Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

148 III. SUBSTANCES OF ABUSEOf the personality disorders, antisocial personality disorder is the mostcommonly diagnosed and can be seen in as many as 25% of opioid abusers seekingtreatment; this is noted in men the vast majority of the time (Brooner et al.,1997). It is inaccurate to assume that drug-seeking behavior learned duringyears of addiction is responsible for the high percentage of antisocial personalitiesamong opioid addicts. Antisocial personality disorder can be reliably diagnosedhistorically in most individuals at a young age, prior to the onset ofopioid dependence. The relationship between opioid abuse and antisocial personalityis complicated and appears to be influenced by a non-sex-linkedgenetic factor. When antisocial personality and opioid dependence are foundtogether, the treatment course is frequently challenging, and the overall outcomeis poor with regard to adequate length of time in treatment, relapse, criminalbehavior during treatment, and ability to establish rapport with a therapistor counselor. The one exception appears to be the antisocial addict who alsohas a diagnosable depression. This group responds much better to treatment, ona par with the average opioid addict without significant psychiatric comorbidity(Woody, McLellan, Luborsky, & O’Brien, 1985).Anxiety disorders, such as panic disorder, obsessive–compulsive disorder,generalized anxiety disorder, and phobia, are seen in approximately 10% ofopioid addicts. Members of this group are typically somewhat younger in ageand higher in socioeconomic status, and their drug use histories are not asextensive.Delirium, dementia, and psychotic disorders such as schizophrenia, mania,and psychotic depression are not usually seen in opioid clinic populations. Thepresence of both a DSM-IV Axis I diagnosis (depression or an anxiety disorder)and an Axis II diagnosis (a personality disorder) in the same opioid-dependentindividual is frequently observed; the proportion of such patients may approach50% in clinic populations (Khantzian & Treece, 1985).TREATMENTThe various nonpharmacological treatment modalities used to treat other typesof substance abusers are also useful in treating opioid addicts, and are discussedin Chapter 19. The focus of this chapter is on pharmacotherapy of situationscommonly found in the context of opioid use, including overdose, withdrawal,detoxification, and maintenance.IntoxicationThe management of opioid overdose is best accomplished in a medical facilitywith the availability of sophisticated expertise and technology. These can bebrought to bear on the potential “worst-case scenario,” for example, opioid