A comparison of the structure and effectiveness of recovery ecosystems for opioid use disorder in Portugal and Appalachia, with a focus on identifying areas for improvement within the Appalachian region.

Ce travail, inscrit dans une perspective psychanalytique propose, au travers de la clinique singulière de l'alcoolisme, une réflexion métapsychologique à propos de l'addiction, à l'appui d'un référentiel freudien et lacanien. Dans une attention particulière portée au triptyque sur lequel est fondée la métapsychologie, l'alcoolisme se voit alors abordé du point de vue économique augmenté des points de vue topique et dynamique, ouvrant ainsi autant de perspectives clinique que psychopathologique. Départi de toute conception déficitaire ou carentielle, c'est dans sa dimension conflictuelle qu'est appréhendé l'alcoolisme, hors du seul sillon narcissique. Au moyen d'une méthodologie croisée alliant cas cliniques issus de psychothérapie et cas cliniques de recherche enrichis des épreuves projectives, c'est au regard du sexuel que se trouve interrogé le symptôme alcoolique, privilégiant ainsi les problématiques œdipienne et de castration. A l'appui des concepts de répétition et de compulsion de répétition, il est dans un premier temps proposé de comprendre l'addiction en tant que conduite compulsive, aux fins de mettre en exergue la dynamique psychique sous-jacente au comportement et ce faisant, ses ressorts inconscient et fantasmatique. Figure d'un temps erratique, c'est dans ses incidences temporelles que l'addiction est mise en lumière, dans un différentiel entre cliniques de l'alcoolisme et de la toxicomanie. Si toutes deux procèdent à une subversion de la temporalité, que de la suspendre au seul profit de l'instant en vue de s'affranchir de toute causalité psychique, chacune relève d'une économie pulsionnelle propre. Si la conduite toxicomaniaque se montre massivement placée sous l'égide de Thanatos, l'alcoolisme n'en connaîtrait que de ponctuelles expressions, la dimension mortifère à l'œuvre dans la conduite alcoolique étant susceptible d'être imputée à Éros, de son excès d'intrication. Poursuivant, l'objet d'addiction, l'alcool, est questionné quant à sa fonction au sein de l'économie psychique du sujet. Envisagée comme tentative de solution de la part du sujet face à la castration et ses écueils, la conduite alcoolique se voit mise en lumière dans sa dimension de ratage, nommément phobique. L'objet d'addiction, alors entendu comme objet d'attraction, se fait le témoin du ratage de la constitution d'un objet phobique, répulsif par définition ; de cet échec, c'est alors la portée structurante de la phobie vis-à-vis de la castration qui disparaît, autant que le nouage de l'angoisse qu'elle offre - l'abstinence pouvant à ce titre être envisagée comme relance phobique. C'est à l'endroit de la figure paternelle et de ses défaillances que se poursuit la réflexion et, de la mise au jour de l'organisation œdipienne singulière qui en résulte, s'augure l'hypothèse d'un « complexe du père mort » chez ces hommes en proie à une conduite alcoolique. Enfin, le symptôme alcoolique se fait le lieu d'un débat psychopathologique entre névrose hystérique, fonctionnement limite et perversion. C'est l'hypothèse de l'hystérie masculine qui se verra défendue, la névrose se voyant ainsi abordée dans la gravité qu'elle peut recouvrir. C'est notamment des considérations quant au féminin, dans son opposition au phallique - et non au masculin - et à ce titre présent dans les deux sexes, que se soutiendra cette proposition. La question de la perte, très agissante dans les problématiques addictives, relue à la faveur du féminin, aboutit à un changement de paradigme, le narcissisme se trouvant relégué au second plan. / This work, part of a psychoanalytic perspective offers, through the singular clinical alcoholism, a metapsychological thinking about addiction, in support of a Freudian and Lacanian points of view. In a particular attention to the triptych on which is founded metapsychology, alcohol will be addressed through an economic point of view, increased with topographical and dynamic points of view, opening many as clinical and psychopathological perspectives. Divested of any deficit or carentiel design is in its conflictual dimension that will be apprehended alcoholism outside the narcissistic single way. Using a cross methodology combining cases from clinical psychotherapy and research, enriched projective tests is that in terms of psychosexuality is found interrogated alcoholic symptoms, and favoring Oedipal issues and castration. In support of the concepts of repetition and compulsion to repeat, it will be initially offered to understand addiction as compulsive behavior, in order to highlight the psychological dynamics underlying the behavior and thereby its unconscious and fantasmatic motivations. Figure of an erratic time, it is in its temporal effects that addiction will be found highlighted in a clinical difference between alcoholism and drugaddiction. If both proceed to a subversion of temporality in suspending it, in favour of instant, in order to overcome any psychical causality, each has is own instinctual economy. If drugaddiction shows heavily under the aegis of Thanatos, alcoholism would know only occasional expressions of the death instinct; mostly morbid dimension in alcoholaddiction may be attributed to Eros, because of its excessive fusion. Continuing, the object of addiction, alcohol, will be questioned as to its function within the psychic economy of the subject. Considered as attempted solution from the subject facing castration and its pitfalls, alcoholic behavior will be highlighted in its dimension of misfires, namely phobic. The object of addiction, then heard as an object of attraction, would witness misfires of the establishment of a phobic object, repulsive by definition. Through this failure, the structuring significance of phobia regarding castration disappears, as far as the knotting anxiety it offers - abstinence as such can be considered as phobic relaunch . This reflection will continue regarding the father figure and its failures and by means of the discovery of the singular oedipal organization that results, will herald the hypothesis of a "dead father complex" in these alcoholic's men. Finally, the alcoholic symptom will be the site of a psychopathological debate between hysterical neurosis, perversion and borderline. This is the hypothesis of male hysteria that will be defended, neurosis addressed in seeing the seriousness it can cover. This is particularly the considerations about the feminine, in its opposition to the phallic and not to masculine - and for that reason, present in both sexes, that will support this proposal, to authorize a re-reading of the issue of loss, very active in addictive problems, in a paradigm shift, narcissism being upstaged.

L’addiction aux drogues est une maladie comportementale récidivante caractérisée par une recherche et une prise compulsive de drogues, une perte de contrôle sur la prise malgré les conséquences négatives et l’émergence d'un état émotionnel négatif lors de l’absence de la drogue. L’addiction implique des neuroadaptations cérébrales persistantes. Des études récentes montrent que le cholestérol joue un rôle crucial dans le fonctionnement cérébral en participant à divers processus cellulaires et, en particulier, au contrôle de la neurotransmission. L’objectif de ce travail de thèse consistait à étudier l’implication potentielle du métabolisme du cholestérol dans l’addiction et en particulier si ce métabolisme était affecté par les drogues d’abus. Dans ce travail, nous avons étudié l’expression de gènes codant des protéines impliquées dans le métabolisme du cholestérol cérébral après une consommation volontaire chronique d’alcool par des rats et après des injections aigues ou chroniques de cocaïne. Nous avons analysé l’expression de ces gènes dans des structures cérébrales impliquées dans l’addiction, notamment le cortex préfrontal, le noyau accumbens, l’amygdale et l’hippocampe. Nous avons trouvé que l’exposition à l’alcool et à la cocaïne modifient l’expression des protéines impliquées dans la synthèse, le transport et la dégradation du cholestérol de façon spécifique de la drogue, du traitement (aigu/chronique) et de la région cérébrale étudiée. Dans une deuxième partie de la thèse, nous avons utilisé une approche virale permettant de surexprimer la CYP46A1, l’enzyme de dégradation du cholestérol cérébral dans le cortex préfrontal afin d’évaluer l’impact de cette surexpression sur la recherche de cocaïne dans un modèle de rechute. La surexpression de la CYP46A1dans cette structure n’a eu aucun impact sur la recherche de cocaïne. Des études futures seront nécessaires pour déterminer si l’altération de l’expression de cette enzyme dans d’autres structures, comme par exemple le noyau accumbens, pourrait avoir des effets bénéfiques sur la rechute. L’ensemble de ces travaux montrent que l’exposition aux drogues d’abus modulerait le métabolisme cérébral du cholestérol dans certaines structures cérébrales. Ce projet de thèse ouvre de nouvelles perspectives quant au rôle du métabolisme du cholestérol cérébral dans l’addiction, et il pourrait en résulter de nouvelles thérapeutiques dans le traitement de cette maladie psychiatrique coûteuse. / Drug addiction is a chronic brain disease characterized by drug-seeking and compulsive drug taking, a loss of control over drug taking despite the negative consequences and the emergence of a negative emotional state in the absence of the drug. Addiction involves persistent neuroadaptations at the cerebral level. Recent evidences show that cholesterol plays a crucial role in brain function by participating in various cellular processes in particular in the control of neurotransmission. The aim of this thesis was to investigate the potential role of cholesterol in addiction and in particular a potential dysregulation of cholesterol metabolism in response to drugs of abuse. In this work, we investigated the expression of genes encoding proteins involved in the metabolism of cerebral cholesterol after a chronic voluntary consumption of alcohol from the rats and after acute or chronic exposure to cocaine. We analyzed gene expression in brain structures involved in addiction such as the prefrontal cortex, the nucleus accumbens, the amygdala and the hippocampus. We found that exposure to alcohol and cocaine modifies the expression of proteins involved in the synthesis, the transport and the degradation of cholesterol in drug-specific, treatment- specific (acute / chronic) and region-specific manners. In the second part of the thesis, we used a viral approach to overexpress CYP46A1, the cerebral cholesterol degradation enzyme in the prefrontal cortex, in order to evaluate the impact of this overexpression on cocaine-seeking in a model of relapse. The overexpression of CYP in this structure has no effect on drug-seeking for cocaine. Future studies are needed to determine whether altering cholesterol metabolism in other structures, for example the nucleus accumbens, may have beneficial effects on relapse. Altogether these studies show that exposure to drugs of abuse might modulate cerebral metabolism of cholesterol. This thesis project opens new perspectives on the role of cholesterol cerebral metabolism in addiction which may ultimately result in new therapeutic avenues for the treatment of this costly psychiatric disorder.

Sociala medier har förändrat männskors sätt att interagera, uttrycka sig och dela information. Det har integrerat sig som en naturlig del av många individers vardagar men trots alla fördelar som det medför, kommer det med en del problematiska aspekter. När någonting används frekvent på en massiv skala så kan det leda till ett beroendebeteende som sedan kan leda till ytterligare svårigheter. En av dessa svårigheter är att man utvecklar missanpassad emotionell reglering. Utifrån detta var studiens syfte att undersöka problematisk användning av sociala medier i relation till emotionell reglering. För att besvara syftet gjordes en enkätundersökning genom en webbenkät baserat på skalorna DERS-16 och BSMAS. Urvalet gjordes så att webbenkäten skickades ut på författarnas privata instagram, facebook och reddit sidor och deltagarna fick en vecka på sig att svara (n=50; 58% kvinnor & 42% män; M ålder = 35). För analys av resultatet utfördes två Pearson's korrelationskoefficient och ett oberoende t-test. Resultatet visade ett signifikant positivt samband mellan socialt medieberoende och emotionell reglering och samtliga fem dimensioner som uppgör emotionell reglering. Dessa fem dimensioner är klarhet, mål, strategier, icke acceptans, impuls. Antal timmar på sociala medier och socialt medieberoende hade ett signifikant positivt samband men det existerade inget signfikant samband mellan emotionell reglering och timmar på sociala medier. Det oberoende t-testet visade ingen signifikant skillnad i män och kvinnors emotionella reglering. Slutatsen är att det finns en stark relation mellan socialt medieberoende och emotionell reglering / Social media has changed people's way of interaction, self-expression and sharing of information. It has integrated itself into a natural part of many individual's daily lives. Although there are many benefits, social media can come with some problematic aspects. When something is frequently utilized on a mass scale, it has the possibility of leading to behavioral addictions that can lead to additional difficulties. One of the difficulties is developing maladaptive emotionel regulation. The purpose of this study was to examine problematic use of social media in relation to emotional regulation. To answer the purpose, a questionnaire webb-survey was developed based on the scales DERS-16 and BSMAS. The selection was done through sending out the webb-survey on the authors instagram, facebook and reddit pages. The participants had a week-long deadline to answer the survey (n=50; 58% females, 42%males; M age = 35). For analyzing the results, two Pearson's correlation coefficients and an independent samples t-test were done. The results showed positive correlations between social media addiction and emotional regulation and between social media addction and the 5 dimensions of emotional regulation; clarity, goals, strategies, non-acceptance, impulse. The number of hours on social media and social media addiction had a positive significant correlation but no significant correlation between emotional regulation and time on social media could be found. The independent samples t-test showed no significant difference between males and females in relation to emotional regulation. In conclusion there is a strong relationship between social meddia addiction and emotional regulation

Sammanfattning Titel: ’’Det är ju ett våldsamt liv, att vara missbrukare’’- Socialsekreterares syn på ASI- intervjuns användbarhet beträffande våld i nära relationer  Författare: Isabell Eklöf och Mimmi Wallin Nilsson  Syftet med studien var att undersöka hur socialsekreterare inom alkohol-och drogmissbruksområdet uppfattar ASI-intervjuns användbarhet att identifiera våld i nära relation samt stödja våldsutsatta och våldsutövare. Data samlades in genom fem semistrukturerade intervjuer med socialsekreterare inom alkohol- och drogmissbrukområdet med erfarenhet av ASI i Sverige. Resultatet analyserades med hjälp av tidigare forskning och begreppen handlingsutrymme samt relationskompetens, yrkeskompetens och handlingskompetens. Resultatet visar att ASI-intervjun är ett bra verktyg för att screena våld i nära relation men inte för att stödja våldsutövare och våldsutsatta. Flertalet faktorer påverkar ASI-intervjuns användbarhet; bland annat klienternas komplexa problematik, relationen mellan socialsekreterare och klient, samt socialsekreterarens intresse att ställa följdfrågor. Troligtvis hade ASI-intervjun varit mer användbar om frågornas utformning justerats. En slutsats är att det är upp till den enskilde socialsekreteraren och dess handlingsutrymme hur användbar ASI-intervjun är. / Abstract Title: ”It is a violent life to be an addict” - Social workers' views on the usefulness of the  ASI interview regarding violence in intimate relationships.  Authors: Isabell Eklöf and Mimmi Wallin Nilsson  The purpose of the study was to investigate how social workers in the alcohol and drug abuse field perceive the ASI interview’s usefulness to identify violence in intimate relationships and support victims and perpetrators. Data were collected through five semi- structured interviews with social workers in the alcohol and drug abuse field with experience of ASI in Sweden. The result was analyzed with previous research, the concept room for maneuver, relational competence, professional competence and action competence. The results showed that ASI is useful for screening violence in intimate relationships, but not for supporting perpetrators and victims. The social workers' interest in asking follow-up questions, clients' complex problems and the relationship between social worker and client are examples of what affects the ASI' usefulness. ASI could be more useful if the questions were adjusted. One conclusion is that the individual social worker and their room for maneuver determines the ASI’s usefulness.

Helicopter parenting has emerged as a prevalent phenomenon in families with adult children. Due to its developmentally inappropriate nature, helicopter parenting sometimes serves as a risk factor for children. In addition, culture and parents’ gender shape parenting and adult children’s outcomes. The purpose of the present study was to identify multidimensional constructs of helicopter parenting among college students and describe how latent classes of helicopter parenting of mothers and fathers are related to college students’ game and social media addictive behaviors in the United States and China. Using a three-step latent class approach, data from 1402 mother and young-adult child (MC) and 1225 father and young-adult child (FC) pairs in the United States and 527 MC and 426 FC pairs in China were analyzed. Four helicopter parenting latent classes (strong, strong but weak direct intervention, weak but strong academic management, and weak) were identified among MC and FC pairs in the United States, but three latent classes (strong, strong but weak direct intervention, and weak) were identified in China. In addition, college students whose parents were in the strong helicopter parenting class reported a higher level of game and social media addictive behaviors than those in weak and weak but strong academic management classes in the United States, but not in China. These findings indicate that helicopter parenting is multidimensional in nature in both American and Chinese families, but the impact of helicopter parenting on college students’ game and social media addictive behaviors differs between the two countries.

Background: The consequences of continued opioid abuse among patients treated with opioid substitution therapy (OST) are serious and can result in abnormal cardiovascular function, overdose, and mortality. Conflicting evidence exists that both implicates and refutes the role of chronic non-cancer pain (CNCP) as a major risk factor for continued opioid abuse within the addiction treatment setting. This thesis aims to 1) evaluate the impact of chronic pain on the treatment outcomes of patients with opioid addiction receiving OST, 2) determine whether a clinical or inflammatory profile exists to distinguish pain in this population, 3) explore the sources of heterogeneity in previous studies examining this question, 4) determine the best therapy for patients with chronic pain, and 5) evaluate the most effective treatment for opioid addiction. We anticipate chronic pain to be an important predictor of continued opioid abuse such that patients with comorbid pain will require careful consideration when managed on OST. Methods: We systematically reviewed the literature to determine the impact of pain in opioid addiction patients receiving methadone maintenance treatment (MMT). We determined the clinical and inflammatory profile of MMT patients using data from the Genetics of Opioid Addiction (GENOA) research collaborative between the Canadian Addiction Treatment Centres (CATC) and the Population Genomic Program. GENOA is a prospective cohort study aimed to determine the genetic, biological, and psychosocial determinants of treatment prognosis for opioid addiction patients receiving MMT. GENOA recruits patients ≥ 18 years of age meeting the DSM-IV criteria for opioid dependence. All GENOA participants are receiving MMT for the management of opioid addiction. Baseline data from the GENOA pilot study (n=235) were used to evaluate the impact of pain on illict opioid use behaviour and determine the clinical and inflammatory profile of patients with comorbid pain. We explored sources of heterogeneity in previous studies using data from the full-phase GENOA study (n=444), examining the prognostic value of different pain measures for predicting illicit opioid use. We then performed a multiple treatment comparison of all opioid substitution and antagonist therapies in efforts to determine the best intervention for improving treatment outcomes for patients with comorbid pain. We lastly determined the most effective treatment for opioid addiction by performing a network meta-analysis using data from a systematic review of opioid maintenance therapy trials. Results: Our initial systematic review confirmed a lack of consensus in the literature, whereby some studies suggest pain increases risk for illicit opioid use and other studies suggest pain has no effect on substance use behaviour. Findings from the analysis of GENOA pilot data confirmed chronic pain to be an important predictor of sustained opioid abuse and also showed patients with pain to have elevated Interferon-Gamma. Using data from the GENOA prospective cohort study we determined the Brief Pain Inventory (a commonly used pain measurement in pervious studies) to be highly sensitive with poor prognostic value. Our final reviews propose 1) there is limited evidence to suggest any OST is superior for managing patients with comorbid pain, and 2) heroin and high-dose methadone are the most effective treatments for improving treatment retention. The final systematic review and network meta-analysis in this thesis also highlights a major problem in the treatment of opioid use disorders, primarily the lack of consensus as to what outcomes matter for determining success in patients with addiction. Conclusion: Patients with comorbid pain and addiction are at high-risk for continued opioid abuse and should be managed closely by clinicians administering OST. Contention in the previous literature likely resulted from the use of pain measurements with poor prognostic value. No OST demonstrated superiority for managing patients with chronic pain. While our findings indicate heroin is the most effective treatment across multiple endpoints, we use this thesis to provide readers with 1) a sense of the feasibility issues associated with heroin administration, 2) a summary of the limitations of this evidence base, and 3) recommendations for how to improve the addiction trials’ design for future research. / Thesis / Doctor of Philosophy (PhD)

Studiens syfte var att identifiera de verkningsfulla komponenterna i 12-stegsprogrammet för minskad användning av beroendeframkallande substanser eller uppnå nykterhet i behandlingen. Detta gjordes genom en integrativ litteraturstudie innehållande 10 vetenskapliga artiklar där de verkningsfulla komponenterna samt andlighetens betydelse för 12-stegsprogammet analyserades med hjälp av KASAM och existentialism. Genom att undersöka dessa verkningsfulla komponenter samt andlighet redogör denna studie för hur dessa bidrar till 12- stegsprogrammets framgång som behandling för missbruk. Studien fann att de verkningsfulla komponenterna i 12-stegsprogrammet för minskad användning av beroendeframkallande substanser eller uppnå nykterhet var följande: grupp, tjänstgöring och sponsring samt andlighet. Vidare fann studien att andlighet spelar en betydande roll för att dels kunna tillgodogöra sig behandlingen, dels för att kunna uppnå antingen minskad användning av beroendeframkallande substanser eller för att uppnå nykterhet. / The purpose of the study was to identify the effective components of the 12-step program for reducing the use of addictive substances or achieving sobriety in treatment. This was done through an integrative literature review containing 10 scientific articles where the effective components and the significance of spirituality for the 12-step program were analyzed using SOC (Sense of Coherence) and existentialism. By examining these effective components and spirituality, this study explains how they contribute to the success of the 12-step program as a treatment for addiction. The study found that the effective components of the 12-step program for reducing the use of addictive substances or achieving sobriety were as follows: group, service and sponsorship, as well as spirituality. Furthermore, the study found that spirituality plays a significant role in both benefiting from the treatment and achieving either reduced use of addictive substances or sobriety.

My diploma thesis is both theoretical and empirical. It deals with modern nondrug addictions which are not yet classified as addictions according to the International Classification of Diseases, but their symptoms and common characteristics with recognised addictions allow us to label them as such. The theoretical part of my thesis concerns mainly a definition of these addictions, their typical symptoms, prevention and therapy. The practical part contains tables derived from the results of research carried out in the form of questionnaire surveys. One questionnaire was designed for adults,another for children and youth adults. Both aim to monitor the occurrence of modern addictions in today's population. The practical part also contains a questionnaire which confirmed or disconfirmed a suspicion of workaholism in the case of two selected persons. The appendixes to my thesis contains all the mentioned questionnaires and a case study of a person cured from a gambling addiction. The appendixes also contain graphs supplementing the practical part of the thesis, a list of rehabilitation institutions where individual addictions can be treated as well as contact information of various workplaces which provide help and counselling.

L’objectif de cette thèse d’articles était de préciser la place respective des mesures objectives (ex., durée et sévérité de la maladie, traitements reçus) et subjectives (ex., troubles psychiatriques, personnalité) en tant que déterminants potentiels de dépression, de qualité de vie (QV) et d’addiction à l’alimentation chez des patient(e)s souffrant de cancer du sein ou d’obésité sévère. En nous basant sur des modèles biopsychosociaux issus du modèle de Wilson et Cleary, nous avons démontré que : 1) La dépression était plus fortement associée aux caractéristiques psychopathologiques de l’individu (personnalité, dépression avant traitement) qu’à la sévérité de la maladie ou aux types de traitements reçus ; 2) Les facteurs associés à la QV dépendent de la dimension de QV considérée (association entre mesures objectives et QV physique ; association entre mesures subjectives et toutes les dimensions de QV) ; 3) Les patients obèses souffrant d’addiction à l’alimentation ont une vulnérabilité psychopathologique spécifique. Nos travaux suggèrent qu’en cas de maladie chronique, les mesures subjectives sont des déterminants potentiels importants de la santé / This article thesis aimed to assess risk factors for three different health outcome measures (depression, health-related quality of life and food addiction) in two populations (breast cancer patients and morbidly obese patients), by assessing the relative impact of biological and physiological variables (i.e., disease duration and severity, types of treatment used), and individual and psychological variables (i.e., psychiatric disorders, personality). By proposing and putting to the test several integrative biopsychosocial models based on Wilson and Cleary’s theoretical model, we demonstrated that : 1) Depression after breast cancer treatment is more strongly associated with variables related to the premorbid individual and psychological characteristics (i.e., personality and depression before treatment) than to biological and physiological variables (i.e., disease severity, types of treatment used) ; 2) Risk factors for lower quality of life are different depending on the quality of life dimension considered (e.g., physical, psychological or sexual) : biological and physiological variables are associated with physical quality of life ; individual and psychological factors are associated with all quality of life dimensions ; 3) Obese patients with food addiction exhibit some specific psychopathological risk factors. Our work suggest to systematically assess individual and psychological variables in patients with chronic diseases because these variables are important potential predictors for different health outcomes