was divorce. Migration was actually higher in the control. When the amount of life events is more it’s much more difficult for family to cope without significant suffering. This presents also the possibility for prevention of development of these severe clinical illnesses by early identification and possibly early therapy for those at risk. In subsequent discussion Dr. Pomini said that while there are many stresses considered for families at this time she thought it most important to look at the major objective factors rather than be caught up in subjective concerns. In this regard they noted major losses for children such as divorce . This was noted to be a significant life event in their population.

Addiction and Pregnancy, Prof.F.Thibaut, Athens Conference

This doctor was a remarkable presenter of a very important topic.  (She not only provided a thorough and moving overview of the research but she also handled extremely well the many questions and positive comments that followed)

Addictions and Pregnancy

Professor F. Thibaut

University Hospital

INSERM, Rouen , France

Epidemiological data

Tobacco and Pregnancy

France

-25% of pregnant women smoke

Ireland

-37% pregnant women smoke

USA

-52% of pregnant women smoke

Alcohol and pregnancy

USA

8-30% - 1 to 6% binge drinking

Australia - 14%

Russia 35%

Chile 57%

Ireland - 89% - 10% binge drinking

Sweden - 23 to 30% regularly

France - 53% not drinking

20-30% 1-4 drinks

14% 1 binge drinking episode during pregnance

Drugs and Pregnancy

USA 1996

 19% cannabis

5% daily

USA 2006

3 to41% 

BRazil 

4% cannabis, 2% cocaine, .3% both

Barcelona 2005

6% opioids, 3% cocaine, 1.5 % both

France 2006

3-10 % cannabis

3-5% cocaine

Consequences of exposure to children

Dose and pattern of use

Timing of exposure

Frequence and duration

Polyconsumption

metabolism of mother and infant

Consumption after delivery

Family environment - violence, personality disorders, psychiatric disorders

75% exposed versus 27% non exposed have medical problems at birth

Alcohol in utero

Fetal alcoholism

1.6 per thousand Sweden

2-7 per thousand USA

1-3 per thousand France

Fetal alcohol spectrum 1-5

Prematurity

FAS - 

Preventable mental retardation

45% of FAS go to committ crimes against persons

Tobacco in utero

Withdrawal at birth

-crying irritability, sleep and digestive disorders

 Cotinine in meconium or hair

-increased risk of sudden death

-growth impairment

-respiratory disorders

-cleft palate

• cognitive disorders 
• language impairment
• dyscalculia
• memory deficits, 
• problem solving
• attention deficit disorders
• pscyhiatric disorders
• addictive disorders

Cannabis in utero

Hypotrohy reduced head size

increased risk of sudden death

Withdrawal at birth ?

learnig impairments

Short term memory disorder

 language impairments

Attention disorders

psychiatric disorders - depression and anxiety

Cocaine in utero

in utero death

growht ipairment

cognitive 

language

ADHD

Behaviour disorders

identification of at risk women

Addiction Severity Index

AUDIT, Fagerstrom, Cannabis Abuse Screen Tests

Mother’s consumption often underestimated by 2-3 factor

At Risk Women

polyconsumption

low socioeconomic statu

single

low education

white women in us - alcohol and cannabis

black women in us - cocaine

psychiatric comorbidity

Conclusion

Avoidance of maternal consumption, tobacco, alcohol, drugs, during pregnancy is necessary

Marijuana Debate - Canadian Society of Addiction Medicine 2011

Addiction Medicine Specialist, Dr. Paul Sobey refereed the marijuana debate between Canadian family physician and marijuana researcher Dr. Mark Ware and Prof. Jag Khalsa.from the National Institute of Drug Abuse.  Good humored laid back Indo American Prof Khalsa should have been the pro marijuana debater if steretypes were true. Dr. Mark Ware in comparison was such a clean cut and measured speaker by comparison. They were both extremely learned and the debate and discussion was one of the best I've heard.
Dr. Sobey did a masterful job of asking questions comparing efficacy of prescription pharmaceutical cannabinoid products, such as cesamet and nabilone,  with smoked marijuana products. Specifically Dr. Ware's research showed that smoked marijuana to date was superior in treatment of neuropathic pain associated with HIV.  Clearly there was benefit from cannabinoids for treatment of spasticity, nausea associated with chemotherapy, neuropathic pain and improving appetite in HIV patient. Other than rare examples the benefit of marijuana or cannabiniods over alternatives was negligible but physicians were generally glad to have as many alternatives as possible in their tool boxes.  . To date there had been no abuse of pharmaceutical cannabinoids noted by Dr. Ware's recent research or Dr. Khalsa's investigation.  There was a lot of 'off label' use of cannabiniods in areas where research had already excluded the benefit.  Such an example was migraines whereas there was need for more research in it's use in multiple sclerosis.
There was clear evidence agreed on by both that 'smoked marijuana' was associated with Chronic Lung Disease. Further there was overwhelming evidence that it caused psychosis and had profoundly negative mental health consequences for many.  The cost/benefit was significantly altered when the drug was now associated with causing or contributing to the development of schizophrenia in adolescents.  Further it was clearly associated with accidents, specifically motor vehicle accidents and fatalities.
Both researchers said that marijuana should not be used by adolescents.  Brain development continues rapidly to age 25 and Dr. Ware was very specific in making clear that he wanted to see more research and perhaps more use of smoked marijuana in chronically medically ill patients of older age. He was very upset that adolescents were quoting him saying it didn't appear to be associated with causing throat cancer as a justification for their using it recreationally.
Both researchers felt there was a strong need for more study of marijuana.  Prof. Khalsa was very pointed in saying that NIDA had not been against marijuana and that there were countless studies done on cannabinoids in the US. The position of NIDA was specifically against 'smoking' as there was no evidence that smoking of any kind was anything but harmful.
Dr. Ware made the telling comment that when the government introduced so called 'medical marijuana' with some 22,000 now smoking marijuana after 5 years in Canada there was no solid research component as part of this politically powered federal legislation.  Obviously any good marijuania program especially one government funded should incorporate an ongoing research component. The University of California was doing just this in the US.
With typical good humor Prof Khalsa responded to Dr. Ware's cry for more research money for the study of smoking marijuana saying that much medical research is done by private funding. There was certainly financially invested interests in the marijuana debate who had not been willing to date to back up their claims of the benefits of marijuana with research funding.  The marijuana industry certainly was making a killing but not as open to research as Dr. Ware was proposing especially in light of increasing evidence of the long term negative consequences for some and the real dangers for children, adolescents and pregnant women.
Dr. Ware's excellent scientific knowledge and reasoned  approach were a pleasant change to the usual paranoid marijuana devotee who bludgeons the medical doctor with phrases like 'organic' and 'herbal'  insisting penicillin is dangerous and marijuana is life's cure.  I
ndeed listening to both these learned men in an excellent discussion was a breath of fresh air given how smokey the discussion has been in past years.
Despite this being Vancouver, and the discussion immensely entertaining, no one lit up a joint during or after the debate.