Alcoholism in heroin use disorder patients. A masked heroin addiction case report

Background: This case report discusses the complex relationship between alcoholism and heroin use disorder, focusing on a clinical case of a patient with a history of opioid use disorder who developed severe alcohol use disorder. The patient, Mr. S.T., had a long history of substance use, starting with multiple psychoactive substances in adolescence and progressing to heroin use. Despite several detoxification attempts, he eventually stopped using heroin but developed a severe alcohol use disorder. In literature, various typologies of alcoholism, including those proposed by Cloninger, Babor, and Lesch, are present. They categorise alcoholics based on factors like onset age, family history, and psychosocial consequences. The metabolic pathway linking alcohol and opioids fortifies that alcohol use is common among heroin addicts in methadone maintenance treatment programs (MMTPs) with negative consequences, such as worsening psychiatric comorbidities and increased risk of HIV infection. The case of Mr. S.T. illustrates the concept of “masked heroinism,” where alcohol use in former heroin addicts is seen as a continuation of opioid system dysfunction. The patient initially failed to respond to common alcoholism treatments but showed improvement with low-dose opioid agonists like buprenorphine. The document suggests that restoring opioid agonist treatment in such cases can help rebalance the opioid system and reduce the need for psychotropic drugs. In conclusion, this case report argues that alcoholism in former heroin addicts should be viewed as a negative outcome of opioid dependence, requiring specific therapeutic approaches. It calls for a broader perspective on polysubstance use and the underlying psychopathological trajectories, including the potential role of bipolarity.