The users treated for concomitant psychiatric pathology, in the public services for addictions-SerD, were 9,470 (Drug Addiction Report, 2022 data), increasing compared to the previous two years. Let’s talk about the increasingly frequent co-presence of substance addiction and mental distress Gilberto Di Pettaneuropsychiatrist, head of the psychiatric diagnosis and treatment service department – Spdc Santa Maria delle Grazie Hospital in Pozzuoli and head of the double diagnosis departmental operational unit.
Di Petta, you have great experience regarding patients who are addicted to substances and who also have psychiatric problems. What can you tell us about the most widespread drugs currently?
There is a strong change in references among users, who have switched from sedative-type substanceslike heroin which experienced a boom in the second half of the last century, to substances that are stimulating, exciting. Of the latter, the progenitor is cocaine, then there are a whole series of substances defined as Nps, new psychoactive substances, of the hallucinogenic, dissociative and stimulant type. This changed things a lot.
How did it change them?
We have gone from the prevalence of use of sedative substances, such as heroin, which were mainly administered intravenously and also carried a load of infectious diseases, including HIV, and to the social and existential drift, to the prevalence of substance use which are inhaled or ingested, which do not sedate and which, in most cases, lead to an increase in performance and are used in entertainment contexts. Unfortunately, these substances often de-stress (bring out) or create psychiatric problemswhile sedative ones such as heroin covered any existential distress.
How do these substances create psychiatric disorders?
Both in terms of productive psychotic symptoms (hallucinations, delusions, psychomotor agitation), and for mood imbalances with behavioral disorders. For example, manic excitement increases, with relapses of depressive forms. We associate this with the fact that the age of first contact with substances has dropped significantly. The kids come into contact with these substances first and foremost, at a stage in which their personality is not yet defined. The big problem we are having is the explosion of psychiatric pathologies and behavioral disorders in the younger population. The change in substance use eliminated Addiction Services as a contact.
What did this entail?
The entire population of heroin addicts was in some way “caged”, controlled, monitored, followed by these services, which provided (and still provide) methadone, a very valid drug for supporting the user. These kids who take stimulants and hallucinogenic substances believe it is useless to go to the SerDs. They think they are places reserved for addicts, they don’t feel like such. They work, use substances at the weekend, or take them to perform better at work. In many cases, these kids have their first contact with the National Health System through the worst door: the emergency psychiatric department.
When and how do these guys get to you?
They are often brought to us on Friday or Saturday evening, in a completely agitated state, after having taken various substances, which we often can’t even understand what they are. Thus, unfortunately, they begin a “psychiatric career” by inflating this intermediate area that did not exist until the end of the last century, which is called “dual diagnosis” or “psychiatric comorbidity”.
What does “dual diagnosis” mean?
The “dual diagnosis” occurs when within the same person there is the competition of two major problems: substance addiction and psychiatric problem. A great “monstrosity” is created. In Italy we have two treatment systems that are completely separate from each other. The addiction system is regulated by law 162 of 1990, the mental health system by law 180 of 1978. Neither of them takes care of these subjects, who are carriers of both pathologies.
What happens to subjects who carry both pathologies?
They are bounced from one system to another like “pinballs” ending up getting lost, to be absorbed into psychiatric chronicity in structures or prisons, which unfortunately are becoming a large social container of deviance. These people also fill the Rems, Residences for the execution of security measures, which were intended to be the overcoming of judicial psychiatric hospitals. These kids, with the substances they take and behavioral disorders, end up committing crimes and enter the criminal circuit. This is the current situation, which is increasingly critical.
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The kids are getting younger and younger, he told me. What age are we talking about?
Ages 14 and up. I like to make the distinction between old heroin and new substances, to understand that there has been an important historical evolution. Which was not followed by legislation. The legislator sleeps while the clinic progresses. The topic of substances seems strangely absorbed into the GDP of liberal and capitalist societies. The substance user, in some respects, is like a person who buys any other goods. Substances have a value that allows the transit of capital, then worse for those who get there. It seems that the problem no longer affects anyone.
Why does it seem like the problem no longer affects anyone?
Not seeing the drug addict falling on the street, people perceive substances differently, it seems that drugs no longer exist or it doesn’t concern us. When the problem explodes at home, parents often thought that their child was just smoking pot, but they were not informed. Not to mention child neuropsychiatry, which really doesn’t have the tools to deal with a 14-15 year old boy who with a group of peers begins to “drop” colored pills in a disco. And he will do it until he explodes from a psychiatric point of view.
What ailments do these kids have?
A very strong mood swing and dysphoria: a disorder that consists of being both excited and depressed. A boy who experiences this dysphoria is unbearable and inappropriate when he is in a group. Behind situations of youthful hardship there is often a load of substances, in a mix. They all have polygamy with respect to substance.
We need to make kids feel that meeting others still remains the most powerful drug. To do this we would need an “army” of psychologists, of educators who would do widespread work in schools
That is to say?
They use different substances. They are inside society, they want to perform, but they are starting to have a angry mood tone. In other cases, they begin to see things that are not there, to hear voices or become “interpretive”, they begin to have jealousies, suspicions about conspiracies. They enter websites and find conspiracy networks or begin to suspect that they are poisoned, to imagine that someone is angry with them. This is thepersecutory aspect. In some cases, they do occur aspects of breaking with realitythere are people who barricade themselves in their homes, live in a very apathetic way or explode into outbursts on the street. There are rather critical and complex situations that also undermine modern pharmacology.
How can pharmacology cure these people?
Today we have effective drugs against depression, which modulate mood, which reduce or turn off hallucinations and delusions. Medicines have evolved, the problem is that faced with those who use a mix of substances, even our medicines are difficult to prescribe, we do not know the level of interaction with these new substances. When people buy substances illegally, it is not clear what they contain. Therapeutic communities, which have been the lifeline of many heroin addicts, are not a place where drug addicts want to go, they either consider them to be addicts or do not want to give up their life of fun, family life and work. SerDs should be made more welcoming and less stigmatized care environments. So it is very difficult to make them go through a process of self-reconstruction. Training and prevention are important, but they must be done in a certain way.
In what way, for example?
We have seen that campaigning in schools, in an academic way, is not of much use. Kids have their own information, which they take from their peer group or from entertainment. Training should be completely reset, for example in my experience It is very effective to bring an “expert user” into the classroom. Prevention should be taken a little way. If children take drugs, they do so because these substances satisfy needs that are not satisfied by social agencies that once existed and which regulated the development of the subject’s emotionality and acquisition of identity: the school, the parents , the church, the political party, the sports association. We are in a catastrophe, there are so many people who encounter drugs. We need to create a sense of group, of solidarity, of cohesion.
How can this be done?
We need to make young people understand what anguish is, make them feel what it feels like to hug another. We need to make kids feel that meeting others still remains the most powerful drug. To do this we would need an “army” of psychologists, of educators (not so much about doctors) that they did extensive work in schools. And then we would need a lot of street units. If anything has made sense in the fight against drugs, it is the street units, where they have managed to be created: operators with a camper who go to places of entertainment, consumption and give information, do drug tests.
We dedicated an investigation to substance use, particularly by young people, in the issue of VITA magazine “Drugs, let’s open our eyes”. If you are a subscriber or subscriber to VITA you can read it immediately from here. And thank you for the support you give us. If you want to read the magazine, receive the next issues and access dedicated content and features, subscribe here.
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