bekhterevОбозрение психиатрии и медицинской психологии имени В.М.БехтереваV.M. BEKHTEREV REVIEW OF PSYCHIATRY AND MEDICAL PSYCHOLOGY2313-70532713-055XV. M. BEKHTEREV NATIONAL RESEARCH MEDICAL CENTER FOR PSYCHIATRY AND NEUROLOGY OF THE RUSSIAN FEDERATION MINISTRY OF HEALTHbekhterev-18Research ArticleВ ПОМОЩЬ ПРАКТИКУЮЩЕМУ ВРАЧУGUIDELINES FOR THE PRACTITIONERКак лечить наркологического больного с двойным диагнозом?How to treat addicted patient with concomitant psychiatric diagnosis?ЕгоровАлексей ЮрьевичEgorovA. Y.draegorov@mail.ruШагиахметовФарид ШамилевичShagiahmetovF. Sh.f.shagiakhmetov@gmail.comФедеральное государственное бюджетное учреждение науки Институт эволюционной физиологии и биохимии им. И.М. Сеченова; Санкт-Петербургский государственный университет; Северо-Западный государственный медицинский университет им. И.И. МечниковаRussian FederationНИИ наркологии, филиал ФГБУ «ФМИЦПН им. В.П. Сербского» Минздрава РоссииRussian Federation201619072018026177Copyright © Егоров А.Ю., Шагиахметов Ф.Ш., 20182018Егоров А.Ю., Шагиахметов Ф.Ш.Egorov A.Y., Shagiahmetov F.S.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.bekhterevreview.com/jour/article/view/18

Злоупотребление алкоголем и алкогольная зависимость часто сочетаются с аффективными, тревожными расстройствами и шизофренией. Наличие двойного диагноза ухудшает прогноз у пациентов. Тем не менее, коморбидные пациенты редко получают комплексную терапию, направленную на оба заболевания одновременно. В работе приводится обзор информации по лечению пациентов с двойным диагнозом, а также рассматриваются вопросы конвергенции общих нейробиологических механизмов на моноаминергических нейронах ствола головного мозга. В частности, актуализируется роль динорфин/каппа-опиоидной системы в качестве универсального модулятора активности мезокортиколимби-ческой дофаминергической системы, играющей, как известно, ключевую роль в патогенезе большинства психических расстройств и химических аддикций. Интерес к каппа-опиоидной системе связан с тем, что эндогенный опиоидный нейропептид динорфин, играет роль мощного эндогенного депрессанта моноаминергической (дофамин, норадреналин и серотонин) и глутаматергической нейротрансмиссии в коре головного мозга и подкорковых лимбических структурах. Это определяет стратегическую роль данного подтипа опиоидных рецепторов в регуляции настроения, эмоционально-волевой сферы, когнитивных функций, восприятия и контроле побуждений. Большинство антагонистов каппа-опиоидных рецепторов (КОР) пока не доступны в широкой клинической практике и находится на различных фазах клинических исследований для лечения терапевтически резистентной депрессии, биполярного аффективного расстройства, диссоциативных расстройств и химических зависимостей. Тем не менее, недавно в РФ и Европейском союзе, для лечения алкогольной зависимости, был зарегистрирован налмефен - опиоидный антагонист с преимущественным сродством к КОР. В данной связи, обсуждается возможная клиническая польза налмефена в терапии сложных коморбидных пациентов, в качестве психофармакологического агента, несущего терапевтический потенциал, не ограничивающийся наркологическими заболеваниями. У коморбидных больных шизофрений доказана обоснованность и необходимость одновременной комбинированной терапии антипсихотиками и препаратами, используемыми для лечения алкоголизма (в том числе блокаторов опиатных рецепторов).

Alcohol use disorders often co-occur with affective disorders, anxiety disorders and schizophrenia. The presence of dual diagnosis worsens the prognosis in patients. However comorbid patients rarely receive specialized treatment that addresses both conditions. This paper reviews currently available treatment options for patients with dual diagnosis, as well as addresses the issues of common neurobiological mechanisms converging on monoaminergic neurons originating from the brain stem. Particular emphasis is made on the updated role for dynorphin / kappa-opioid (KOP) receptor system modulation of the mesocorticolimbic dopaminergic circuitry - a neuronal hub playing a major role in the pathology of the majority of mental disorders and chemical addictions. The interest to the kappa-opioid system is caused by the role of endogenous opioid neuropeptide dynorphin being one of the most powerful endogenous depressants of monoaminergic (dopamine, norepinephrine, and serotonin) and glutamatergic neurotransmission in the cerebral cortex and subcortical limbic structures. This designates the strategic role for the kappa-subtype opioid receptor in regulation of mood, emotions, motivation, cognitive performance, perception and impulse control. Most of the KOP-antagonists are still being under clinical development and are not yet routinely available to clinicians. These agents are being developed for the treatment-resistant depression, bipolar, dissociative disorders and addictions. However, recently nalmefene - a new treatment for alcohol addiction, has been approved in Europe and Russia. Nalmefene is an opioid receptor antagonist with the preferential affinity to the KOP receptor. As this psychopharmacological agent carries therapeutic potential beyond substance abuse and addiction, possible clinical benefits of nalmefene in the treatment of complex comorbid patients are discussed. In comorbid schizophrenia patients the validity and necessity of the simultaneous therapy with antipsychotics and drugs used for the treatment of alcoholism (including opiate receptor blockers) were proved.

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The authors declare that there are no conflicts of interest present.