Aggressive Behavior and Substance Use Disorder: The Heroin Use Disorder as a Case Study

Introduction: In this perspective review, we analyzed the aggressive behavior of our patients suffering from heroin use disorder (HUD). Methods: As investigating tools, we used the Buss-Durkee Hostility Inventory, the Anger-Hostility factor of Symptom Checklist-90, which was obtained in psychiatric patients, and our violence/suicidality (V/S) factor. Results: Eight out of every 10 HUD patients treated by us showed highly aggressive behavior: 2.5 without physical contact, 7.5 with physical contact, and 4.5 with an ego-syntonic perception of their aggressive behavior. At treatment entry, Buss-Durkee Hostility Inventory Negativism and Assault could differentiate HUD from their nonuser peers; violence and self-harm were correlated with dual disorder/HUD patients; in dual disorder/bipolar-HUD suicidality increased; predominantly V/S patients were more frequent in younger HUD age brackets; the V/S dimension only minimally affected HUD state-conditions, and was closely correlated with HUD trait-conditions (addictive behavior and posttraumatic stress disorder spectrum); and it was possible to differentiate HUD from other psychiatric patients (depressed and psychotics) and nonpsychiatric ones (obese), but it was not possible to differentiate patients affected by nonpharmacological addictions. On the therapeutic level, the presence of aggression negatively influenced general practitioners' office-based methadone and naltrexone maintenance. More methadone dosage was needed to stabilize methadone-treated or buprenorphine-treated aggressive patients; predominantly V/S patients were better stabilized with buprenorphine treatment. Conclusions: Our studies suggest an in-depth psychopathologic evaluation of HUD patients, with particular attention to be focused on aggressive symptoms. Moreover, our data are in agreement with the self-medication theory of Khantzian, which looks at heroin addiction as a way of controlling violent manifestations. For this reason, providing an adequate amount of opioid agonists seems to be crucial in the management of violent opioid addicts.